Five Bad Root Cause Analysis Questions You Should Never Ask
by Kevin McManus, Chief Excellence Officer, Great Systems
How effective are your root cause analysis questions? As a Western culture, we don’t do very well when it comes to root cause analysis. All too often, we blame people, equipment, or the weather. You can hear it at work when people talk about problems and their causes. Here are five bad root cause analysis questions you should NEVER ask if you want to find the true root causes of a problem.
Bad Root Cause Analysis Question #1: Who should we blame?
This the worst question we can ask when we want to fix a process problem. Human error is often a contributing factor to a problem. However, it is rarely the root cause. When we blame people, we block the potential for true process improvement. Essentially, we predestine ourselves to weaker fixes, such as reminders, warnings, and punishment.
Unfortunately, it is human nature, in many cultures, to blame the person for the error. Similarly, people are prone to blame the equipment when a component fails. One key to work culture change lies in how we change our problem-solving conversations. How often do you hear people blame other people for problems at work? How often is the process the focus?
To better understand a human error, ask ‘How did process design affect correct task performance?’ Also, look at the types of support that are used to perform the task in an error-free manner. How did the person prepare for work? What type of work package were they given? How did they develop their task performance competencies?
Bad Root Cause Analysis Question #2: How can they be so stupid?
In our youth, we don’t make as many little mistakes as we do when we are older. Even as we age, people typically do the job right each day. Often, we make errors less than 5 out of every 100 process cycles. What can cause those ‘one time’ mental lapses or glitches that lead to rare, but problematic, errors? Why do people make silly mistakes?
Few humans can sustain mistake-free work without some form of work system support. Poor sleep, bad diet, stress or overwhelm, dehydration, and fatigue can all cause cognitive blips. Plus, these cognitive challenges can often occur simultaneously. How do your work team leaders determine if their team members are fit for duty each day?
Typically, job aids, sound ergonomics, training, rules, and supervision fill daily task execution support roles. As the risk potential from task errors increases, we should decrease our reliance on memory alone. We should flex our safeguards to accommodate the expected higher risk level for that daily work.
Bad Root Cause Analysis Question #3: Why won’t they just pay attention to their work?
Without direction and feedback on a consistent basis, people will tend to go their own way. Similarly, when a leader provides little or no attention or feedback, people tend to care less about their work. This also causes one’s attention to drift. Sheer job boredom, where little interaction with the work environment or equipment occurs, has a similar effect.
As a plant manager, if someone on my team was not paying attention, I would start with one question. How did we somehow fail to design a work environment that keeps everyone’s attention? Multiple strategies exist to help keep people focused – what was missing or failed? Also, these strategies must be flexed from day to day to accommodate shifts in workforce cognition levels.
One best practice uses work environment cues to keep peoples’ attention on task. Signs and supervisor warnings are two weak examples. More effectively, wearable devices can notify a person when they enter a relatively high-risk work area. Pop-up box and drop-down menu design play key roles in helping people complete tablet-based forms accurately and quickly.
Bad Root Cause Analysis Question #4: Why won’t they learn?
All too often we wonder why people fail to absorb the hours of content we dump on them during an onboarding session. What keeps them from remembering all our work rules? We review them at least once a year. Is the problem a failure to learn or a failure to apply what ones knows?
From a formal training perspective, skill gaps are often due to content gaps, delivery challenges, and/or a lack of practice. Typically, people receive too much content, with too little time to absorb it all. Also, they rarely get much time to practice the basics. In other cases, leaders fail to effectively identify skill gaps that exist. How effective are your training and learning work systems?
As humans, we also struggle to learn from our past mistakes. Do you struggle to understand why people fail to learn from their past errors? If so, look at yourself. How often do you make changes to keep repeat errors from the past from occurring again?
Bad Root Cause Analysis Question #5: Why doesn’t anyone fix this
If you want to understand why components fail, here are some better root cause analysis questions you can ask. What is the history of failure? What types of failures does this equipment experience, and how often? How have past attempts to repair this equipment failed? Who are the different people that have interreacted with this equipment over its lifetime? How has the equipment operating environment or operating parameters changed over time?
To understand component failure, you must understand the path to failure. This path to failure is usually made up of human errors or omissions. For example, how often were upgrade, repair, or overhaul projects delayed? What equipment or service features did the designers purposefully choose to omit? What types of repair or inspection errors might we have made over time?
Do you want some better problem solving questions to ask?
Too many problem solvers rely on the investigation form questions or their experience to guide their evidence collection efforts. Such a practice will cause you to miss potential problem root causes. I consistently see such challenges in the virtual 3-day TapRooT® root cause analysis workshops that I teach.
Instead, every problem solver should build standard question sets to help kick off their evidence collection efforts. The goal is to understand why the error occurred from a human factor perspective. Assume that most people want to do the job right. What process design challenges prevented this from happening?
Usually, most investigators only need one or two pages of questions to explore a given error. Plus, such a job aid is easy to make digital. The challenge lies in finding the good questions to ask. Here are a few links to help you get a start on that research:
- Five Tips for Effective Evidence Collection
- Six Great Problem Solving Questions
- How to Measure Investigator Competency
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