Tag Archives: philosophy

Systems Thinking, Complexity, and Root Cause

I'm getting so very tired of safety/accident researchers claiming that root cause analysis is an invalid, blame-focused practice that ignores systems and complexity. Most root cause investigators that I know are pretty well oriented towards process, organization, and system issues as the fundamental sources underlying problems and accidents... and even some of our simplest analysis tools (e.g., TWIN) include specific checks for complex-system characteristics/behaviours (e.g., hidden system responses, separation between cause and effect).

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Root Cause Analysis – Art or Science?

There are many commonly held beliefs about root cause analysis that bother me. Perhaps the single most irksome to me is the statement "it's an art, not a science." I don't have anything against art, but I don't believe that this statement does justice to the practice of root cause analysis. In fact, I believe it is one of the most damaging perceptions that can be held by an investigator or be communicated to others.
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Einstein, Root Cause Guru

I've been seeing quotations from Albert Einstein in various places lately. Here are a dozen of my favourites that I feel apply to the practice of root cause problem solving. I've tried to present them in a particular order that I think helps create a coherent message. I hope you'll mark these words... they may not be the keys to paradise, but I believe they tap the root of something very important.
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Human Error

How many times have you read a news article about a major problem or incident, and seen Human Error in the headline? A quick search of Google News for that phrase provides plenty of examples. The latest big incident of note (when this article was written in 2005) is the August 12, 2005 Los Angeles blackout -- sample headline "Human Error Led to Widespread Outage." Well, what a blinding flash of the obvious -- people make mistakes!
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Root Cause Analysis – Large or Small Events?

Root Cause Analysis (RCA) can be applied to events of any size or significance. However, it's usually applied to large events, i.e. those with serious consequences. Even so, it can and should be applied to smaller events as well. Statistically, smaller events are more likely to occur than larger events. Thus, application of RCA to small events may identify many significant opportunities for improvement.
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Phases of Root Cause Analysis

Root Cause Analysis (RCA) is generally conducted in several phases. I've seen some methodologies that break down the RCA process into as many as a dozen different steps. In reality, however, there are just three main phases we need to be concerned about. More importantly, these three phases are very different from each other... so different that they should always be kept distinctly separate. I've designated these phases Investigation, Analysis, and Decision. Read on to see why.
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The Fortunate Near-Miss Event

What do you consider to be an event worthy of investigation? Do you look only at events that had serious consequences, or do you consider less serious events as well? What about near-misses?

I've recently been involved in the investigation of a near-miss event. By near-miss (or near-hit?), I mean an event that almost happened -- an event that terminated one step before a serious consequence was experienced. As is often the case, the event sequence was a seeming string of coincidences. It ended without consequence simply because there was nobody at the event location to be injured.
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Event Frequency and Severity

In 1931, HW Heinrich published his findings from a review of hundreds of thousands of safety incidents. His data showed that on average, for every 300 near-miss events without injury, there would be 29 minor to moderate injuries and 1 major injury or fatality. Similar studies done since 1931 have yielded similar results. The data is deceptively, compellingly simple -- the meaning, however, is not. What is implied by a 300:29:1 ratio of near-misses to moderate injuries to major injuries? Why do we care? Is there some deeper, underlying pattern to this data?
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Four Ignoble Truths

Before you decide how to fix a problem, you should probably seek first to understand it... perhaps with a root cause analysis. That is, unless you happen to enjoy delays, lost productivity, injuries, or worse. In that case, feel free to implement any pseudo-random, flavour-of-the-month "solution" your heart desires. Realize the four ignoble truths, and follow the ignoble eight-fold path.
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