Top 5 Reasons for Failed Root Cause Analysis
Root cause analysis is one of the best ways to solve difficult or significant problems, but sometimes, root cause analysis efforts fail because the corrective actions weren't effective. If the original problem happens again, or the needed improvements haven't materialized, or a new problem arises because of the corrective actions, you need to figure out what happened and why so you can fix whatever went wrong. Here is a list of the issues you should be considering -- the top 5 reasons for failed root cause analysis.
- Wrong basis: If a root cause analysis stops short, bypasses important causal factors, or just plain misses the mark, there is probably little chance that its corrective actions will be fully effective. Look hard at how the original analysis was done. Was a robust method like 5x5 Whys or Causal Factor Tree Analysis used, or something like a Fishbone, simple Pareto, or traditional 5 Whys? Was it based on facts and evidence, or wishful thinking and political expediency? Did it have adequate breadth and cover all the necessary and sufficient factors, or does it look like a straight line? Did it dig deep to find fundamental, underlying causes, or did it stop well short of anything meaningful?
- Bad solutions: Even the most perfect root cause analysis can't be successful if it only leads to "solutions" that are weak, misdirected, incomplete, or purely cosmetic or political. Corrective actions actually have to do something of substance... lame, expedient gestures are generally pretty useless. Was there any reasonable hope at all that the corrective action, as written, could actually prevent recurrence of the problem, lead to substantial improvement, or significantly reduce risk? Were there alternative actions that had a higher chance of success?
- Poor execution: What if the original corrective actions were darn near infallible, but weren't carried out as intended? Watered down, delayed, gutted, or pencil-whipped into oblivion -- you will probably see these much more than you would like. Pay close attention to what was actually done and how it compares to the original intent.
- Lessons forgotten: If effective corrective actions get rolled back or overridden, the original problem will probably return. Organizational memory is important; forgetting why a problem occurred and how you fixed it is a first step down the path to repeat problems. Examine the conclusions from the previous root cause analysis and ask yourself if there was any reasonable chance that the organization could learn anything from them.
- Other changes: Sometimes, a problem will come back when a seemingly unrelated change is made. This can happen if the original root cause analysis didn't consider other paths to the same problem (i.e., parallel risks). It can also happen if the organization forgot about the problem and how it was fixed (see previous item). Look at interfacing or interacting processes, organizations, systems, etc. and identify any crossover points that could lead to unexpected effects.
The list isn't complete, of course, but it captures the biggest issues. Considering that some of these can occur in combination, it's easy to see that the potential can be high for even relatively decent corrective actions to go bad. That's not a knock on root cause analysis though, because every other problem solving strategy is most likely going to be worse.
Strong, substantive, and comprehensive corrective action plans are important. So is learning from past problems. Some people might say that cause analysis is unimportant, that effective solutions are all you need... but if you don't know the root causes, what have you actually learned? Three years later, if your organization can't recall the problem, why it happened, and how it was fixed, how are you ever going to make sure you don't recreate it through ignorance?
If you want to have more effective solutions to problems, your first step should be to improve your root cause analysis capabilities. Check out my root cause analysis guides; there are two versions (short or long), and one of them may be exactly the free root cause analysis training guide that you need!
by Bill Wilson