Have you ever watched Air Disasters television show?  If you have then you see that all too often the reason for the disaster is a series of events that lead to a disaster.  Some of these miss-steps are quite small, but when added to the other miss-steps, ends up in disaster.  This is often the problem with root cause analysis in the business setting.  The sense of urgency often stops the exploration at the most immediate finding.  Even the 5-Why approach may be too short of an exploration.  Combinations of preceding events influence the outcome which is not taken into consideration.

Another problem with root cause analysis in the business setting is often the business processes.  First, there may be the little documented process (pilot documentation such as checklists and flight data recorder) in the organization so exploring the root cause via paper trail or process structures may not be possible.  We then must resort to word of mouth (no cockpit voice recorder), and what can be uncovered perhaps via informal documentation (email chains).  Second, even if we do have process assets such as documentation, we may not have followed the instructions; which leads us back to the prior set of implications and identification of those deviations from the documented process may be difficult.

There are many other issues that can make determining the real causes of the failure we are investigating such as the level of transparency within the organization.  Specifically, how willing the departments are to take a critical look or review of the events leading up to the failure.  Continuous improvement requires critically thinking about the details of the failure (not the people but the mechanisms) and how things can be improved.  Anything less than objectively seeking the truth that leads up to the failure is a disservice to anybody impacted by the organization failure, the company, and the employees.

Take your time, as the old idiom goes, make haste slowly employ an organized approach to discovering the situation.  As you learn, refine the questions, do not expect things to end at the answer to the fifth question in the 5-why.  Take a systems view of the problem running the evidence to the logical conclusion.

Effective root cause analysis is important for the organization as the failures provide is with opportunities for learning, and these learning opportunities are mechanisms by which the organization can improve. We would not want to burn our hand on the metaphorical stove over and over again – if we can help it.