Monday, June 11, 2012

Three Silly Secrets About Root Cause Analysis

Here are three not so closely held secrets that can help clarify a few of the points around Root Cause Analysis (RCA). I hope you find them enjoyable and they help you think about a few things differently.
There is no such thing as one root cause...
  • The connected causes or causal chains as we call them continue forever in an infinite continuum moving out from the event. Lets say you were doing a root cause on your office mate tripping over your computer cord, and you took it to an extreme, if your office mate had not been born then the cord could not have been tripped over tripped by him today. Now we know you can not control your office mates parental breeding patterns in order to prevent the fall but the point here is that you can investigate and build well beyond your ability to effectively mitigate or eliminate the causes and you would still not be at the one root cause. The key here is to try to find the paths that lead to the systemic and latent causes and then take the time to evaluate solutions at that level for the best return on investment. This may mean that they may be out of your span of control but within the span of control of your managers or others allowing you to be successful.
  • Rob Base and DJ E-Z Rock once said "It takes two to make a things go right" I would add "or wrong": With RCA those two things are existing conditions and instantaneous actions.  There are always at least two causes per one effect therefor it should be called Root Causes Analysis. Using the example from above there was a cord which was the condition and a walking office mate which is the action. When you consider both you can look for the hidden causes and lowest cost solutions as you drill down into the problem.
Cause and effect are the same thing...
  • The cause of the event or reason for the RCA is the effect of it's cause. 
  • For example from above: Falling office mate was the effect of the action of walking across the floor. The action of walking across the floor was the effect of the action of you requesting help moving your monitor. In this example they are all effects rewritten they can all be causes. You requesting help with your monitor was the cause of your office mate walking across the floor and your office mate walking across the floor was caused of him tripping over the cord. The point is don't get hung up on either word. Use which ever you like the best to build the causal chains but to avoid confusion don't mix them together.
Root Cause Analysis reports create no return on investment...
  • You do not get a return on investment from a report. The return on investment comes from the implementation and verifications of the solutions. Why is this important? If I have to choose between spending all my time creating a beautiful report or spending my time ensuring implementation for the solutions then I choose the latter.


  1. AMEN, Shon!! I've been trying to explain the idea about there being no single root cause for a while at work. It's nice to see someone voice a similar viewpoint.
    I also agree with your point about getting things done. I use a similar analogy with FRACAS. It isn't until the Corrective Action step where someone actually makes changes.
    Keep up the good work.

  2. Especially the take action part - the report is not the goal or terribly useful. Do something based on the information learned during the RCA. Otherwise, what's the point of the exercise.

  3. Shon,

    I especially like your third point. So many times organizations get so busy manufacturing reports that they lose a great deal of effectiveness at improving their operations. In turn they are deluding themselves with being busy instead of being productive.

    Mark J. Cundiff

  4. Don't sell short the ROI potential of a complete & accurate RCA report guys. For w/o the quality RCA report we run the risk of repeating the same event elsewhere in the enterprise don't we? Good RCA will seek not only to implement solutions for a recent event in location X but will also include a mechanism to leverage learnings across the enterprise. This includes a timely & efficient means of communicating RCA results and linking to a user friendly interface for others to quickly access/review the simple yet clearly documented RCA. Shouldn't have to be a "one or the other"...take the time to do both w/excellence to ensure we maximize the value intended for not only our personal needs but those of the enterprise. "Those unaware of history are doomed to repeat it..."

  5. It is nice to see after teaching the principles of causation to hundreds of thousands of people for over 20 years that my message seems to be coming into its own. I like the presentation of three silly secrets about RCA – very true. In my most recent book I have expanded on the notion of the infinite set of causes to point out that it should teach us to be humble above all things. Because we know that every time we ask why, we must find at least two causes in the form of an action and a condition and that each time we ask why of these answers, an infinite set of causes exist. At some point in asking why, we always come to our point of ignorance where we no longer have answers, That should be humbling enough, but when you consider that for every effect at the ends of our causal understanding there are at least two more causes. It puts into prospect the old adage that the more we know, the more we know we don't know, and if that doesn't humble you, I don't know what will. If you want to know more, you can download my pdf eBook at and enter the following code: WJG512 Enjoy,
    Dean L. Gano