Don’t Implement a BAD PRACTICE

New Best Practice

Practice doesn’t always make perfect. Not when you are implementing a bad practice.

I read all sorts of company newsletters, and I saw an article the other day that caused me concern.

It was from a company that had previously trained their “expert” investigators in TapRooT® RCA. These few experts (five people) on the corporate staff were supposed to perform all the company’s root cause analysis. But it seems they couldn’t keep up with all the investigations.

What did the company do? Their newsletter proclaimed they had discovered a new best practice. Instead of having their experts investigate everything, they could have their supervisors investigate the smaller problems by asking “Why?” five times.

Now they were teaching all their supervisors to ask “Why?” five times because:

“People can then do their own root cause analysis and
solve their own problems without help from the corporate staff.”

This was their new best practice!

I’ve explained in talks and articles why asking why five times (and other forms of cause-and-effect analysis) doesn’t work well. I won’t repeat that here. Instead, let me emphasize the results I’ve seen when supervisors are taught to “ask why” five times when performing investigations in their spare time.

Results…

Sometimes people trained in 5-Whys get further toward a root cause than just blaming someone. But they seldom get close to the root causes found using the TapRooT® System. Instead, they frequently stop at symptoms. Then they fix the symptoms with ineffective corrective actions. Here are three examples…

Equipment Troubleshooting

A failed bearing was the 5-Why “root cause” of an equipment failure. A new bearing became the corrective action. (The reason for the bearing failure was not corrected. The bearing failed again and again.)

Human Error

Human error (they just goofed up) was the 5-Why “root cause” for a mistake made by an operator. Additional training became the corrective action. (The training didn’t address the reason for the human error. Similar human errors happened again in the future. Some resulted in discipline. But the cause of the human errors was not corrected until a major accident happened and a more thorough root cause analysis was performed.)

Breaking the Rules

Inappropriate behavior was the 5-Why “root cause” of an operator not using a procedure. Re-emphasizing the need to use procedures became the corrective action. (The re-emphasizing only lasts so long. Then the incentives to not use the procedure eventually win out, and the procedure is not used again. The problems with the procedure and the incentives were never fixed until a thorough root cause analysis was performed after a more serious incident.)

All three examples above are real examples from real applications of 5-Whys. Note that every investigation only had a single root cause.

NONE of the corrective actions fixed the real problems that had caused the original incident.

The real root causes were not fixed. The failure to fix the root causes led to additional incidents.

And this type of poor root cause analysis is not the exception when using 5-Whys. It is the rule.

Predicting the Future

I know what happens when a “good practice” (using TapRooT® Root Cause Analysis) becomes a “bad practice” (using 5-Whys for the simple incidents).

People think they are improving performance. There is lots of activity. But they are actually wasting effort, implementing ineffective fixes, and making management believe that progress is occurring when, in reality, they continue to misunderstand the causes of their problems. Why? Because they fail to fix the real root causes of the problems.

Yes, in the video above, there is activity but no progress. Don’t mistake activity for progress.

When 5-Whys are used to investigate precursor incidents, problems aren’t solved. The activity covers up the lack of progress. The company gets closer to major accidents that could:

• Kill someone,
• Cause major production losses,
• Cause significant product quality issues,
• Cause significant environmental damage
• Lead to a public relations black eye
• Cause hefty fines from a government regulator

The serious accidents that occur prove that instead of being a good practice, this easy analysis (5-Whys) is actually a BAD PRACTICE.

Why Do People Use Bad Practices?

Management is often tricked into thinking they can get something for nothing.

But root cause analysis is serious business – a business-critical activity. You shouldn’t take shortcuts in a business-critical activity. To highlight why this was a bad idea, I created Spin-A-Cause™ back in 1992 to make a point.

I used Spin-A-Cause™ to get management’s attention. Spin-A-Cause™ gets the same type of results as 5-Whys and takes even less effort. So, if you are going to take a shortcut, why not go all the way? Buy a Spin-A-Cause HERE.

What Does Management Need?

Management needs to take a good hard look at what they want from a root cause analysis. Most managers would say they want to stop repeat problems and would certainly like to stop more serious accidents caused by similar root causes (in slightly different situations).

What about:

• The cost of the investigation?
• How easy the investigation is to perform?
• How long the investigation takes?

Management believes these factors are important but not nearly as important as the effectiveness of the corrective actions.

Root cause analysis is serious business. Of course, you want a system that is as simple as possible, but don’t forget Albert Einstein’s wisdom:

“Everything should be made as simple as possible, but not simpler.”

And don’t forget this wisdom…

Colin Harmon drew the graphic above for his blog because everybody wants GREAT graphic design, but they also want Fast and Cheap (maybe even free). But as his diagram shows, you can’t have all three.

The same is true for root cause analysis. You need great. You CAN afford to invest some time and effort and adopt a great root cause analysis system to get the results you need.

Not Every Incident Needs a Full-Blown Investigation

Obviously, I believe that great (not just fast and cheap) root cause analysis is needed to solve real problems. But I also understand that not every incident deserves a full-blown investigation. So what should management do? The answer is the TapRooT® Essentials Training and Book to help people understand the simplest way to investigate low-to-medium risk precursor incidents on a budget.

You can get the book HERE.

Or you can learn the TapRooT® System in just two days and get the book when you attend the 2-Day TapRooT® Root Cause Analysis Course. See our upcoming public course dates and locations HERE.

The Real Best Practice

One additional note.

The real “best practice” that this company missed is getting the right people trained to use real root cause analysis to solve problems and then provide them the time to do it right. This has been proven OVER AND OVER AGAIN to save time and money. For proof, click here to see the business success stories at the TapRooT® Website.

Take Action

If you want to avoid the wasted time and effort of ineffective root cause analysis and the failure to prevent major accidents, you need to talk to one of our TapRooT® Implementation Advisors and develop a roadmap to root cause analysis success.

Just call one of them at 865-539-2139 or CLICK HERE to send them a message, and they will be glad to help you implement TapRooT® RCA to achieve root cause analysis success.

(NOTE: This article was first published in the Root Cause Network™ Newsletter in October 2005 -copyright © 2005, used by permission. We updated it, added some graphics and the video from Venice, and reprinted it in this blog because the lessons are just as applicable today as they were in 2005. People are still being tricked into implementing a bad practice as a good practice.)