What do we miss by focusing on “THE ROOT CAUSE”?
Many organizations focus on trying to boil down their problems, even extremely complex ones, into the one “root cause”. One of the problems with this is the overgeneralization that results. This overgeneralization may allow organizations to feel that they are “off the hook” if, for example, the “root cause” ends up being “human error.” Because human error is unavoidable, there may be no steps taken to prevent or mitigate further occurences. Overgeneralization can also lead to a warped perspective of the problem in question, based on the desire to find the one true “root cause” of the event. If you ask people what the cause of the EXXON VALDEZ oil spill was, many people will say that the Captain was drunk (overgeneralization of a complex issue into human error, specifically pointed at the man in charge). However, not only was the Captain not present on the bridge at the time of the grounding which resulted in the oil spill, he was found not guilty of operating a vessel under the influence of alcohol.
Another issue with attempting to find the “root cause” is all of the other contributing causes that will be missed. This is especially important when the solution for the “root cause” is not 100% effective. TWA Flight 800 went down for many reasons, but according to the National Transportation Safety Board, the airlines sole focus on preventing fuel tank explosions is preventing ignition energy from entering the tank. However, that solution is not foolproof - ignition sources can be minimized but not entirely removed. That is why some are turning their focus towards solutions for the other causes - namely the flammability of the fuel tanks and the presence of oxygen that would allow an explosion to occur.
So if finding the “root cause” isn’t the answer, what is? Well, in order to effectively combat a problem, we have to find the best solution. In order to find the best solution, we have to find all the solutions, and in order to find all the solutions, we have to find all the causes. We do this by making a Cause Map, a visual root cause analysis. This Cause Map asks “why” until all possible and contributing causes have been identified. The next step is to identify any potential solutions for each cause. Once all potential solutions have been found, an organization needs to determine which solution, or solutions, is best based on the severity of the issue, the effectiveness of the solution(s) and the availability of resources to implement the solution(s).