Investigation by form filling
I was working with a major national power organisation recently. They had been using the ‘5 Whys’ as their incident investigation tool and Root Cause Analysis process.
This organisation had provided no specific training for this approach to RCA and the main tool that the team had received was a ‘ 5 Whys’ form with some brief instruction. The form had a section headed ‘Problem’ and then five boxes linked by some arrows, and then a box for a solution.
On the form there was brief note that during the course of filling out this form consideration should be given people, processes, resources, hardware and environment.
When I talked to the people completing the forms they had been under the impression that they had to address the five identified areas (people, processes, resources, hardware and environment) and give one example of a cause from each thus completing the five boxes in the pro-forma. So the final outcome on the form was the problem, five boxes that had an example of a cause from each area, and a solution. However, what the form did not have, nor had it provoked, was any drilling down to understand what lay beneath the causes. Nor did the solution have any strong link to the five random causes that had been identified.
This approach seemed to me to highlight the dangers of putting the emphasis on the form being the most important part of the process in RCA.
The example above is not about people being incapable, but people not being trained to understand that the emphasis of Root Cause Analysis is on the process ofanalysis - that is the separation or breaking down of material or a situation into its constituent parts and their inter-relationships. It is only once the situation has been broken down can it then be re-synthesised - combining the separate elements of the analysis to form a coherent whole, thus giving us the final outcome, the report.
The six most common shortcomings that I find when looking at RCA reports are:
- 1. What is the problem?
The completed form does not clearly tell me what problem it is that people are trying to solve, or why they are trying to solve this problem eg what impact has this problem had on the organisation, the organisation’s goals, their customers, stakeholders and service users?
This lack of clarity in defining the problem also causes problems when it comes to solutions - if we have not been clear on what problem it is that we are trying to solve then how will we know when we have solved it?
- 2. Use of Storytelling – as opposed to analysis
That the analysis or findings or detail (it goes under many names) of the incident is little more than ‘story-telling’. This is not meant to be a perjorative term, just to highlight that the telling of the ‘story’ comes before or instead of the analysing.
If this approach is taken, the ‘story telling’ will often start at a particular point in time – ie it all started on Monday morning…How do we know it started on Monday morning? What might have been happening before Monday morning?
And importantly the ‘story telling’ does not lend itself to clearly identifying what we don’t know, ie where we have questions. In ‘story telling’ when we reach the limits of our knowledge we just tend to put a full stop and carry on, instead of highlighting our lack of knowledge with a question. Story telling kills curiosity…
- 3. Lack of Evidence
Where there is evidence applied to the findings in this sort of report, this is often again broadly done. The incident ‘analysis’ is done in a narrative form, the evidence is attached as an appendix therefore it is often not clear exactly how much of the analysis or narrative is evidenced – and what the quality of the evidence is.
- 4. Use of Categorisation.
This is a term used for a broad descriptor and these are often found in reports where the emphasis has been filling in the form rather on than on performing analysis. The most common of these categories is ‘human error’, but there are plenty of others that I see, ‘management issues’, ‘poor maintenance’, ‘lack of communication’. These categories will have different meanings to different readers ie they are very broad descriptors.
The difficulty with these as categories as causes is that when we come to apply a solution to a category, the solution will have to be equally broad as opposed to specific and therefore in all probability a less effective solution.
- 5. Random Solutions
Solutions are stated on the form but are not clearly and tightlylinked to the causes (partly because these have not been clearly identified in the body of the report). In addition that the solutions have not been systematically evaluated again clearly stated and identifiable criteria.
- 6. Lack of Coherence
Each section of the report form may have been filled in but that there is lack of coherence throughout the reporting. The thread that you might expect to weave its way tightly through the report ie through the problem statement, analysis (acknowledging boundaries of knowledge) evidence and solutions is not there or evident to the reader.
With this back drop it is therefore interesting that the most common web search term in relation to Root Cause Analysis is for Root Cause Analysis templates or pro-formas as opposed to Root Cause Analysis process, ie understanding what makes effective Root Cause Analysis.
It does rather beg the question whether RCA is being used for its stated aim of improving productivity, quality, service or similar aims – or whether the completion of an RCA form has become an end in itself?
