If you want to stop good root cause analysis, introduce blame into the process.
In recent years, good analysts have fought to eliminate blame from root cause analysis. But there are still some root cause systems that promote blame. They actually build blame into the system.
How can this be? Maybe they just don’t understand how to make a world-class root cause analysis system.
WhenTapRooT® Root Cause Analysiswas new, I often had people ask:
“Where is the place you put ‘the operator was stupid?’”
Today, this question might make you laugh. Back in the day, I spent quite a bit of time explaining that stupidity is not a root cause. If you hire stupid people, send them through your training program, and qualify them, then that is YOUR problem with your training program.
The “stupid people” root cause is a blame-oriented cause. It is not a root cause.
What is a root cause? Here is the TapRooT® System definition:
The absence of best practices
or the failure to apply knowledge
that would have prevented the problem.
- Attention less than adequate
- Step was omitted due to mental lapse
- Individual’s capabilities to perform work less than adequate
- Improper body positioning
- Incorrect performance due to a mental lapse
- Less than adequate motor skills
- Inadequate size or strength
- Poor judgment/lack of judgment/misjudgment
- Reasoning capabilities less than adequate
- Poor coordination
- Poor reaction time
- Emotional overload
- Lower learning aptitude
- Memory failure/memory lapse
- Behavior inadequate
- Violation by individual
- Inability to comprehend training
- Insufficient mental capabilities
- Poor language ability
- In the line of fire
- Inattention to detail
You might laugh at these root causes but they are included in real systems that people are required to use. The “operator is stupid” root cause might fit in the “reasoning capabilities less than adequate,” the “incorrect performance due to mental lapse,” the “poor judgment/lack of judgment,” or the “insufficient mental capabilities” categories.
You may ask:
“Couldn’t a mental lapse be a cause?”
Of course, the answer is yes. Someone could have a mental lapse. But it isn’t a root cause. Why? It doesn’t fit the definition. It isn’t a best practice or a failure to apply knowledge. We are supposed to develop systems that account for human capabilities and limitations. At best, a memory lapse would be part of a Causal Factor.
To deal with human frailties, we implement best practices to stop simple memory lapses from becoming incidents. In other words, that’s why we have checklists, good human engineering, second checks when needed, and supervision. The root causes listed on the back side of the TapRooT® Root Cause Tree® are linked to human performance best practices that make human performance more reliable so that a simple memory lapse doesn’t become an accident.
What happens when you make a pick list with blame categories like those in the bulleted list above? The categories get overused. It is much easier to blame the operator (they had less than adequate motor skills) than to find out why they moved the controls the wrong way. It’s easy to say there was a “behaviour issue.” It is difficult to understand why someone behaved the way they did. TapRooT® looks beyond behaviour and simple motor skill error to find real root causes.
We have actually tested the use of “blame categories” in a system and shown that including blame categories in an otherwise good system causes investigators to jump to conclusions and select these “easy to pick” blame categories rather than applying the investigative effort required to find real root causes.
You may think that if you don’t have categories, you have sidestepped the problem of blame. WRONG! Blame is built into our psyche. Most cause-and-effect examples I see have some blame built into the analysis.
If you want to successfully find the real, fixable root causes of accidents, precursor incidents, quality issues, equipment failures, cost overruns, or operational failures, don’t start by placing blame or use a root cause system with built-in blame categories. Instead, useadvanced root cause analysis.