Why root cause analysis doesn’t always work

Political savvy and diligent follow-through back up good science and engineering work.

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By Robert J. Latino

PlantServices.com

Have you ever conducted a comprehensive, disciplined and accurate root cause analysis only to find that the recommendations fell on deaf ears, or worse, nobody followed through on the approvals that were granted? Getting to the root causes is the easy part. Getting something done to eliminate them is a different matter.

Picture this scenario. You identified a failure worthy of root cause analysis. You know the total value of the loss in terms of maintenance dollars, manpower dollars and lost profit opportunities--somewhere in the six- to seven-figure range. You strategically organize a team to address the problem, develop a charter and list the elements that constitute success. The team skillfully develops strategies, collects appropriate data and analyzes it. The team also uses a little deductive logic to validate hypotheses and determine the various physical, human and organizational root causes. You make recommendations that mitigate or eliminate identified causes. The team makes a presentation to decision-makers who authorize the implementation of the recommendations. And that is the last that anybody hears of the root cause analysis.

If this scenario is familiar, someone in your plant is committing an organizational cardinal sin. Think of the resources used in performing such a beautiful work. Think of the thought, diligence and dedication that went into the process. Think of the anticipation and expectations of the team members regarding their recommendations. Think of how they feel when nothing happens as a result of their work. If you were on the team, would you be willing to try it again?

Why does this happen?

As a teacher and a practitioner of root cause analysis, I see not only the physical motions of going through such an effort, but also the psychology behind what makes or breaks it. When you consider the effort that goes into determining root causes and developing recommendations, why should it be such a hard sell to get something done?

It is ironic that we see average returns for root cause analysis in the neighborhood of 800 to 1,000 percent, yet no one believes these figures because they are considered too "pie-in-the-sky." If management honestly believed that such returns could be realized, they should have no problem making sure recommendations were executed immediately. The problem is they do not believe it. Some of this thinking may be well founded. For instance, maybe past efforts have not produced what they promised. Therefore, why take the risk again? Others say they conduct root cause analysis on everything. This is impossible. I have not seen a company yet that can afford to perform rigorous root cause analysis on everything. One  problem is what people define as root cause analysis.

If management questions the economic feasibility of implementing the solutions, then the original failure was not worthy of root cause analysis. Rigorous root cause analysis involves getting past the physical components of failure and into specific humans actions that triggered the cause-and-effect chain that led to physical failure. It also involves determining "why they did it."

Most people value their income as a support for their lifestyle. Therefore, most people do not intentionally make bad decisions that lead to failure. In most cases, the decisions were made with good intentions but with bad information. This bad information comes from what we call latent roots, or management system roots. These are the rules and regulations in a plant--the policies, procedures and specifications that apply to training systems, stores systems and other aspects of daily operation. They are the sources of information on which people base their decisions. If the sources are flawed, so will be the decisions that spring from them.

It is a commonplace misapprehension that when we fix something tangible, the problem will vanish forever. Even worse, some still believe that witch hunting prevents failures from recurring.

Neither is true.

Management is generally satisfied when a physical root has been resolved. However, this temporarily prevents the failure from recurring. Unless the flawed decision-making process is corrected, another person will use the same flawed source to make another decision that will result in the same (or similar) failure happening again.

Figure 1. By using a Logic Tree we can use deductive logic to determine physical (PR), human (HR) and latent (LR) root causes.

Figure 2. Success has not been achieved unless there has been a demonstrated positive impact on the bottom line as a result of implemented recommendations.

Politics to the fore

People are more amenable to spending money on tangible items, such as a motor or a coupling, than on modifying a start-up procedure, changing the specifications on a seal or providing training in proper maintenance practices. The truth is that the physical roots typically cost much more that the latent roots. The hard part about dealing with latent roots is that they are soft issues that deal with human beings. Whenever you delve this deeply into root cause analysis, you can expect plant politics to become a factor. Turf protection, bonus incentive systems, retirement dates and future promotional opportunities are some of the issues we run into when trying to get management to act on latent roots. What would you do if one of the latent roots was a flawed procedure that your boss implemented? Do you cover it up and run the risk of recurrence? Or, do you strategically plan your presentation in a manner that protects and gives your boss the appearance of the open-minded hero?