7 Secrets of Root Cause Analysis

Posted by
Mark Paradies
Whos keeping the Secrets?

In over 25 years of human factors and root cause analysis study, Ive learned a few things that everyone should
know. I dont keep these root cause best practices a secret, but you would think that I did. Why? Because I find so
many experts and lay people alike that dont understand what I see as obvious. So I thought, Why not share the
seven most important secrets here?
7 Secrets
Heres the list of the 7 Secrets (Ill explain them in more detail in this, and upcoming, newsletters):
1. Your root cause analysis is only as good as the info you collect.
2. Your knowledge (or lack of it) can get in the way of a good root cause analysis.
3. You have to understand what happened before you can understand why it happened.
4. Interviews are NOT about asking questions.
5. You cant solve all human performance problems with discipline, training, and procedures.
6. Often, people cant see effective corrective actions even if they can find the root causes.
7. All investigations do NOT need to be created equal (but some investigation steps cant be skipped).
Garbage In = Garbage Out

Most root cause systems operate as a stand-alone module. Information goes in and an answer comes out. They
dont help investigators collect accurate info.
To make matters worse, some root cause tools actually start by developing a hypothesis and then collecting
information to verify (or perhaps disprove) the hypothesis. Extensive research has proven that once an investigator
becomes invested in a particular hypothesis, his/her brain automatically starts looking for facts to confirm the
hypothesis and disregards facts that are counter to the hypothesis. The result? You find what you want to find.
This is not a robust root cause analysis process.
Investigation Tied To RCA

7-Step Process
Step 1: Planning

The investigator starts using this tool to organize the investigation and decide what evidence needs to be gathered
and assigns a priority to securing evidence that might be lost.
First Secret
Thats the first secret. Get accurate, complete, necessary information to understand the incident. If you try to
analyze assumptions, you will be guessing at the root causes and fixing your guesses. That would be a bad
practice.
Secret 2

your knowledge (or lack of it) can get in the way of a good root cause analysis.
What? You think this is obvious? Thats OK. Many dont recognize how this secret interferes with root cause
analysis.
Lets start with a popular root cause myth: Cause & Effect. Many think they can use the theory of cause & effect to
find root causes. They assume that an experienced investigator who has seen a cause produce an effect can use that
knowledge to diagnose future problems by using his/her experience to deduce the complex causal links (cause &
effect chain) of an accident. This theory is the basis for many root cause analysis tools like 5-Whys, Cause-and-Effect
Analysis, and FMEA.
An obvious problem with this theory is that inexperienced investigators dont know many cause & effect
relationships. They cant find what they dont know.
But many dont understand that even experienced investigators may be led astray by the assumptions behind cause
& effect analysis. How? Read on
Investigator Trap
Experienced investigators are often trapped by the same cause & effect assumption that traps amateurs. How? First,
even the most experienced investigators dont know all the cause & effect relationships that cause accidents. This is
especially true of the causes of human error. Many experts have little or no training or understanding of the
psychology behind human error.
To combat the lack of knowledge, they recommend putting together teams of investigators with the hope that
someone on the team will see the right answer. Of course, this depends on team selection to counter the inherent
weakness of the assumption behind cause & effect. Also, it assumes that the rest of the team will recognize the right
answers when another team member suggests it. Good luck!
More likely, the strongest member of the team will lead the team to arrive at the answers that he/she is
experienced with.
Favorite-Cause-Itis
Experienced investigators often fall into the favorite-cause-itis trap. They use their experience to guide the
investigation. This leads them to find cause & effect relationships that they are familiar with. Why? Because that is
what they look for. They search for familiar patterns and disregard counter evidence. (The technical name for this
phenomenon is confirmation bias.) The more experienced the investigator is the more likely he/she is to fall
into the trap.
Exposing this secret doesnt make me popular with experienced guru investigators. They dont want to admit that
they have the same weakness as inexperienced investigators when it comes to cause & effect analysis. They try to
explain that they dont have preconceived ideas about the cause of any accident. But of course, this statement flies in
the face of the basis of cause & effect analysis that experienced investigators know the cause & effect relationships
of accidents and can recognize them during an investigation.
Secret 3
You have to understand what happened before you can understand why it happened.
This secret seems obvious. Of course, you must understand what happened. But many investigators, and some root
cause tools, start by asking Why? when they should be trying to understand What happened?
Starting by asking Why is jumping to conclusions. And this can lead the investigator to find causes that they have
jumped to because they didnt first seek to understand.
Secret 4
Interviews are not about asking questions.
What? you might say Ive always been taught to ASK questions as an interviewer. What about the open ended
and close ended questions routine that is commonly taught in some root cause training? And what about asking
Why? five times? I thought I had to ask questions during an interview?
Lets start with the popular 5-Why myth.
I wont review all the problems with the 5-Why technique. Ill just mention the one that most applies to
interviewing. Consider this what happens when you ask somebody a question like:
Why did you do that?
Does the person answer with lots of information or with justification?
The Why question turns off the remembering trail that we want the brain to go down and turns on the
justification trail. After all, isnt the purpose of an interview to collect information (not justification)?
Next, lets look at the whole process of questioning during an interview. If the purpose of an interview is to collect
information, we should use a process that stimulates remembering.
Researchers Fisher and Geiselman determined that the biggest problem with police interviews was the police
interrupting the interviewees memory process with questions. It didnt matter if the questions being asked were
open ended or closed ended. Every time the interviewer interrupted the interviewee, his/her memory had to shift
gears. S/he lost her/his train of thought and didnt remember as much as s/he could. The interviewer didnt get to
important facts. (Facts were omitted when the interviewee was distracted by questions.)
Not only did interruptions for questions cause problems, but also the questions being asked didnt help stimulate
remembering. Fisher and Geiselman came up with a new interviewing process called cognitive interviewing that
helps the interviewer encourage the interviewee to remember much more and thus improve the amount of
information collected.
Another problem that was noted in Fisher and Geiselmans research was that interviewees often tried to provide
the interviewer with the most important information. They filtered what they told the interviewer. The
interviewee didnt understand that some detail that they thought was unimportant was something that the
interviewer really needed. Because the interviewer didnt know the detail, they couldnt ask about it. Therefore, the
information was lost.
Secret 5
You cant solve all human performance problems with discipline, training, and procedures.

If you look at most industrial accident/incident investigations, you find three standard corrective actions:
1. Discipline. Which starts with the common corrective action: Counsel the employee to be more careful when .
2. Training. This may be the most used (and misused) corrective action of all.
3. Procedures. If you dont have one, write one. If you already have one, make it longer.
The misuse of these three standard corrective actions is the reason that so many accident investigations dont really
cause performance to improve. They dont solve the real problems.
What do we need to get better results? First, better root cause analysis. Second, development of better corrective
actions based on the root causes of the problems. And third, corrective actions that provide the strongest safeguards
to future errors.
Secret 6
Often, people cant see effective corrective actions even if they can find the root causes.
Why? Because they have performed the work the same way for so long that they cant imagine another way to do it.
I didnt initially believe this. I thought that once someone saw the root cause of a problem, the answer would be
obvious. But students in a course finally convinced me that I was wrong.
Back in 1994, a team of students analyzed the root causes of a fairly simple incident. One of the root causes was that
the valves being operated were not labeled. So far, so good.
But here was their corrective action:
Tell operators to be more careful when operating valves without labels.
They just couldnt see that valves could be labeled. It was beyond their experience.
.Secret 7
Now for the final secret
All investigations do NOT need to be created equal
(but some investigation steps cant be skipped).
Ive seen people cringe when performing a root cause analysis of a problem is suggested. They think this means a
team of selected experts spending months locked up in a room. After all, didnt the CSB take three years and spend
almost $3 million investigating the BP Texas City explosion?
Its true that some investigations may take too long and cost too much. But that doesnt mean that every root cause
analysis needs to take too long and cost too much.
Root cause analysis should be scaled to the size of the problem and the risk of future accidents with similar causes.
Small risk = small investigation. Big risk? Then spend more time and more investigative effort dot each i & cross
each t.
The hard part of responding appropriately is projecting the risk of the problem before the investigation starts. For
example, sometimes an incident that seems quite simple can have complex causes that could, in different
circumstances, cause a big accident.
Scale an Investigation
For simple incidents, a single investigator draws a simple Snap Chart of the sequence of events and identifies one to
three easy to spot Causal Factors. They can do this working with those involved in a couple of interviews. Just one or
two hours total.
Drawing a Snap Chart is required because you have to understand what happened before you can find out why it
happened.
Next, take Causal Factors through the Root Cause Tree. (Perhaps an hour of work.) Then another hour to develop
some simple, SMARTER corrective actions and to document it with some short written sections. You are ready for
approval. (About one half days work.)
What if management says that half a day is too long? After all, couldnt you ask Why five times in about five
minutes and then suggest a corrective action?
Of course, you could. But that isnt root cause analysis. Thats just taking a guess and going with it.
Some small problems dont deserve root cause analysis. Dont waste time implementing poorly thought out
corrective actions. Just categorize the problem and repair the failure. Paper cuts cant cause fatalities.
The big accidents? Go all out. A full-blown investigation team with an independent facilitator. Snap Chart, CHAP,
Change Analysis, Equifactor, Safeguard Analysis, and the Root Cause Tree. Look for generic causes of each root
cause. Then remove the hazard or target or change the human engineering of the system. Not the normal training/
counseling simple corrective actions. Something really effective at eliminating the root causes or the hazard.
Something in between? A response in between. Dont go overboard. Just do what you need based on the size of the
problem. And if you discover that a problem is bigger than you thought, let management know and change the scope
of the investigation.
Applying the 7 Secrets
Know that you know the seven secrets, apply them in your investigations.