Root Cause Analysis – or Root Cause Paralysis?
Working across a wide spectrum of the aviation industry, we see trends that perhaps others don’t, and something interesting has happened over the last 12 months. We’ve noticed a significant upsurge in conversations about Root Cause Analysis, including;
- ‘inadequate root cause’ leading to corrective action proposals being rejected by Regulators
- specific requests for specialist training
- senior managers and executives demanding ‘the root cause!’
Increasingly becoming a buzzword in recent times, Root Cause Analysis is entering our common language and being used in daily conversations. A challenge perhaps is that this is resulting in inaccurate application of the words; albeit unconsciously. We have seen this phenomenon with other words such as ‘risk’ and ‘culture’ in recent times too. The intent of getting to the bottom of problems is faultless, perhaps it is more the expectation that the establishment of root cause is a ‘silver bullet’ in problem solving rather than recognising that it is really only a vehicle for identification of where contributing factors originate from that is at fault.
One of the key causes of the increased focus on root cause appears to be stemming from a more rigorous and focussed approach from National Aviation Authorities. As we move towards a performance based environment the gradual shift from direction and guidance by the Regulators to ownership by the Regulated means there is a growing emphasis on accountability – and holding to account. Organisations are clearly being challenged more robustly; to take charge and address any audit findings. The logical start point being the proposed action plan and we are seeing these plans being rejected as they ‘do not identify or address the root cause’. Sticking plasters over the symptoms are no longer being accepted it would seem.
The knock-on effect of this is that Quality or Compliance Monitoring teams are the ones coming under pressure to identify a more appropriate answer. They are the ones seeking the support or training courses – but should they be? Ownership of non-compliance is clear no matter the regulation you look at. The intent is that compliance owners who are responsible for the relevant part of the operation should own the issue, find out why it happened and be satisfied that any resolution is effective; preventing it happening again. Ambiguity in this compliance ownership and the understanding of the intent behind it seems to be making the ‘root cause’ challenge harder to deal with.
To be clear, Root Cause Analysis in its simplest form is working out why something happened when it shouldn’t have, or didn’t happen when it should’ve done – it doesn’t in itself fix the problem. I fear that sometimes we lose sight of this! There are a number of tools designed to support the analysis, from simple ‘5 whys’ questioning through to more structured Fishbone or Ishikawa diagrams, Pareto graphs or 8 Disciplines (8D). The important thing is that they all have their time and place – it depends on the presenting problem and the level of complexity. Some organisations with more mature and well-documented management systems have clearly defined processes and procedures for determining the root cause, others are less mature or poorly captured. That said, even those with well-founded tools and instructions aren’t necessarily following them – are we back to ownership and understanding again perhaps?
We are also seeing Executive and Senior Management demands to ‘get to the root cause!’ as if there is always a simple, linear explanation for events. Unfortunately, this oversimplification is having knock on consequences – the learning opportunities are being stymied when complex events do happen because the support and resource to unpick the messy and complicated systems that have been built is not made available. As humans, we want a quick answer that is easy to address by taking minimal action, ideally at little cost. If we don’t like the answer we blame the tool or the process, or worse still, the people involved. During our many engagements across the world we talk about multiple causal and contributory factors rather than ‘The Root Cause’ – we dispel the myth of the singular, and talk about the many, the interconnected.
Overall, it feels that as an industry we are looking at Root Cause Analysis as both the problem and solution. Has the focus on Root Cause Analysis as an end in itself caused us to lose sight of the root causes that need to be addressed; and by who? Is there paralysis caused by our focus on Root Cause Analysis?