Root cause analysis has become a buzzword in organizations for trying to get to “the root” of the problem. The principles for performing an effective analysis and finding effective solutions are consistent with the scientific method. They are also the same principles that were in the quality movement of the ‘80s, the reengineered business processes of the ‘90s and the recent push to a six-sigma reliability approach. The cause and effect principle is a consistent element throughout all of these “movements.” Avoiding the program of the month schemes and establishing a principle-based, systems approach to improving business is a sound plan. An easy experiment to demonstrate this systems approach is to ask a group of people “What is the single most important part of a car?” Their responses will vary from the fuel tank, to the steering wheel, to the engine, to the battery. In reality the question, “Which part of the car is the most important?” is a poor one. It takes all parts of a car, functioning together to be a car. Since a car is a system there is no single most important part. Interestingly, ask anyone within an organization which department is the most important and they will typically respond by stating the one in which they work. “If it weren’t for the things that get done in my department, none of that other stuff would matter.” Because an organization is also a system everyone within an organization is able to say this. All parts of an organization must work together for the organization to be effective – to meet its goals. This cooperative systems view is not always our first choice within an organization. Many departments point to other departments as the “cause” of their problems. Businesses strive to meet their goals by preventing problems from occurring, but how they approach problem solving varies widely. Effective problem solving requires a systems approach that focuses the organization on prevention. Another example of this lack of system thinking is how organizations view problems and solutions. There is a significant difference between the questions “What’s the right answer to 2 + 4?” and “What’s the right way to improve the reliability of this system?” The first question has a convention that dictates a right answer equal to 6. The second question is a systems issue that has no single right answer. There are many causes that would need to be considered to arrive at effective solutions to the second question. Most of our grade school courses consisted of learning the right answers, from state capitals to memorizing multiplication tables. We developed a bias toward this right-answer approach. However, that is not the “real world.” We don’t provide our managers with a solution circled at the bottom of our homework. We live and work in a world of primarily systems issues with trade-offs, budgetary constraints, scheduling issues, deadlines, resource limitations, etc. Many people and organizations approach systems issues with a right-answer frame of mind. When people get together to solve a systems issue and they’re each thinking right-answer it can quickly lead to miscommunication, defensiveness and wasted energy.
This right-answer approach is also referred to as linear (or binary) thinking. Linear thinking creates a search for the right answer. This linear approach affects how we analyze problems at work. The conventional explanation of the cause and effect principle is “For every effect there is a cause.” A more accurate definition of the cause and effect principle is “For every effect there are causes.” This seemingly subtle modification of making causes plural is significant. In reality there are causes to every effect. Ask a group of people “What was the root cause of the Titanic sinking and they will respond, “hitting the iceberg.” Ask the group what the root cause was of the Space Shuttle Challenger disaster and they will say “the o-ring failure.” This is a right-answer response to a systems issue. This is an example of why using the term root cause within an organization can be such a disservice. The “root cause” search perpetuates and reinforces this right-answer approach. It steers the group toward that magical one thing that caused the problem. In reality the root of any tree or weed or plant is a system. Identifying the root of a problem is the process of revealing the system of causes.
Recognizing that there are causes significantly improves our communication when analyzing a problem. The “5 Whys?” approach is a good start to understanding that there are causes but it needs to go further. The conventional “5 Whys?” tends to create linear analyses with the supposed root cause at the end of the fifth “Why?” Any four-your-year old child will be glad to demonstrate their capacity to ask “Why?” questions. Every time we ask “Why?” of a cause it’s turned into an effect which allows another “Why?” question to be asked. This simple exercise tells us every effect is also a cause and every cause is also an effect. John Stuart Mill was one of the first to recognize this phenomenon in the 19th century (Williams). We can now ask as many “Whys” as we need to on an issue. The goals of the organization always dictate how extensive an analysis should be. Most organizations stop their analyses too early, at one of the following – human error, equipment failure, procedure not followed or training less than adequate. It is true that these four things occur in organizations, but they are general causes. There is no specific action that can be taken from a general cause. We need specific causes by asking specific “Why?” questions. The systems approach to investigating and solving problems is fundamental for better communication because it is based on an accurate application of the cause and effect principle.