Monday, June 18, 2012

Democratic Root Cause Analysis?

So we had primary elections last week and it reminded me of an RCA process that a client just shared with me. I call it Democratic RCA among a few other things.  Let me describe it for you. The first step was to draw a "cause and effect" or fish bone diagram for the problem. Then they get a group together and add causes to each category. So far so good. This is a great way to get the team going, encourage participation and and cleans the palette, if you will, before you dive into the more advanced RCA tools. This is where things went awry. Once they finished the cause list for each branch or bone of the cause and effect diagram they then voted for the most likely causes and those became the root causes for their analysis. While democracy and the power of the vote works in government it has no place in root cause investigations. RCA is about facts not conjuncture. It is not about opinion unless you can show the data to back it up. This root cause popularity contest will lead to limited if any out of the box thinking and will be steered by the most convincing group member or members. Causes will become a reinvention of something that has occurred in the past and is comfortable to the team. This is not root cause analysis.
If the team wanted to use their fish bone they could have skipped the vote and divided the group up into sub teams that could attack each branch of the fish bone. The sub team could go out and look for evidence on each of the possible causes and then they could choose one of the other RCA tools like fault tree to perform a more in-depth analysis. Now the analysis would be based on the facts that the sub team brought back from the field not a voting process for the teams favorite solution. In the end, this data based process will allow for more open-minded solution development and better fact based results for the effort of the team.


  1. Jumping to a solution is a common problem given the pressure to get the line running, continue shipping, get to market, etc. Experienced engineerings should know the product and process solutions, yet the inclination to skip RCA is often fraught with problems. I agree, democratic RCA is not useful most of the time.

    1. I firmly believe that an effective RCA should contain only provable facts , conjecture, emotion,jumping to conclusions ,past experiences can all be misleading . Operators and mechanics should be involved in the RCA and all participants have an equal voice , it is very important to get the right people around the table . A facilitator from outside the company should be involved to ask pertient embarrassing questions and to be the devils advocate.
      Rarely is there a single root cause to the problem .