RE: Root cause???

["Julian Simcox" <julian.simcox@blueyonder.co.uk>]

WAl Viswanathanhat asks : What is the definition of the term "root cause"?
How does one find the
"root cause"? How would I know I have found the "root cause"?  Is there
anything called the "root cause"?


"What is the root cause?" - This is a commonly asked question by workers,
managers and leaders alike.

When faced with a problem, virtually everyone believes they know what THE
root cause is. What systemic thinking enables us to become aware of is that
very seldom is there just one single root cause. In a system there are
myriad causes of variation within that system. This is the insight that
Shewhart and Deming have brought to me.

It is not unhelpful per se to have individual workers or manager/ leaders
brainstorm what the root causes might be - provided each are aware that
their proposals are theories to be tested, rather than answers - and such a
test might be designed and conducted if an economically sound way can be
found. What is more unhelpful is that the person with the loudest voice, or
most power :

-	decides which experiments to do based on their own hunches alone
-	does the experiment in a way that is unnecessarily costly
-	does the experiment in a way that leads to low levels of learning for the
future
-	proceeds as if their theory is fact, having conducted no experiments at
all

It is my understanding that if Deming and Shewhart used the phrase "root
cause" at all, it was only when dealing with special (assignable) causes of
system variation as revealed by a well set-up control chart. The chart is a
powerful guide as to a cause (usually, but not always, single) that is
"economically" worth investigating and possibly eliminating.

There are several traps in the way people deploy so called Root Cause
Analysis - often results unintentionally in blame, and/or working in one's
Sphere of Concern :

1.	IF I KEEP LOOKING FURTHER AND FURTHER UPSTREAM, I WILL FIND THE ONE ROOT
CAUSE OF OUR  PROBLEM/ DISCONTENT - in reality, we all work in a system, so
upstream becomes downstream. In addition, when intervening each of us can do
only what we can do, which usually is something close to home i.e. within
your own Sphere of Control - which in time you can widen to include your
Sphere of Influence
2.	IF I CAN LABEL SOMEBODY ELSE'S BIT OF THE SYSTEM AS CONTAINING "THE" ROOT
CAUSE I CAN SAFELY DO NOTHING UNTIL THEY SORT IT OUT - of course, if every
individual in the system does this, no improvement can occur because
everyone is paralysed waiting for everyone else
3.	IF I CAN TREAT COMMON CAUSE VARIATION AS SPECIAL CAUSE (mistake No. 1)
THEN I FEEL VERY GOOD ABOUT DOING SOMETHING - but, of course you are likely
to be making things worse by increasing variation in the system. What you
should be doing with common cause variation is systematically reducing it
via well-designed collaborative experimentation - but maybe this requires
too much humility to be practical?

Julian Simcox

Bristol UK