Bad Root Cause Analysis and Countermeasures

Improvement Insights Blog

Bad Root Cause Analysis and Countermeasures

After the recent terrorist attempt on Northwest Airlines Flight 253, some zealous, knee-jerk root cause analysis led to simple, easy-to-understand, wrong-headed countermeasures: passengers shouldn’t be able to get up during the last hour of any flight, anywhere.

Punishing millions of passengers to protect against a few extremists is a bad countermeasure stemming from bad root cause analysis. Random screenings of elderly women who have had knee replacement surgery or young children, a sampling technique, also seems to be silly.

Root cause analysis should get to the root of the problem: Why was a known extremist allowed to board any flight, anywhere?

After some investigation, it appears that the intelligence community knew about the problem, but just failed to put his name on the no-fly list. Duh! We can invest in expensive, invasive, whole-body scanners or just automate updates to the watch and no-fly lists.

It’s clear that TSA has become trapped in a visual scanning mindset. This requires the “inspector” to catch all of the “defects,” but humans make at least six mistakes a day.

Businesses do this as well, they become trapped in one way of solving a problem which usually costs more money and takes more people. Often, however, the problem can be solved inexpensively by shifting to another way of looking at the problem.

As the inventive procedures of TRIZ suggest, perhaps we could find a safe airborne catalyst that would cause an odor or color change when it interacts with known explosives. Maybe we could add screening technologies from some other physical field or method (i.e., olfactory). If dogs can do it, why can’t we?

(Where did I get this idea? In a related incident, J&J recalled Tylenol Arthritis Caplets that interacted with chemicals used in packaging and transportation pallets to create a moldy, musty, mildew-like odor that caused nausea, stomach pain, vomiting and diarrhea.)

Let’s imagine the Ideal Final Result (IFR). A good countermeasure would be simple, inexpensive and minimize the impact on travelers while detecting 100% of dangerous people, materials and weapons. I know it’s a tall order, but that’s how innovation happens.

Businesses should imagine the Ideal Final Result before coming up with knee-jerk countermeasures to perceived problems. When I worked in the phone company, wait times in the call center ranged up to 30 minutes at times. Someone decided that a better call director technology would solve the problem. They spent $12 million upgrading the call director and wait times didn’t change by a nanosecond.

At the time, 51% of all calls were for repair. Truth was, but no one wanted to explore it, that we needed less repair; less repair would have meant fewer calls. We never did get to the “root cause.”

Everyone from the smallest small business to the federal government needs to get better at root cause analysis and countermeasures. All you have to do is ask “Why?” five times (fishbone diagram); imagine the IFR; and implement countermeasures that prevent the problem as inexpensively and effectively as possible.

This entry was posted by Jay Arthur in Six Sigma and tagged , . Bookmark the permalink.