There is NO Root Cause
No Root Cause
Have you heard someone say there is no such thing as a root cause? Usually, this “no root cause” statement leads to the explanation that there are either multiple root causes for most major accidents (thus, no ONE root cause) or that it is impossible to define a “root” cause (there is no such thing as a “root” cause). Also, some say that systems are so complex that there is no such thing as a root cause (more about that concept HERE).
If you need examples of the “No Root Cause” thinking, here are several links to articles…
- The Root Cause Fallacy
- Each necessary, but only jointly sufficient
- No such thing as a root cause
- No, seriously. Root Cause is a Fallacy.
How Does TapRooT® Handle This “No Root Cause” Dilemma?
First, TapRooT® defines A root cause as:
The absence of a best practice
or the failure to apply knowledge
that would have prevented the problem.
The complete history of our definition of a root cause can be seen at this link:
But the definition of a root cause is just the start. In our classes, we explain that there isn’t one root cause of an accident. Instead, in the TapRooT® System, we look for root causes of Causal Factors. And that there may be multiple Causal Factors for any incident.
What is a Causal Factor?
Our definition of a Causal Factor is:
A mistake, error, or failure that directly leads to
(or causes) an Incident (the circle on the SnapCharT®) or
fails to mitigate the consequences of the original error.
To see more about Causal Factors, visit this link:
But How Do You Find the Root Causes of a Causal Factor?
First, please note that we say there can be multiple root causes for each Causal Factor. We have already said that there are usually multiple Causal Factors for an incident. Thus, there are usually multiple root causes to be identified in any incident investigation.
But how do you find these multiple root causes and how do you know you have reached the “root cause” level?
EASY! You use the TapRooT® Root Cause Tree®!
An outline of how the tree can be used to find the root causes of human errors can be viewed at this link:
You know you have found a root cause when you reach the root cause level in a Basic Cause Category. An example is the “lights NI” (NI stands for Needs Improvement) as shown in the Human Engineering Basic Cause Category shown below.
Finding Root Causes IS NOT the End of the Investigation
In the TapRooT® Major Investigation Process (shown below), finding root causes is NOT the end of the investigation. You see below that the next step is finding Generic Causes.
A root cause is a specific cause of a particular Causal Factor. After finding a root cause you (the investigator) may wonder:
What allowed that root cause to exist?
We call that level of searching for a reason for the root cause a “Generic Cause Analysis.” What is a Generic Cause?
The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates
whole classes of specific root causes.
Or, you might say that a Generic Cause is the root cause of the specific root cause of that Causal Factor.
Let’s look at an example of a Generic Cause to make the concept clearer.
If you found the root cause “labels NI” for a Causal Factor, you would like to know if labeling is a generic (widespread) issue. This is suggested in the Corrective Action Helper® Guide (the second from the top book in the stack of books pictured below) under the section on Ideas for Generic Problems where the guide says:
1. If you think that labeling is a generic problem …
and suggests several ideas to solve the generic problem.
Therefore, you would check to see if other detectors, pipes, valves, tanks, and equipment are properly labeled. You find that many items have no labels at all. Also, the few that are labeled don’t meet the guidelines of the questions in the Root Cause Tree® Dictionary (the book on the top of the stack in the picture above – to order the books above, click on the picture).
What would happen if you just fixed the one label on the one detector and didn’t correct the other unlabeled components? You would prevent an identical incident but you would not fix all of the other potential problems with labeling.
Also, you would not fix the system problem that allowed these labeling issues to exist. Therefore, future equipment, valves, detectors, and pipes might be installed with no or confusing labels. You would be allowing a broad problem to continue without corrective action.
In simple investigations, we suggest saving effort by not looking for or fixing Generic Causes. But when performing investigations of moderate to serious risk incidents (major investigations), we include Generic Cause Analysis as part of the 7-Step TapRooT® Major Investigation Process and recommend fixing Generic Causes.
Thus, for each root cause identified using the Root Cause Tree® Diagram, we recommend:
- Review the “Ideas for Generic Problems” section of the Corrective Action Helper® Guide for the root causes you have identified.
- Ask: “Does the same problem exist in more places?”
Thus for the labels NI root cause, you reviewed the Corrective Action Helper® Guide and found that there are many examples of no or poor labeling at your plant (steps one and two above). Next, you would ask:
3. Ask: “What in the system is causing
this Generic Cause to exist?”
You are looking for systemic weaknesses – lack of policy, programmatic failures, or generic management system weaknesses – that need to be identified and fixed.
In this example, you would find that the company has no guidance for labeling detectors, valves, pipes, or equipment. Thus, without guidance, no or poor labeling has become your company’s standard. We have found a Generic Cause.
What do you do when you find a Generic Cause? That’s part of the next step in the 7-step process. Step 6 is developing fixes (Corrective Actions) using the Corrective Action Helper® Guide, SMARTER, and Safeguard Analysis. You move on to develop fixes once all the root causes have been analyzed to see if they have Generic Causes.
What if you don’t identify other examples of this kind of problem? In our example, what if all the other equipment that was checked was labeled properly and there is a good system for making sure that new equipment is properly labeled? Then there is no Generic Cause and you can fix the “one-off” problem that you identified in this incident and that will be the end of your corrective action for this root cause.
(A note for nuclear industry personnel: The second step in Generic Cause Analysis is the same as analyzing “Extent of Cause” in a regulatory-driven investigation. In an “Extent of Cause” Analysis, the investigator looks to see where else the same cause may exist. The second step is:
2. Ask: Does the same problem exist in more places?
Thus, Generic Cause Analysis helps nuclear industry personnel perform effective Extent of Cause Analysis.)
From “No Root Cause” to a Complete Understanding of a Root Causes and Generic Causes
Now that you understand how to go beyond “no root cause” and can clearly understand how the TapRooT® Root Cause Analysis System solves problems that cause difficulties in other systems (like 5-Whys and Cause-and-Effect) by
- Ensuring that investigators find all the root causes
- Providing detailed guidance about what is a root cause
- Going beyond root causes to find Generic Causes
You may want to learn more about the TapRooT® Root Cause Analysis System.
Learn More About TapRooT® Root Cause Analysis
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