The problem with focusing on finding "root causes" is that it presumes there is such a thing: the one action or defect, which, if eliminated, would have prevented the problem. A common definition of "root cause" is "that most basic reason for an undesirable condition or problem which, if identified and corrected, would have prevented the problem from occurring." My extensive reading on this topic leads me to conclude that root cause is largely an arbitrary construction, done after the fact, by people who's perspective is contaminated by hindsight. What is the definition of "the most basic reason"? I strongly believe that any explanation of "most basic cause" would be a matter of individual opinion and strongly influenced by bias about the things over which you believe you have control.
The basic reason for investigating and reporting the causes of problems is to enable the identification of corrective actions adequate to prevent recurrence." It is also unrealistic to think that we can find some magic formula that will "prevent recurrence. The focus on root causes is a wasted effort because we are seeking solutions, not root causes. Regardless of how hard we try, it is not possible to find the real root cause of a fire because there are many possible causes of a fire. More importantly, there are several ways to prevent the fire, assuming this is our goal. To reach our goal of prevention, we must find at least one cause that we can act upon such that it meets our goals and objectives and is within our control.
"Root cause is a myth. The world is much too complicated for any effect to be traceable to a single cause." - Dr. James Quinlan)
Once you accept these premises:
- The ultimate goal of an investigation is to learn from failure.
- The purpose of error investigations is to implement solutions, not find root causes.
- The solutions we choose to implement are always limited by what we can control and how much money we have.
- Accident causality is almost never linear (A caused B. B caused C. Since C happened just before the problem, remove A and C will never happen.)
- Cause is something we construct, not find.
- Finding and highlighting people's mistakes explains nothing. Saying what people did not do does not explain why they did what they did.
- Mishaps are the result of everyday influences on everyday decision making, not isolated cases of erratic individuals behaving exceptionally (in most cases).
you will stop talking about finding "root" causes. I am interested in hearing from anyone that thinks the premises above are in error or false.