May 20, 2009 | Mark Paradies

Senate Says Military Must Perform Root Cause Analysis of Serious Cost Overruns in Acquisition Programs

According to a story in Army Times, Defense officials will be charged with performing a root cause analysis of major cost overruns in military acquisition programs. Here’s the parts of the story dealing with root cause analysis:

“Under the conferees’ proposal, the department would be required to ‘perform a root cause analysis’ on each breaching program.”

“Further, the House-Senate bill, if approved and signed by the president, would require the secretary to designate one defense official in charge of conducting program-specific performance studies and ‘root cause analyses.’”

“The summary says this official would be ‘responsible for issuing guidance related to performance assessment for acquisition programs and for analyzing the root causes of poor performance, including reviews conducted after Nunn-McCurdy breaches.’”


We all know that some forms of root cause analysis are no more than a witch-hunt looking for someone (usually down the chain of command) to blame. This has been true in many military accidents. If you were at last year’s Summit, you heard the first hand account (from Lt. Col. (Ret.) Ralph Hayles) of a Army cover-up during an investigation into a friendly-fire accident. Or you can read the book Silent Knights by Alan Diehl to find out how facts are covered up to keep system problems causing military aviation accidents from being exposed (and fixed). Or you can look into the botched 1989 Navy investigation of the explosion of a gun turret on the USS Iowa (that killed 47 sailors). Or more recent investigations that have been discussed here:



Air Force

[You might look at the list and assume that the Navy has the worst root cause analysis. I think the preponderance of posts about the Navy is because I’m a Nuclear Navy veteran and I watch press stories about the Navy more closely and post more about them.]

But let’s assume that the military can get beyond the blame game (the Military Healthcare System has gone beyond blame and adopted TapRooT® to make significant patient safety improvements). The next fault in many root cause analyses is using root cause analysis system that is too simple. Examples? 5-Whys, Fishbones, Cause-and-Effect, and Fault Trees. See some reasons why they are too simple here:

So what should this new military directorate do? What system is robust enough to handle potentially politically sensitive cost overrun investigations? As a reader of this blog, I hope you already know the answer.

I hope to see everyone that will be performing these military procurement root cause analyses at a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.

TapRooT® has already been proven effective in many industries for a wide variety of types of problem solving/root cause analysis. I can still remember talking to the former Commanding Officer of the USS Greeneville,Scott Waddle, after he attended 2-Day TapRooT® Course. [You may remember that Scott was blamed for the collision of the USS Greeneville with the fishing vessel Ehime Maru (nine crew members of the Ehime Maru died). He also spoke about the collision at the TapRooT® Summit in 2005.] What was his comment about using TapRooT® to investigate military accidents? He was amazed. He started to see the system causes that were involved in the collision of the USS Greeneville and the Ehime Maru. He could see that the blame that was placed on him and the guilt that he felt after the accident were insufficient to improve the system that caused these types of accidents. He was amazed that such powerful technology – TapRooT® – wasn’t already being applied by the military to stop accidents and save lives.

Unfortunately, the military has not changed much since 2005. The blame culture still exists. Cover-ups still happen. Lives are still being lost needlessly. But if the military adopted real, advanced root cause analysis – major improvements are possible. Especially with the support of Congress. Maybe real positive change in the defense procurement system – change based on advanced root cause analysis … TapRooT® – could actually occur. Change that saves taxpayers money … potentially saves troops lives … and increases our defense stature. That could be another real success story about the effective application of TapRooT®.

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