Obstacles to Learning from Things that go Wrong

By Robert J. Latino, SVP, Reliability Center, Inc.

Abstract: The unique advantage those of us in the Root Cause Analysis (RCA) field have is that everyone has problems that must be solved.  No matter what your occupation nor the industry you are in, things do not always go as planned and someone must address “Why?”  Sounds simple doesn’t it?  Why is it that when we try to formalize such RCA-type efforts, that there is often resistance and lack of commitment?   

As long as there is human involvement in any process, the system is prone to the errors of human.  Conversely, as long as humans had a hand in causing an adverse outcome, they will also have a hand in solving it. 

Oftentimes we will hear of efforts to solve bad outcomes such as Root Cause Analysis (RCA), Problems Solving, Brainstorming and the like.  Usually the differences in these conceptual approaches revolve around the breadth and depth of the approach itself.  However, that is another article!  

What we want to focus on here is simply getting to the point where our organization feels that understanding what went wrong is the right thing to do, and there is value to the bottom line for this type of activity. 

In a recent discussion on an RCA discussion forum, its moderator Robert Nelms (www.rootcauselive.com) asked the following question:

“What do you see as the obstacles to learning from things that go wrong?”

I have been an active participant on this forum for years and know that the membership includes providers and users ranging from novices to veterans.  In my view, this is a very respected group of analysts who are reflective of the industry as a whole.  Here are the final compiled results of the answers to the questions grouped into categories with representative statements provided. 

1.      RCA is almost contrary to human nature – 28%

a. People don't like to admit they made the mistake

b. Accountability. If you are the boss - that is it!

c. We are unwilling to change our own behavior

2.      Incentives and/or priority to do RCA’s are lacking – 19%

a. It is not expected of them

b. There is no personal incentive to do so

c. The work environment does not condone, nor accommodate, such a proactive activity

3.      RCA takes time/we have no time – 14%

a. People are too busy due to daily work/problems

b. Variations on "I'm too busy"

4.      Ill or mis-defined RCA processes – 12%

a. No agreement on either "how far back" you have to go in your analysis

b. Vaguely defined processes

c. It is a theoretical approach.  It is practically impossible.

5.      Our "Western Culture" – 9%

a. The stock market – short-term focus

b. Managers being rewarded for short term results

c. The tyranny of the urgent

6.      We haven't had to do RCA in the past – why now – 8%

a. Not how I was trained, not how I/we do things

b. Some behavior is so entrenched that it would be like being struck by lightening for some individuals to be aware of the need

7.      Most people don't understand how important it is to learn from things that go wrong. – 5%

a. It never occurs to most people that learning from experience is a cost-effective activity

8.      RCA's are not my responsibility – 5%.

a. It's NIMBY (not in my back yard)

b. That's not our job

While these results were not surprising to most providers and veterans, this quasi-poll supports what we have been saying for years.  Notice that 88% of the responses have nothing to do with the analyst or the methodology, but rather the work environment itself – the organizational culture!

It is my guess that if any organization had conducted an RCA on why their “RCA Effort Failed in the Past”, this would be a representative listing of “root causes” that would be found.  Look at this list and keep in mind that it would likely apply to any industry, anywhere, it is not discriminating. 

Let’s look at the categories in a little more detail.

1.      RCA is almost contrary to human nature – One of the biggest hurdles to overcome in RCA is that the organization has to learn to accept the truth.  This is contrary what we are used to.  While it is simple to state this, it is difficult to shift the organizational paradigm in this direction.  “Lip Service” will not work in these situations.  This is a “Walk-The-Talk” situation that must start from the top.  Executives must understand and demand that the organization learn from past adverse outcomes and provide incentives to encourage such activities.

2.      Incentives and/or priority to do RCA’s are lacking – If the nature of our daily activities involve primarily reacting to the needs of the work environment, then that is likely where our performance incentives are placed.  How many of us have incentives for preventing adverse outcomes from occurring?

3.      RCA takes time/we have no time – The leading objection we hear in our RCA training efforts is “we do not have time to do RCA”.  This is quite the oxymoron, because if we simply ask them “what are you working on that you are so busy?” they realize what they are saying – “I am so busy fixing things, I do not have time to figure out why they need to be fixed?”  This is an endless cycle and sadly becomes a default management strategy in many cases.

4.      Ill or mis-defined RCA processes – When looking simply at methodologies, this is the primary reason for failure.  Everyone does it differently and yet all the results are considered equal.  This is not the case and can be very misleading.  Brainstorming is not RCA, yet oftentimes the results are considered commensurate with each other.  Brainstorming typically will allow “hearsay” to pass as fact, whereas true RCA will require “evidence” to back up its hypotheses.  If the corporation were focusing on RCA, then proper methodologies would be researched for the organization.  Then proper funding would be provided to train analysts in the unified methodologies and any applicable software tools.

5.      Our "Western Culture" – While this is a more national view, this does impact our executive levels and create the paradigms about “today” as opposed “tomorrow”.  Because our corporations tend to be financed through shareholders, executives tend to be focused on quarterly reports and satisfying shareholders by paying dividends.  This is a different perspective then other global corporations who may be financed through banks, which would provide a more long-term perspective.  This is just a demonstration of the factors that influence executives and how it trickles down to create the cultures in which we work.

6.      We haven't had to do RCA in the past – why now – Many organizations have created a “blame” culture where employees will be skeptical of such new thinking.  Therefore they will think that these are new attempts by management to pin the blame on individuals.  If RCA become a corporate strategy, such eventualities will be provided for in the training and incentives programs developed.

7.      Most people don't understand how important it is to learn from things that go wrong – When people have worked their entire careers in a reactive environment; they become conditioned to the fact that doing business in that fashion is acceptable.   If I worked in an organization for 30 years and no one ever asked for my opinion in this fashion, then all of a sudden they did ask, I would be suspicious.  Unfortunately, when we get to this point, proactive activities seem like a waste of valuable time because we could be fixing more things with that extra time!

8.      RCA's are not my responsibility – When RCA efforts are ill-defined this is a common paradigm.  If I am tasked as a “fixer” and that is how I get my bonuses, then giving me the task of RCA tasks away from my ability to make my bonuses.  What we have to realize is that we are all human and therefore we are problem solvers.  While RCA’s may not be my responsibility, I still possess the skills to solve problems whether it is at work or home.  It is our responsibility to improve our skills to solve problems.  It is our employer’s responsibility to create the environment that encourages me to use these skills for the betterment of the organization.

Conclusion: While selecting appropriate RCA methods for the organization is important for the sake of consistency of results, it plays a minority role in the success of the effort in total.  If an organization is committed to learning from things that go wrong, they will walk-the-talk and issue appropriate policies, procedures and incentive systems to support the proactive activity.  With such an infrastructure, the effort will likely last only until the few who do it on their own retire or “seek other opportunities” with companies who see value in such activities.