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).
One of the more annoying claims by such researchers is that root causes don't exist... that they are not found, but constructed. They say that the very act of analyzing an event using principles of causation is Newtonian and reductionist, the immediate implication being that causal analysis is out-dated and obsolete. The deeper implication -- established and reinforced by continual labeling of "root cause analysis" as simplistic, linear, and focused on a misguided need for blame -- is that the search for root causes is philosophically and morally bankrupt. What they propose as the obvious (and obviously superior) alternative is systems thinking. Thus, "root cause analysis" and "systems thinking" are set up by their arguments as opposing practices, the former being "old-fashioned" and "bad", while the latter is "modern" and "good".
I say that's a load of bull; systems thinking vs. root cause analysis is a false dichotomy.
Root cause analysis is not just some fixed and unchanging practice. It also isn't a pre-defined set of rules, processes, methods, and tools. It is actually more like a basic philosophy of problem solving, one that simply says "focus on deeper issues rather than immediately observable symptoms".
Systems thinking is not just some brand new and revolutionary practice. It also isn't a pre-defined set of rules, processes, methods, and tools. It is actually more like a basic philosophy of problem solving, one that simply says "focus on system issues rather than immediately observable symptoms".
Oh wow... those two paragraphs are basically identical. What if "deeper issues" and "system issues" are basically the same? Does that mean "root cause analysis" and "systems thinking" -- when applied to problem solving or accident investigations -- are basically the same, or at least compatible?
"Ah", says the systems thinker, "you've forgotten to consider complexity, which root cause analysis cannot handle."
"Ah", says I, "that's bull... I can very happily use your oh so modern, non-linear, holistic, complexity-accommodating systems techniques to help me find root causes."
The systems thinker then exclaims "root causes are constructed, not found, and therefore aren't a valid concept... especially since they are inextricably linked to blame for human error".
"More bull", I say. "Your understanding of the system is also constructed. It's a model, a theory, something that you hope -- but cannot prove -- is an accurate representation of the system. As George Box might say, your model may be useful, but it is still wrong... or perhaps René Magritte would simply state «Ceci n'est pas une pipe»."
"And what about human error and blame?" asks the system thinker.
I roll my eyes and sigh. "Look, any so-called root cause analysis that claims human error as a root cause is clearly full of it; the investigator was either inexperienced, or was pushing an agenda. Good tools can be used honestly and effectively, or poorly or maliciously... even in systems thinking. Don't tell me that it would be impossible to skew a system model to yield a particular conclusion -- which is actually worse than a root cause of human error because the skewed model is a much less obvious problem!"
Okay, enough fake dialogue. My point is this: root cause analysis can be (and frequently is) conducted from a systems thinking viewpoint, with knowledge of complex systems phenomena and a focus on understanding the system rather than fixating on blame and human error. Systems/complexity-focused safety proponents that denigrate "root cause" because it isn't "systems thinking" are doing so out of ignorance and a stubborn unwillingness to consider the possibility that an old concept like "root cause" can actually evolve and improve over time. I'll still read your books and blogs, because I think they have a lot of value overall... but I'm telling you, you're wrong when it comes to root cause, and I'm going to speak up every time I see you making those claims.
by Bill Wilson