Firefighters Guide to Root Cause Analysis
When researchers studied firefighters, they discovered significant differences between novices and veterans when looking at a burning building:
- Novices notice obvious things like flames and their locations.
- Veterans saw a story. They noticed where and how the fire started, how it progressed and what it was likely to do next.
In essence, veterans did a root cause analysis (where the fire started and why).
Often, business owners and employees complain about the amount of firefighting required on a daily basis. The rewards in these companies go to the heroes who put out the fires. And companies create whole departments just to put out fires (e.g., customer call centers).
Most employees look at these "fires" like a novice, not a veteran. They notice the mistakes and errors. They sense the customer's anger. But few bother to wonder why the mistakes occurred in the first place.
Veterans look at corporate "fires" as a story, as cause and effect. Veterans notice how and why the mistakes were made in the first place. They ask why, why, why, why, why until they discover the root cause. Then they ask: "How can we prevent this problem completely."
Root Cause Analysis (RCA)
Root cause analysis is pretty simple:
- State the problem.
- Ask why, why, why, why, why until you've identified the potential causes.
- Verify which causes are actually at the root of the problem.
Perhaps the biggest mistakes people make in root cause analysis is assigning the blame to:
- People (untrained)
- Not enough Money
- Not enough Time
Invariably, employees get stuck in mental traps. It takes creative, out-of-the-box thinking to figure out ways to change existing processes and systems to make them mistake-proof (i.e., prevents mistakes completely). The goal should be that even a brand new employee should be able to do the task error free.
I worked with a call center group that had too many time sheet errors. Time sheets were kept in Excel spreadsheets. There were two symptoms:
- Employees overwrote formulas in cells
- Employees entered time incorrectly (e.g., 4.30 instead of 4.5 for four and a half hours).
They had spent a lot of time trying to teach employees how to fill out the spreadsheet correctly, but to no avail. Since I'm an Excel geek, I showed them how to use Excel's Data Validation to prevent incorrect time entries and how to protect formulas in cells from changes (Protect Sheet).
These two changes made it impossible for these two errors to occur. Excel enforces correct data entry. No training required.
Here's My Point
Are you still treating business "fires" like a novice or a veteran? Do you see a blaze or a story? Sure you need to put out fires when you find them, but veterans go back and identify the source of the fire, and put methods in place to prevent future fires.
Root Cause Analysis is easy; just ask "why" five times. Figuring out how to mistake-proof the system or process to prevent the problem forever is a very creative, rewarding activity.
Remember, Deming said that 99 problems out of 100 are caused by the system. Fix the system, prevent the fires. It's that simple. So why don't more people do it? Maybe because the rewards go to the novice firefighters that simply put out the fire, not the veterans who would rather prevent them.
Which are you? Heroic firefighter? Or veteran fire preventer?
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