“No such thing as a root cause… it’s a human performance problem!”
No Root Cause
Uh oh . . . it’s back again. I was on a call with a client recently and the client said that a consultant told their company’s management team:
“There really isn’t any such thing as a root cause.”
The consultant said human errors are just random human performance problems. If you just think really hard about the error, you’ll be able to fix it. Human performance problems are just too variable to have anything systematic like a root cause.
The leadership team raised their eyebrows in surprise, which was probably the consultant’s intent.
This introduction of Newspeak (a term from George Orwell’s book 1984) to eliminate the term “root cause” seems to come and go in cycles. I remember hearing this 10 or 12 years ago. It was a fad and then seemed to go away. Consultants use the new words to set themselves apart from other performance improvement tools. They say outlandish things to grab management’s attention. Things like human error is just a part of normal variation and should be encouraged and learned from – especially errors that could be an improvement. Eventually, the fallacy of the concept allows it to die out (hopefully without causing too much damage).
Apparently, this fad of accepting human error is back again. When experienced performance improvement experts hear this, they need to be prepared to refute the drivel and show how real performance improvement tools can be used to find and fix the root causes of incidents, quality problems, and equipment failures.
Why is the “Random Human Performance” Concept so Appealing?
There are a several reasons that smart people become convinced that random human human errors need a new approach other than root cause analysis…
- It removes the burden of responsibility for doing something about it. If there are no root causes, then problems occur for random reasons or because “humans are just fallible.” Leadership teams can just fall back on the fallacy that, since humans just make mistakes, incidents that occur are “not our fault.”
- We agree that humans make mistakes, but it is NOT correct that there are no root causes as to why humans make mistakes. There are proven, human factors reasearched reasons why a person makes an error. Finding these root causes allows your company to apply effective corrective actions aimed at fixing the problem. You can feel confident you’ve eliminated future repeat incidents
- It’s easy to identify and focus on the mistakes themselves. When a human makes a mistake, we can just point our finger at the human, accept that they’re just going to screw stuff up, and then think really hard about how we can make the system fail gracefully.
- Again, there is nothing wrong with putting safeguards in place to strengthen our defenses against human errors or make systems more resilient or failures less damaging. For example, removing a Hazard is a great idea (and part of Safeguard Analysis – a TapRooT® RCA technique). However, that is not the same thing as trying to avoid errors in the first place. By using advanced root cause analysis and understanding the reasons people make mistakes, we can avoid those mistakes, not just catch the mistakes after they happen.
- Just getting smart people together in a room to think really hard about the problem is easier than performing a root cause analyses. Your smart employees might come up with adequate fixes by “thinking really hard.”
- Yes, you probably do have smart employees. But is “thinking really hard” really easier than advanced root cause analysis? How many of your employees are experts on human performance? Control panel design? The color to make an alarm light? What should an alarm sound like? Do your smart employees have that kind of human factors training? Even if your employees are really smart, they need guidance to find and fix human performance problems. Advanced root cause analysis guides your investigation teams to look for human factors (and other) types of issues. What happens without this guidance? Most likely, they will revert to the same old fixes they have used before: training, warnings (or discipline), and longer procedures.
The consultant will explain how they have done great things without root cause analyses. But what happens when the consultant goes away. Who provides your investigation teams with guidance? You’ll have to bring the consultant back for additional consulting support to keep the process working!
Get the Smart People Together But Instead, Do This…
There are benefits to having smart people in a room during an investigation. System experts can explain how the process works. They can describe how the job was designed to be performed. They clarify questions about the process. That’s a standard part of any successful evidence collection process.
Also, it’s good to have smart people help write effective corrective actions. Involving the stakeholders up front can get buy-in for the implementation of corrective actions.
What these consultant-proposed philosophies are NOT good at is understanding why people make mistakes. That is where advanced (but easy-to-use) human-factors-based root cause analysis can help you prevent the recurrence of problems. Skipping root cause analysis in your investigation results in ineffective fixes and people making the same mistakes over and over again. And if no one was seriously hurt this time … they might not be so lucky next time. Repeat incidents can result in fatalities, failed equipment, or a polluted environment.
“There is no such thing as a root cause” is more than just a silly concept. It puts your business at risk.
Also, it doesn’t have to be hard to find root causes! The 5-Step TapRooT® Investigation Process (shown above) and the essential TapRooT® RCA techniques takes just two days to learn.