Root Cause Analysis: Helping Us Understand Why Things Go Right

Every once in a while when I’m conducting training, I have the good fortune to have someone ask a particularly atypical question that gets me thinking and helps me to develop more tools and techniques. This serves to not only augment my own bag of tricks but also increases my capacity to serve my clients.

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A few weeks ago during a training session on root cause analysis, one of the attendees asked: “Can we use the same technique to figure out why something worked really well?” My initial reaction reflected my skepticism as I responded with a lukewarm: “I suppose….” I had occasionally taught people how to use some of the tools to assist in preventive action. “What would cause something to go wrong—and what would cause that?” But this was different.

The gist of the conversation posited the possibility of using investigative tools to understand the cause of success. The more we talked about it, and later on as I thought about it some more, I concluded that the idea made perfect sense. Why not use the same thought process to understand why processes run smoothly and with minimal error or problems? Comprehending the nature of a process and the factors that contribute to its effectiveness should provide insight and increase the likelihood of being able to replicate desired results.

Two of the most powerful tools we can use for root cause analysis are flowcharts and the fishbone diagram. A flowchart allows us to understand the flow and sequence of a process. By looking at a stable (i.e., effective) process, we can perceive both the steps that must be taken and the sequence in which activities must be performed. We can observe the specificity of information provided for each step and the efficiency that may be inherent in the sequencing of activities. The points at which verifications (e.g., tests and inspections) occur are also denoted, providing information on the in-process controls that may mitigate errors. We can see if the sequence is the result of a well-designed work area that optimizes space and minimizes travel time between various steps. We can note the influence of good planning or rigorous and elaborate scheduling.

With a fishbone diagram we can look at the six traditional elements of a given situation: material, manpower, machinery, method, measurement, and environment. The extent to which we define, control, and utilize each of these elements has direct impact on the integrity of a process. What did we do to ensure that we had the right material, in the right quantity, at the right location on time? Was this caused by good inventory management, fostering good supplier relations, prepping components before issuing them to the floor, or packaging them on trays for easy retrieval? How about manpower? What did the organization do to optimize the skills and knowledge of employees? How did we manage absenteeism to ensure all shifts and tasks had adequate coverage?

The same questions can be asked for the other four elements. What great things did we do that have contributed to our success? And, what prompted the decisions that directed us to select specific equipment, incorporate a particular methodology, or make changes to the work environment? Was this the result of some related data analysis, new technology, or employee initiative?

There’s no denying that it would also be useful to compare an optimal process with one that has bottlenecks, defects, and reworks. By understanding the difference between the two, we can figure out what’s wrong with the problematic process. But that really is looking at the root cause of a problem from a different angle.

This isn’t about comparing good with bad. It’s about scrutinizing our successes. We don’t give ourselves enough credit for our successes. And too frequently, we don’t understand why we succeed.

Despite the fact that we do develop plans, schedules, and work instructions, there are many instances in which there’s still a sense that our success is somewhat serendipitous. “If the parts arrive on time….” “If the first article inspection is approved….” “If the machine doesn’t jam….” “If there isn’t too much traffic en route to the field installation….” “If the server doesn’t crash….” We cross our fingers, stroke our lucky rabbit’s foot, and invoke the help of our chosen deities. And when everything falls into place perfectly, we thank our lucky stars. We often fail to ask. “Why did things go so well this time?” “What did we do, what plans did we develop, and what resources did we acquire that allowed us to achieve our goal?”

So, I guess using root cause analysis tools should help us understand why things go well. It should help us to understand what factors contribute to our success so that we can learn and make optimum use of that knowledge to bring consistency and sustainability to our success stories. We’re too eager to ask, “Why did something go wrong… and who should we blame?” instead of, “Why did everything go so well, and who can we thank?”

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