Failure of Root Cause Analysis

U

Umang Vidyarthi

#1
I wish to start this thread with a view to having eloberate discussion over the three layers-physical,human and latent-of RCA;and how to overcome the 'Failure' of RCA at any perticular level.There are plenty of RCA tools in vogue,but I haven't yet come accross a fool proof one.

Any takers?

Umang :cfingers:
 
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Jim Wynne

Staff member
Admin
#2
I wish to start this thread with a view to having eloberate discussion over the three layers-physical,human and latent-of RCA;and how to overcome the 'Failure' of RCA at any perticular level.There are plenty of RCA tools in vogue,but I haven't yet come accross a fool proof one.

Any takers?

Umang :cfingers:
In general, the quality of RCA is directly proportionate to management's sincerity in wanting to see problems solved. RCA in general doesn't fail because people aren't smart enough to know how to solve problems; it fails because management encourages--either implicitly or explicitly--the path of least resistance to be taken.
 

Randy

Super Moderator
#3
In general, the quality of RCA is directly proportionate to management's sincerity in wanting to see problems solved. RCA in general doesn't fail because people aren't smart enough to know how to solve problems; it fails because management encourages--either implicitly or explicitly--the path of least resistance to be taken.

And there it is:applause:

Add on "Fear of the truth"
 

CarolX

Super Moderator
Super Moderator
#4
In general, the quality of RCA is directly proportionate to management's sincerity in wanting to see problems solved. RCA in general doesn't fail because people aren't smart enough to know how to solve problems; it fails because management encourages--either implicitly or explicitly--the path of least resistance to be taken.
Jim,

You are so very correct here. And this statement applies to any system within a business. If management encourages a process, it is completed to the best extent possible with the available resources. Without that support - any system is doomed to failure.
 
U

Umang Vidyarthi

#5
In general, the quality of RCA is directly proportionate to management's sincerity in wanting to see problems solved. RCA in general doesn't fail because people aren't smart enough to know how to solve problems; it fails because management encourages--either implicitly or explicitly--the path of least resistance to be taken.
And here enters 'Human Error' (in the form of management).Should the system be left at the mercy of management?Why can we not devise an 'Error free' system,by systemic & systematic approach,by plugging all the loop holes,flying over the path of least resistance and stalling the blame game.This is what I'm lokking for,if someone has developed 'near error free' seystem and would be kind enough to share on the cove.(The system is also required to cover all the three levels of RCA).

Thanks & Regards

Umang :thanks:
 

Steve Prevette

Deming Disciple
Staff member
Super Moderator
#6
What I've seen for problems in Root Cause Analysis basically boil down to what are you doing a Root Cause Analysis on? Here in the Department of Energy, I've seen most folks focus upon individual events, individual symptoms and do a "root cause analysis" on them. Because they are not looking at the system that created the individual event or symptom, the RCA is doomed to failure because it is looking at too micro of a level.

Another issue with RCA's that I've seen is that people doing them don't segragate the issue they are looking at into stable and non-stable systems. So often a "trend" is declared on 2 or 3 events and an RCA is done, without recognizing that the so called trend is the result of a stable system, and again, that implied the whole system should be looked at. Now, if there is a statistically significant trend on a control chart, then an RCA of that trend should provide benefit.

I suppose it all comes down to most RCA's are a dissection of an issue, rather than an integration as part of a larger system. To illustrate this (and borrowing from Russ Ackoff), this is like doing a root cause analysis of hand pain by chopping off your hand, laying it on a table, and trying to determine the source of the pain. As an aside - how many people dissected a frog in science class, and then learned how to put it back together again?
 
D

DsqrdDGD909

#7
I think the NTSB has a very good approach to fact finding, but IMHO seldom does systems wide analyses.

I would think that some of the things done in health care quality would be of interest in this discussion.
 
Last edited by a moderator:

BradM

Staff member
Admin
#8
I used to think that NASA had very good RCA, but the Challenger and Columbia disasters dissuaded me from that POV.
Really? Personally, I thought they did a really good job of getting to the root of the problem. Especially having bits and pieces to work with, and determining what the problem was.

Too, when they interview people, this is a close knit group. But these same people are the ones having to be involved with the investigation. It would be easy to sit, finger point, and never get to the problem.

But... certainly great minds could differ on that.:agree1:
 

Steve Prevette

Deming Disciple
Staff member
Super Moderator
#10
Really? Personally, I thought they did a really good job of getting to the root of the problem. Especially having bits and pieces to work with, and determining what the problem was.

Too, when they interview people, this is a close knit group. But these same people are the ones having to be involved with the investigation. It would be easy to sit, finger point, and never get to the problem.

But... certainly great minds could differ on that.:agree1:
I think an issue with NASA is they do very good RCA after the fact. Their ability to soul-search prior to an event and have a questioning attitude appears to be a weakness. It's darn easy to do RCA and justify what happened after an event (read Nassim Taleb's "Black Swan"). Doing an RCA on the system that led up to the accidents PRIOR TO the accident is another thing.
 
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