Welcome to another episode of embracing differences with me. Nippin Anand, in this episode, we will discuss what is the problem with root cause analysis using a social experiment. And my point is this, that could it be that root cause analysis, and most specifically five whys have been designed to create simplistic stories of human error. Some years ago, I was facilitating a workshop in London during a mock interview. There was a seasoned investigator, and he was trying to find out why an interviewee had followed Well, had not followed the procedures for entering into an enclosed space. So this was a little experiment between an investigator and a seafarer, and I would like you to just look at the this little exchange between them. So the investigator asked the question, why did you not follow the enclosed space entry checks and to which the interviewee responds by saying, because I did not have sufficient time to go through the checklist. Why did you not have sufficient time? Because we were in port and we had a lot of other things to attend to, okay, but why were you attending to those other things when you already had a task in hand. I don’t know, but it seems like I’m in trouble now. And the two of them had a very good laugh, actually. And I think there’s a lot to reflect upon in this little exchange, but let’s begin with something very, very basic, which is, let’s just look at the style of questioning, the exchange between the two. And the first thing that you see is, without making any attempt to understand the situation, the investigator straight begins with the assumption that there has been a breach of procedure, ie, why did you not follow the procedure? Right? And what will happen in this instance is that, because you start with a question like this, the first thing is, people become defensive, so you have already lost this person. But the question is, what gives him the basis to ask a question like this? Now the next thing is that response to the first question, the answer that you get to that first question becomes the basis to inquiry or your subsequent question. So you can see how this is becoming a line of inquiry in very, very literal terms. It is becoming a straight line of inquiry, which means that it becoming a linear and deductive way of understanding the problem, which is least helpful. But anyway, let’s, let’s look at the go further. There is an implied assumption in this line of inquiry that a decision made in a moment of uncertainty was actually made in a conscious awareness. Yeah. Why did you do that? As if the person knew where before doing it. He was fully, fully conscious of his decision. Third, the onus throughout is on the interviewee to justify his actions. You just have to ask the question and let go and let loose. The interviewee now has to explain. You’re put in a fix throughout this line of inquiry. Fourth, it’s always at the discretion of the investigator where to start and where to end, and that is how an investigation is turned into a simplistic story of human error. And it’s a quest for certainty, for control, and always for winning to the one who has the power, ie the investigator or the auditor. And it makes you wonder why and how root cause analysis has prevailed over the years. So here’s a few reasons why I believe root cause analysis has worked so well for across industries. One, I think it is time efficient and it is aimed at certainty and control. So in many ways, it is a match made in heaven for industries, organizations and people who are looking for quick fixes and easy solutions, perfect recipe. Then I think there is a related problem, which is that people cannot endure doubt, uncertainty, questioning for too long, when something goes wrong, any cause is better than no cause. Any solution is better than no solution. Any story is better than no story. So in many ways, what root cause analysis does is that it provides a very existential solution. It gives, gives us a reason to come back to Office each day because we have solved the problem. So in many ways, it’s an existential solution to problems that are so complicated in nature, but they bring us back to work each day because we can, we can solve them very quickly through root cause. Analysis, whether right or wrong doesn’t matter. We have solved it right. It also gives a very legitimized basis the root cause analysis as a method. It gives a very legitimized basis to reveal just enough information without disrupting the status quo. So you can focus on the area where you think will be least resistance, and you can stop where it matches with your agenda. And this is the beauty of root cause analysis. In many ways, it gives a lot of power and control to the one who’s investigating it’s a political tool in many ways. Where has it become problematic? It hands disproportionate power to the one who is investigating. Of course, we discussed this, but it also makes the one who is being investigated totally powerless or audited. For that matter, it seeks rational explanations to decisions made in uncertain moments, and in many ways, it creates a delusion of certainty and control, even when there is none. It also has does not take into account habits, heuristics, biases, social influences, political elements that are so foundational to understanding social decision making and human decision making, because all decision making is influenced by the social context, by the political context, and it actually affects our unconscious more than the conscious mind. But root cause analysis does not engage with the unconscious in the unconscious space. And funny enough, because 98% of our decisions are actually made in the unconscious mode, but we have no discussion on that in the discourse of roots root cause analysis, it seeks objective truth from people who are always subjective. People see things differently. I don’t see what you see when we look out the window. But that does not matter to root cause analysis. In fact, it goes against the idea because we are seeking objective things from subjective people. It is also quiet on two very, very important aspects of what it means to be a human being, sense making and meaning making, as fallible humans, root cause analysis is also, can also be turned into a ritual of anti learning, basically the idea that it reinforces what is always known, without giving space to dissent and to questioning, which is so, so essential for transformation and change within Any organization, because it continues to give us back what we already know through this linear deductive line of inquiry which gives so much power to the investigator who has very little incentive to bring about any kind of meaningful change because of many, many different reasons, of course. So these are some of the things that we need to consider when we are using a tool such as five why root cause analysis, or, for that matter, any causal reasoning mechanism? The key to all of this is becoming aware of what it can and cannot do for us. So I hope this little podcast was helpful to you to understand why we are turning accident investigation to simplistic stories of human error, because our methods and tools don’t give us anything otherwise. Thank you for listening, and I hope you enjoyed listening to this podcast. You.