Five Bad Root Cause Analysis Questions You Should Never Ask

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.  Why do people make silly mistakes? Do they want to make errors and cause problems?

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.

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.

Four better questions to help understand how cognitive load and mental health affect the potential for human error:

1. What can cause those ‘one time’ mental lapses or glitches that lead to rare, but problematic, errors?
2. What types of safeguards were in use to help perform the task in an error-free manner?
3. How do your work team leaders determine if their team members are fit for duty each day?
4. How do your work teams ‘amp up’ their workplace safeguards when task performance risk increases?

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 tend to go their own way. Similarly, when a leader provides little or no attention or feedback, people care less about their work. Plus, a lack of feedback can cause 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 did not pay 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.

Three better questions to help understand how daily supervision and the work environment affect the potential for human error:

1. What daily strategies do your leaders use to keep their work teams focused?
2. How did the design of our work environment fail to help maintain everyone’s focus and attention?
3. What types of cues exist in the work environment to help alert people to heightened levels of error potential and risk?

DISCOVER MORE: How great are your work systems?

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. Why can’t they remember all of our work rules? Too many people only receive refresher training once a year. Memory has its limitations, even with annual reinforcement.

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.

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?

Three better questions to help understand how training effectiveness affects the potential for human error:

1. Was the problem a failure to learn or a failure to apply what ones knows?
2. How do you measure and improve your training and learning work systems?
3. How do you systematically share and embed the lessons you learn as process changes to keep repeat errors from occurring again?

EXPLORE MORE: Buy my ‘Error Proof’ book on amazon.com or in the Great Systems Shop!

Bad Root Cause Analysis Question #5: Why doesn’t anyone fix this?

To understand component failure, you must understand the path to failure. This path to failure is usually made up of human errors or omissions. Unfortunately, too many people address equipment problems with a standard fix – replace the broken equipment.

Such a fix may buy time in the short-term. However, it is not a sustainable strategy for long-term profitability and effectiveness. Worse yet, the weak analysis that is often behind such weak repairs fails to uncover how human errors and choices affect asset health. Such errors can occur anywhere along the life cycle of the equipment, from design to regular use and maintenance.

Seven better questions to help understand how human error and other factors drive equipment reliability and asset health:

1. What is the history of failure? What types of failures does this equipment experience, and how often?
2. What equipment or service features did the designers purposefully choose to omit?
3. How often were upgrade, repair, or overhaul projects delayed?
4. What types of repair or inspection errors might we have made over time?
5. How have past attempts to repair this equipment failed?
6. Who are the different people that interact with this equipment over its lifetime?
7. How has the equipment operating environment or operating parameters changed over time?

LEARN MORE: Does Your Work Team Structure Drive Operational Excellence?

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 prevent this from happening?

Explore More of My Root Cause Analysis and Investigation Effectiveness Content!

Here are some additional pages that will help you optimize your process improvement tool set:

• Evaluating Root Cause Analysis Processes
• Frequently Asked Root Cause Analysis Questions

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:

• How to Measure Investigation Process Effectiveness
• Workplace Safety Best Practices
• How to Measure Investigator Competency