Inhumane Root Cause Analysis – Can We Make Root Cause Analysis Humane?
Inhumane Root Cause Analysis
I recently read a blog post by Casey Rosenthal about root cause analysis in the software industry. It started out with this paragraph:
Root Cause Analysis (RCA), a common practice throughout the software industry, does not provide any value in preventing future incidents in complex software systems. Instead, it reinforces hierarchical structures that confer blame, and this inhibits learning, creativity, and psychological safety. In short, RCA is an inhumane practice.
I can only guess what kind of root cause analysis they were using. Perhaps 5-Whys or some other cause-and-effect based system where the analyst can stop at a human error and the automatic corrective action is to place blame and discipline (or humiliate) those who were working when the incident occurred. Or perhaps, for a software problem, they punish those who touched the program last?
Maybe this is what he has experienced…
Reminds me of the article: 5 Whys and Who Do We Fire?
Does Root Cause Analysis Require Blame?
If you read this blog, you know I often write about blame. Or should I say I rail against blame and inhumane root cause analysis? Read any of these articles:
- Trapped in the Blame Vision (2017)
- Is Blame Built Into Your Root Cause System? (2018)
- Why Does Blame Make Sense? (2018)
- Is Blame the Best Root Cause Tool? (2019)
- Will Blame Improve Safety? (2009)
- Finger Pointing, Blame, and Firing … The Standard Corrective Action for the US Navy (2008)
- Navy Root Cause Analysis Focused on Blame Vision, Crisis Vision, or Opportunity to Improve Vision? (2016)
- Blame Game Is Serious Business for Navy Commanding Officers (2019)
- BP VP Blames 6 Workers for Not Following Procedures as Cause of Blast (2007)
- Stop the Management Blame Game (2008)
- Using TapRooT® to Improve Investigations by Focusing on Fixable Causes Rather Than Blame (2011)
- Finding Root Causes Without Blame (2011)
- The Blame Culture Hurts Hospital Root Cause Analysis (2016)
That’s not all the articles about blame from this blog, but it gets the point across (and it is more than you will read).
Let me make a statement…
Blame and root cause analysis don’t go together!
Not All Root Cause Analysis is Blame Oriented
But, as I point out in almost all of the articles above, the problem Casey is discussing may not be the fault of “root cause analysis” but rather is the fault of the system they are using and the leadership vision.
In our book:
we describe three leadership visions:
- Crisis Management
If you have leadership with the blame or crisis management visions, they probably have picked a blame-oriented root cause analysis tool. This tool reinforces their vision. It becomes a vicious cycle of fault-finding, blame, cover-up, and failure.
Start Changing the Vision and Improve RCA
We designed the TapRooT® System to stop this vicious cycle (downward spiral). Of course, getting management to change their vision to the “Improvement Vision” is difficult. But at least you have a start when you aren’t using a tool that reinforces the Blame Vision.
Perhaps you should leave a copy of the book, TapRooT® Root Cause Analysis Leadership Lessons, on your manager’s desk (anonymously of course – make sure there aren’t any security cameras).
Maybe Casey will discover TapRooT® Root Cause Analysis (a humane root cause analysis system that has resilience engineering built-in) and the fundamentals of good root cause analysis. That could help them solve their complex software issues by applying a different kind of root cause analysis. Root cause analysis not focussed on blame.
Learn More About No-Blame Root Cause Analysis
When and where can you learn more about root cause analysis that finds fixable causes and doesn’t place blame? At one of the many TapRooT® Root Cause Analysis Courses being held around the world. See the course dates and locations at this link: