I have recently been challenged by a safety group about the Root Cause Analysis methodology. Often Root Cause Analysis is perceived as the process by which the ‘single cause’ is found; what is the one thing that can be blamed for failure?
This group of safety professionals was so frustrated with the term ‘Root Cause Analysis’ that I was asked to refer to the process as Causal Analysis instead. I complied, and the facilitation went smoothly. As technical people we perhaps miss some of the nuisances of language that can effect perception.
There are multiple definitions of the word root; one definition is “origin”. That definition has resulted in the miss-use of the term Root Cause Analysis. Using the singular word ’cause’ also directs folks to searching for the ‘single thing’. But nature leads us to a different definition.
At Think Reliability we see a root as a system; an incident has a system of causes.
Where is the origin in the above photo?
Our process is not to identify one, simple and clean cause for an incident. Rather, we are tasked with untangling and mapping what is often a tangled mass of causes that worked together. Focusing on one ‘cause’ in a root system will not eradicate the issue any more effectively than pulling one strand from the tangled system of roots in the picture would kill the weed.
Causes Analysis does not roll off the tongue. Using the phrase Root Cause Analysis is accurate but it may require an explanation. As the investigators we have a responsibility to provide that explanation and educate. Maybe next time, I’ll bring the picture.
Cheers,
Loyd.
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