Some Limits of Root Cause Analysis

Root Cause Analysis (RCA) was developed to resolve defects in manufacturing. When the error rate of a production process is too high, we use RCA to discover why and fix it. In manufacturing, RCA works pretty well. Sometimes it even works with software development and other processes that generate nonphysical outputs. But when we try to apply RCA to problems among people, trouble appears.

We're usually unaware of RCA thinking. Some indicators are questions and statements like these:

• Who started this trouble?
• She's the common factor in all these problems.
• I did Y, but only because she did X.
• If we send Jeff to communication training, everything will get better.

Sometimes, RCA thinking does lead to noticeable improvement, but too often, it ends in exasperation or exacerbation.

We can understand why if we remember that RCA makes two critical assumptions. First, it assumes that we'll find causes that have no internal structure. Second, it assumes that these "atomic" causes are independent, adjustable forces. The very term "root cause" captures these two ideas.

In human systems, both assumptions can be invalid, and often are. For instance, consider the assumption of atomic causes. A simple example: our project is late because we keep changing things; so we add resources to speed it up; but adding resources is a change; that change further delays the project.

Because these so-called "causality loops" violate the assumption that we can always find atomic causes, people have extended the method to deal with this situation. But in organizational applications, the term causality loop doesn't quite capture the complexity of the difficulty — causality web is more accurate.

In seeking organizational
improvement, changing just
a few things rarely worksWhen we encounter causality webs, process repair can entail broad organizational change — a process so daunting that we convince ourselves that changing "just a few things" will do the trick. Often, when we do make changes, the web does break temporarily — until the elements we chose not to address can restore its structure.

Assuming independent, adjustable forces also fails from time to time. For instance, in a business unit troubled by toxic, destructive conflict, an objective application of RCA might find causes such as manipulative management, oppressive schedules, or human resource policies that lead to high turnover. Since such environments rarely allow even discussion of these factors, adjusting them is often precluded.

In many cases, even though these causes are independently adjustable, the structure of organizational power can prevent their adjustment. Unable to deal with what everyone can see and nobody can acknowledge, the organization sometimes falls into "analysis paralysis."

It's useful to remember that we seek not the cause of organizational failures, but their elimination. Confusing the two objectives is a cause — if not a root cause — of the misapplication of root cause analysis.  Top    Next Issue

Are your projects always (or almost always) late and over budget? Are your project teams plagued by turnover, burnout, and high defect rates? Turn your culture around. Read 52 Tips for Leaders of Project-Oriented Organizations, filled with tips and techniques for organizational leaders. Order Now!

Your comments are welcome

About Point Lookout

Thank you for reading this article. I hope you enjoyed it and found it useful, and that you'll consider recommending it to a friend.

This article in its entirety was written by a human being. No machine intelligence was involved in any way.

Point Lookout is a free weekly email newsletter. Browse the archive of past issues. Subscribe for free.

Support Point Lookout by joining the Friends of Point Lookout, as an individual or as an organization.

Do you face a complex interpersonal situation? Send it in, anonymously if you like, and I'll give you my two cents.

Related articles

More articles on Personal, Team, and Organizational Effectiveness:

Critical Thinking and Midnight Pizza

When we notice patterns or coincidences, we draw conclusions about things we can't or didn't directly observe. Sometimes the conclusions are right, and sometimes not. When they're not, organizations, careers, and people can suffer. To be right more often, we must master critical thinking.

FedEx, Flocks, and Frames of Reference

Your point of view — or reference frame — affects what you see, and how you experience the world around you. By choosing a reference frame consciously, you can see things differently, and open a universe of new choices.

In the Groove

Under stress, we sometimes make choices that we later regret. And we wonder, "Will I ever learn?" Fortunately, the problem usually isn't a failure to learn. Changing just takes practice.

Annoyance to Asset

Unsolicited contributions to the work of one element of a large organization, by people from another, are often annoying to the recipients. Sometimes the contributors then feel rebuffed, insulted, or frustrated. Toxic conflict can follow. We probably can't halt the flow of contributions, but we can convert it from a liability to a valuable asset.

Virtual Interviews: II

The pandemic has made face-to-face job interviews less important. And so we must now also master virtual interviews, and that requires understanding the effects of the attendance list, video presence, and the technologies of staging, lighting, and makeup.

See also Personal, Team, and Organizational Effectiveness and Critical Thinking at Work for more related articles.

Forthcoming issues of Point Lookout

Coming May 1: Antipatterns for Time-Constrained Communication: 2

Recognizing just a few patterns that can lead to miscommunication can reduce the incidence of miscommunications. Here's Part 2 of a collection of antipatterns that arise in communication under time pressure, emphasizing those that depend on content. Available here and by RSS on May 1.

And on May 8: Antipatterns for Time-Constrained Communication: 3

Recognizing just a few patterns that can lead to miscommunication can reduce the incidence of problems. Here is Part 3 of a collection of antipatterns that arise in technical communication under time pressure, emphasizing past experiences of participants. Available here and by RSS on May 8.

Coaching services

I offer email and telephone coaching at both corporate and individual rates. Contact Rick for details at rbrendPtoGuFOkTSMQOzxner@ChacEgGqaylUnkmwIkkwoCanyon.com or (650) 787-6475, or toll-free in the continental US at (866) 378-5470.

Get the ebook!

Past issues of Point Lookout are available in six ebooks:

• Get 2001-2 in Geese Don't Land on Twigs (PDF, )
• Get 2003-4 in Why Dogs Wag (PDF, )
• Get 2005-6 in Loopy Things We Do (PDF, )
• Get 2007-8 in Things We Believe That Maybe Aren't So True (PDF, )
• Get 2009-10 in The Questions Not Asked (PDF, )
• Get all of the first twelve years (2001-2012) in The Collected Issues of Point Lookout (PDF, )

Are you a writer, editor or publisher on deadline? Are you looking for an article that will get people talking and get compliments flying your way? You can have 500-1000 words in your inbox in one hour. License any article from this Web site. More info