On Her Own

How to perform a root cause analysis, and why

When something, anything, bad happens, it’s easy to attribute it to the most obvious and direct cause. A car crash because someone ran a red light. A skinned knee because you fell. A broken window because a kid threw a ball.

Addressing those causes can be a quick fix. Punish the driver who ran the red. Remove the hazard you tripped over. Take the ball away from the kid. But what about the next driver, the hazard on the next street over, the replacement ball? Often, it turns into a game of whack-a-mole when you try to stop each problem as it comes up and have it almost immediately repeated by another, almost identical situation.

In the science, engineering, and business worlds, the better way is to engage in a root cause analysis and try to find the true source of the problem so that it can be headed off earlier. Instead of breaking off each stem of a plant you don’t want as you see it sprouting up, the idea is to identify the weed and pull it out by its roots so that it can’t grow at all. It can be more difficult to find the true problem and cause and more challenging to solve it, so it’s easy to avoid when you think you can get by just cutting off each hydra head when it bites you. You might even be right, but here at OHO, we’re all about complexity and nuance, which means digging deeper to understand why things happen and what we can do earlier in the process to affect the final results. As we do so, we might find that the hurdles to solving the problem are more theoretical than real, or that the early effort can lead to far more positive outcomes than simply preventing a result we don’t like.

Sometimes, defining the problem seems simple, but part of root cause analysis is realizing that the surface issue might not be what is actually wrong. That T-bone accident might not have merely been a matter of a driver ignoring a traffic signal. We need to dig deeper and ask why – why did the driver drive through the light? Was it not working or not visible? Or was the driver impaired in some way, fatigued or under the influence? Or were road conditions slick and slippery? Being curious about the true cause can lead down surprising avenues, as we discover issues we didn’t know existed. If you use your imagination to consider all potential factors, you can be sure not to miss the actual key.

Continuing to explore why a bad thing happens by asking questions about the chain of events leading to that bad thing is the core of root cause analysis. There might be multiple causes, all stacking up and contributing to the final result. The concrete of the sidewalk might be broken up and uneven. There might be some trash or debris scattered across it. You might be wearing stiletto heels, while a little bit tipsy from the party you were leaving at night. If you hadn’t been drinking, then you would have been able to balance on your fabulous shoes and successfully navigate the treacherous sidewalk. Tracing back everything that led to that one moment might find the one reason that led to the result you’d like to avoid in the future, but it’s more likely that there were a stack of failures. If you focus on only one, like just the shoes you think are a little less fabulous now, you may miss the actual cause or causes.

Because it’s more likely that there will be a number of contributing factors, you will need to consider which has the most impact, or the one that can be changed with least economic or practical cost for greatest effect. There might have been broken windows from neighborhood kids playing in the yard next door, or the Little League in the diamond across the way. It might be impossible to move or stop the baseball games, but simpler to put a fence up or ask the kids to play in the back yard instead of the side yard. There can be multiple root causes, so you’ll have to pick what you can. Or it might be beyond reach to fix the true root or roots, but you can reach to some of the branches close to it, so you can interrupt entire types or groups of incidents instead of individual ones.

The trick is to never be satisfied with the superficially simple and easy preventatives unless you have systematically examined all of the avenues that could end in the thing you’re worried about, and considered which alternate turns might have resulted in another outcome, at costs that are reasonable and acceptable. It will take more thought and more effort, which I know you’re up for because you’re still reading. Besides, making your way through the process will reward you not only with a more effective fix, but the satisfaction of knowing that you aren’t settling for a feel-good but ultimately ineffective solution.

At the time I’m writing this, it’s perhaps obvious that I’m thinking about the current gun rights and reproductive rights debates. However, the principles of defining problems precisely, performing root cause analyses, and dealing with problems at their sources are not unique to big, societal issues. They’re also helpful when it comes to the issues you personally face in your everyday life, from the breakouts that keep happening on your face to a fraught area in your relationship with a loved one.

Hi, I'm Annette.

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