January 25, 2008 | Barb Carr

Finding a Castle in a Haystack is what Good Root Cause is All About

Farmer hides castle from building inspectors behind a wall of hay bales. Now I have heard of searching for a needle in a haystack but wow, a castle? But think about it , can you find the “castle” in your root cause analysis when it is right in front of your eyes? Unfortunately, this is the problem we have when using cause and effect diagrams and 5 why’s where you fill in the questions needed to be asked. If you are not familiar with human factors engineering and human behavior in systems, you might as well be looking for a “needle”.

 Illusions Youngladyoldlady
Why are these other root cause tools ineffective you ask? WITHOUT getting technical, our own “rules-of-thumb” prevent us from seeing or recognizing anything that does not match our current understanding of the world we live in. Look at the picture above, do you see a young woman or an elderly woman? The mind prevents us from seeing one image over the other at the same time. A good root cause analysis prevents us from investigating an incident or reoccurring problem using our past understanding of limited subject matter expert experience. When I say limited, the implication is that the operator, safety officer, manager, and quality inspector only understand their part of the company processes; while good at what they do, total system influences on human performance is usually limited. A good root cause analysis should ask questions at the system level creating a new way of looking at the “castle”. This is why TapRooT® is a root cause analysis system and training that helps solve problems both reactively and proactively. Call us at 865.539.2139 if you are tired of looking for the “needle”.

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