Root cause analysis can be characterized in many ways. Some refer to it as a tool for continuous improvement. Others call it a method for finding performance problems. Those at the receiving end, however, often view root cause analysis as just a repackaged version of "the blame game". Who can blame them when operator error or lack of attention to detail are so often listed as causes?
All too often during root cause investigations, a line of inquiry will end at human behaviour without digging deeper into the factors affecting behaviour. I believe this happens, unfortunately, because many investigators feel that this issue is the cause, i.e. "humans are unreliable" or "that's just the way people are." With that viewpoint, you often end up with corrective actions like the following.
- Discipline the people involved.
- Issue a management directive.
- Provide training.
- Revise a procedure.
The problem is, these actions are rarely effective in the long run. Yes, they usually yield some changes in behaviours for a while. You may even be able to extend the effectiveness of these actions by repeating them periodically. However, if the underlying factors affecting behaviour still exist, people will eventually start behaving in ways you don't want. Yelling louder and more often can only get you so far.
People behave as they do for reasons that make perfect sense to them. This is true for actions they took in the past, and for actions they may take in the future. In order to change behaviours, we've got to work on the reasons supporting the unwanted behaviours. Instead, though, we usually fall back to the standard corrective actions listed above and then hope for the best.
So, is there a better way? YES. I'll be discussing these in the next few articles on this blog. Stay tuned!
by Bill Wilson