Are You Ready to Perform a Root Cause Analysis of the Levee Failures in New Orleans?
Above is a pdf of an independent report sponsored by the Army Corps of Engineers. Very interesting reading.
Digging in to it made me want to draw a SnapCharT®, define the Causal Factors, and start through the Root Cause Tree®. The problem is that the information is so extensive and the sequence of events is so long that it would takes weeks - or maybe months - to do a good, thorough root cause analysis. Then we would be ready to analyze Generic Causes and start developing corrective actions.
I already have so much to do that I just can’t find the time to dig in, find the root causes, and answers to fix the problems. To tell the truth, I barley had time to read the report (ah - great vacation reading).
Plus, my guess is that the Management System causes (of which there seem to be many) would require the government - local and national - and even Congress to change. Sometime you shouldn’t start a root cause analysis if you aren’t ready (or able) to fix the problems you find because root cause analysis without the ability to implement corrective actions is a waste of time.