What’s wrong with Root Cause Analysis

A car skids while cornering at a certain point, turns turtle, and bursts into flames. From the car-driver’s point of view the cause of the accident was cornering too fast, and the lesson is that one must drive more carefully. From the county surveyor’s point of view, the cause was a defective road surface, and the lesson is that one must make skid-proof roads. From the motor-manufacturer’s point of view, the cause was defective design, and the lesson is that one must place the center of gravity lower.”

Notice that in each case the selected necessary condition (the attributed “cause”) is relative to the potential range of control of the attributer. Notice that the attributed “cause” (the selected necessary condition) is not everything that is logically relevant to a causal analysis but, rather, the one thing that is practically relevant because the attributer is in a position to set it right.

Unquote

(Source: Brandt and Rozin, 1997)

This little example helps to understand what is wrong with Root Cause Analysis (RCA):

• The root cause is the limit of the investigator’s imagination
• The root cause is what the investigator believes
• The root cause is a trade-off between what is discovered and what can be disclosed as part of the process
• There cannot be a root cause without a corrective action
• If it can’t be fixed, it ain’t a cause
• Look closer and ask yourself, is causation my own construct?
• Your causation is what you believe
• Scientific methods (and investigations are just one subset) are also rooted in a belief
• We confuse Causation with Attribution
• Causation deals with the objective; attribution is what gives meaning to subjective persons
• This confusion is inevitable because we are a meaning-making and not an evidence-seeking species
• Belief always precedes Science

There seems to be so much skepticism about the term ‘Root Cause Analysis’ as if it is a swear word. We are told that we should avoid using Root Cause Analysis (RCA) and move on to more sophisticated methods. This is misleading to say the least.

There is nothing wrong with causation or ‘root cause’; our real challenge is not knowing what a method is capable of doing and what is the (hidden) methodology behind the method or the tool.

The real issue lies in a lack of critical thinking and questioning the (hidden) ethics of risk and safety.

Ethical problems cannot be solved by technology or AI; ethical problems are resolved by questioning and declaring our ethics.

Unless we discuss ethics, no method or tool will help us to learn from accidents, work and everything in between.