The limitations of root cause analysis

October 15, 2012

Learning lessons from projects is not as simple as you may think! Projects are complex adaptive systems linking people, processes and technology – in this environment, useful answers are rarely simple.

Certainly when things go wrong stakeholders, almost by default, want a simple explanation of the problem which tends to lead to a search for the ‘root cause’. There are numerous techniques to assist in the process including Ishikawa (fishbone) diagrams that look at cause and effect; and Toyota’s ‘Five Whys’ technique which asserts that by asking ‘Why?’ five times, successively, can you delve into a problem deeply enough to understand the ultimate root cause. The chart below outlines a ‘Five Whys’ analysis of the most common paint defect (‘orange peel’ is an uneven finish that looks like the surface of an orange):


These are valuable techniques for understanding the root cause of a problem in simple systems (for more on the processes see WP1085, Root Cause Analysis); however, in complex systems a different paradigm exists.

Failures in complex socio-technical systems such as a project teams do not have a single root cause. And the assumption that for each specific failure (or success), there is a single unifying event that triggers a chain of other events that leads to the outcome is a myth that deserves to be busted! For more on complexity and complex systems see: A Simple View of ‘Complexity’ in Project Management).

Complex system failures typically emerge from a confluence of conditions and occurrences (elements) that are usually associated with the pursuit of success, but in a particular combination, are able to trigger failure instead. Each element is necessary but they are only jointly sufficient to cause the failure when combined in a specific sequence. Therefore in order to learn from the failure (or success), an approach is needed that considers that:

  • …complex systems involve not only technology but organisational (social, cultural) influences, and those deserve equal (if not more) attention in investigation.
  • …fundamentally surprising results come from behaviours that are emergent. This means they can and do come from components interacting in ways that cannot be predicted.
  • …nonlinear behaviours should be expected. A small change in starting conditions can result in catastrophically large and cascading failures.
  • …human performance and variability are not intrinsically coupled with causes. Terms like ‘situational awareness’ or ‘lack of training’ are blunt concepts that can mask the reasons why it made sense for someone to act in a way that they did with regards to a contributing cause of a failure.
  • …diversity of components and complexity in a system can augment the resilience of a system, not simply bring about vulnerabilities.

This is a far more difficult undertaking that recognises complex systems have emergent behaviours, not resultant ones. There are several systemic accident models available including Hollnagel’s FRAM, Leveson’s STAMP that can help build a practical approach for learning lessons effectively (you can Google these if you are interested…..)

In the meantime, the next time you read or hear a report with a singular root cause, alarms should go off, particularly if the root cause is ‘human error’. If there is only a single root cause, someone has not dug deep enough! But beware; the desire for a simple wrong answer is deeply rooted. The tendency to look for singular root causes comes from the tenets of reductionism that are the basis of Newton physics, scientific management and project management (for more on this see: The Origins of Modern Project Management).

Certainly starting with the outcome and working backwards towards an originally triggering event along a linear chain feels intuitive and the process derives a simple answer that validates our innate hindsight and outcome bias. However the requirement for a single answer tends to ignore surrounding circumstances in favour of a cherry-picked list of events and it tends to focus too much on individual components and not enough on the interconnectedness of components Emergent behaviours are driven by the interconnections and most complex system failures are emergent

This assumption that each presenting symptom has only one cause that can be defined as an answer to the ‘why?’ is the fundamental weakness within a reductionist approach used in the ‘Five Whys’ chart above. The simple answer to each ‘why’ question may not reveal the several jointly sufficient causes that in combination explain the symptom. More sophisticated approached are needed such as the example below dealing with a business problem:


The complexity of the fifth ‘why’ in the table above can be crafted into a lesson that can be learned and implemented to minimise problems in the future but it is not simple!

The process of gathering ‘lessons learned’ has just got a lot more complex.

It is OK to ask for help

November 6, 2011

Far too many people think that asking for help is a sign of failure or weakness. In fact the opposite is true. If you don’t know something and waste your time trying to find out, or worse still make an expensive mistake, no-one benefits least of all you! Effective leaders, managers and team members know what they don’t know and proactively seek help to build their knowledge and capability.

Most people seem happy to offer help when someone asks for it, but are shy or embarrassed to ask for help themselves. Rather than asking, they try to work out the answer, even when it’s clear that it is not possible; or hide and not tell anyone they’re wrestling with something; or just hope it goes away. By asking for information or help, rather than wasting time and energy trying to solve the problem, you move forward and the energy that was being wasted wondering and struggling can be used for positive purposes.

This will make you a better leader and will also show those under you that it’s OK to ask for help. Demonstrating to your team that you ask for help when needed encourages them to do the same and frees up communication, energy and the flow of information in a positive way. It seems obvious, but it won’t happen without a push in the right direction.

Things you can do:

  1. First, stop talking to yourself and decide that you are going to talk to someone else.
  2. Decide who that will be.
  3. Craft the conversation. Write down not only what you are going to ask them, but how you hope they will respond. The art of asking effective questions is outlined in our White Paper: Active Listening & Effective Questions
  4. Schedule a meeting and promise you will ask them for help.
  5. Tell someone of your intentions; someone who will hold you to account for having the meeting and asking for help.

Then be pleasantly surprised; most people are honoured to be asked to assist friends and colleagues – by asking for help you are showing them you respect their knowledge and abilities.


October 1, 2011

Experience is that marvellous thing that enables you to recognize a mistake when you make it for the second time and fortunately we all have a wonderful capability for accruing experience! It is almost impossible to do anything new without the probability of mistakes occurring.

A mistake is an error in action, calculation, opinion, or judgment caused by insufficient knowledge, poor reasoning, carelessness or a misunderstanding or misconception. Examples include forgetting our passwords; eating more food because it is served in a bigger bowl and overpaying for gym memberships and phone plans.

We all tend to:

    • Look but not always see: when we look at something we think we see all there is to see, but we don’t. The eye’s area of clear vision is a cone of about 2 degrees – the size of a 5 cent coin (or quarter) at normal viewing distances.
    • We connect dots we don’t know we’re connecting, the sub-conscious mind does this for us based on preconceptions and stereotypes!
    • We wear rose-colored glasses and/or think the grass looks greener – our innate biases drive us to these errors (for more on ‘bias’ see: WP 1069 – The innate effect of Bias).
    • We are really terrible at really appreciating probability, perspective, size and shape – if you don’t believe these two table tops are the same size go to:

Shepard's Parallelogram Illusion

    From a stakeholder management perspective, the challenge is not eliminating mistakes – this is impossible, rather designing systems and processes in a way that will minimise unnecessary mistakes and accepting there will always be others that will require managing.

We can minimise mistakes by being aware we make them and avoiding the known traps and pitfalls. Joseph T. Hallinan’s book, Why We Make Mistakes is a good starting point.

Another impossible image by Roger Shepard

Dealing with the mistakes that occur requires acknowledgement of the error and appropriate actions to rectify the mistake. This applies equally to you, your team members and other stakeholders. The biggest mistake is expecting perfection (ie, the absence of mistakes)! The second biggest is failing to acknowledge a mistake once it has happened; as Confucius said “A man who has committed a mistake and doesn’t correct it is committing another mistake.”

So the next time the wheels fall off your project because someone made a mistake, rather than blaming the person, recognise mistakes are normal and be prepared to deal with ‘normality’.

The Zero Cost of Stakeholder Management

August 11, 2011

I am on my way to the Academy of Management 2011 Annual Meeting in San Antonio, Texas. The focus of my presentation is based on the philosophy of the Quality movement: quality is free! I am developing a line of argument that advocates a proper investment in stakeholder relationship management is more than balanced by the reduction in the failure dollars needed to fix the issues caused by poor stakeholder relationship management.

The cost of implementing effective quality and safety procedures is visible and accepted by management, but the result of effective processes is to make the cost of the failures these processes avoided invisible. You cannot measure what did not happen!

At the moment, measuring the cost of failed stakeholder management processes is relatively simple; several examples are discussed in the paper. However, management remain reluctant to invest in the solution to achieve similar outcomes to quality and safety. The challenge is cultural.

To read more on this emerging concept, see:

Australia’s new Prime Minister – Julia Gillard

June 24, 2010

It has been a fascinating 24 hours in Australian politics. The former Prime Minister Kevin Rudd was dumped and we now have our first female Prime Minister Julia Gillard. The unfolding drama was a mixture of ruthless efficiency in the coup to oust the previous Prime Minister, immediately followed by the start of a process of inclusion and healing.

Managers faced with difficult decisions can learn a lot from today’s events. My thoughts on several key issues are:

  1. Ethical dilemmas are always difficult and need decisions. As Henry Kissinger said: “Competing pressures tempt one to believe that an issue deferred is a problem avoided, more often it is a crisis invented”. There is no right answer to a dilemma, every option has a downside. Leaders choose a way forward and live with the consequences.
    [See: Ethics and Leadership]
  2. When you do decide on a course of action, don’t hide the issues that created the dilemma in the first place, explain your reasoning and acknowledge both the greater good and the consequential harm. When a Deputy takes over from her leader there are inevitable questions of loyalty and trust, honest reasoning lets observers understand the reasons for the decision.
  3. Conversations and transformational negotiations lead to better outcomes than win-lose transactional negotiations but often you need to make the first concession to start down this path [see: Win-Win Negotiations]. The Government and the mining industry were locked in a head to head battle over a new tax. In the space of 5 hours the new Prime Minister had unilaterally cancelled government advertising over the issue and offered open negotiations. The mining industry had reciprocated and suspended their advertising campaign. The negotiations may or may not reach a consensus (no one like having their taxes increased) but both sides are likely to end up with a better outcome if the transformational negotiations work.
    [See: Negotiating and Mediating]
  4. In a disagreement over principles, you only need to achieve your objective; you don’t need to destroy the other party. The former Prime Minister has been offered a position of his choosing in the new government. If accepted, this means his talents and knowledge are still available to the team. Reluctant allies are better than committed opponents.

It’s certainly been an interesting day watching a really effective communicator in action in action; I feel as though I have learned a lot.

The Cultural Dimension of Stakeholder Management

December 28, 2009

The importance of understanding culture in designing successful communications to influence and inform stakeholders cannot be understated. But as discussed in previous posts, culture is multi-dimensional. Some of the facets include:

  • corporate culture – how the organisation works
  • industry/professional culture – the way people in a profession work and relate
  • age – baby boomers, Gen X, Y and Z (at least in the western world)
  • national/ethnic cultures

The last of these facets tends to be over simplified in many texts. There is not just an east/west divide! Robert J House in Culture, Leadership and Organizations (2004 – Sage Publishing) reported on the Global Leadership and Organizational Behaviour Effectiveness (GLOBE) program that is undertaking a long term study of 62 societies.

The GLOBE study identifies ten national culture clusters that have distinctive leadership and management behaviours:

  1. Asian:
    a. South Asia – Philippines to Iran, including ASEAN countries and India
    b. Confucian Asia – China, Japan and Korea plus Singapore, Hong Kong and Tiwan
  2. European:
    a. Anglo – North America, UK, Australia /NZ and ‘white’ South Africa.
    b. Germanic – Germany, Austria and Netherlands
    c. Latin – Portugal, Spain, France, Italy, Israel.
    d. Eastern – Poland and Greece to Russia.
    e. Nordic – Denmark to Finland, Iceland.
  3. Arab – Qatar and Iraq to Morocco
  4. Sub-Sahara Africa including ‘black’ South Africa.
  5. Latin America – Mexico to Argentina.

The GLOBE study focused on the interrelationship between societal culture, organisational culture and organisational leadership. Attributes such as uncertainty avoidance, power distance and performance -v- human orientation were considered.

Yoshitaka Yamazaki in Learning Styles and Typologies of Cultural Differences (2005 – Science Direct) identifies six dimensions:
–  Cultural typologies in anthropology
      1. High-context vs. low-context cultures
      2. Shame vs. guilt cultures
–  Cross-cultural management literature
      3. Strong vs. weak uncertainty avoidance
      4. M-type organizations vs. O-type organizations
–  Cross-cultural psychology
      5. Interdependent-self vs. independent-self
      6. Field-dependent and field-independent

High context societies place great importance on ambience, decorum, the relative status of the participants in a communication and the manner of the message’s delivery. Effective communication depend on developing a relationship first, because most of the information is either in the physical context or in the context of the relationship, therefore relatively little needs to be in the coded, explicit, transmitted part of the message. Communication in low context societies tends to have the majority of the information vested in the explicit code transferred by the message. People from high context societies (eg, France or China) may think people from a low context society (eg, Germany or USA) think they are stupid because the low context people include all of the information in a message. Similarly, people from high context societies are unlikely to express their disagreement or reservations in an open meeting, circumstances and relationships are as important as work so they would comment in a more private or appropriate occasion but only if the opportunity is provided.

Shame or guilt considers whether a person has an outwards orientation based on the judgement of others or an inward orientation focused on their core ethical values to encourage high performance and moderate poor performance.

O-Type organisations are where the employees see themselves as a permanent part of the group; they are part of a social collective. M-Type organisations are more focused on individual achievement.

Field-dependent societies adhere to structures and perceive or experience communication in a global fashion. Field-independent societies and people are analytical; they can self-structure situations and have self-defined goals and reinforcements.

These differences in approach were one of the reasons I posed the question ‘do we need cultural extensions to the PMBOK?’ (see: PMI’s Voices on Project Management). But while understanding cultural stereotypes may be a helpful starting point, no grouping or stereotyping will provide the necessary subtleties needed for important communication.

Firstly, everyone’s experience is unique and the person you wish to communicate with will have been moulded by a range of influences including the corporate and professional cultures they have worked within. Second, no study I am aware of has focused on the effect of the global communication network on national cultural behaviours. The concept of baby boomers, X, Y and Z Gen, is very much a western phenomena, there are certainly likely to be age groupings in other cultures but where the divides lie and how technology interacts with the national characteristics is largely unknown (at least to me). Thirdly, people travel widely for both education and work, even after returning home they will have absorbed some of the influences of the other cultures they have lived in.

So how should you approach the planning of an important communication? As a start, try to define the normal communication mode of the person you are seeking to influence or inform. Understanding national characteristics helps, but is not enough; you need to seek information from a wide range of sources. Err on the side of caution if there is any doubt about the optimum mode for communication. Then carefully observe the effect of your initial communication on the receiver and adjust the mode until you achieve a satisfactory result.

My paper for the PMI Asia Pacific Congress, Beyond Reporting – The Communication Strategy, is also focused on the topic of effective communication, as is my next book, Advising upwards: A Framework for Understanding and Engaging Senior Management Stakeholders due for publication in 2011. So expect more on this subject in the New Year.

Issue Management & Stakeholders

December 19, 2009

Our business manager was a passenger on Qantas flight QF10 Singapore – Melbourne on 17th Dec. that experienced an engine failure after take off and had to return to Singapore.

From and risk and issues management perspective, overall the Qantas response was very good. In flight the information provided to passengers was timely, accurate and relevant.

By the time the aircraft landed some 40 minutes after the incident, busses and hotel rooms were organised, the hotel had found additional staff, check-in was quick and an evening meal provided (not bad for a problem that occurred close to midnight Singapore time.

The pre-organised emergency response plans even included bright orange stickers to ware so people directing the 350 passengers to the busses, etc could identify the people from the flight. Overall, from the flight crews response to the initial problem through to the ground crews management of 350 disoriented passengers the initial response was great an clearly demonstrated a well thought out response plan.

However, once the initial issues were managed, the following 12 to 18 hours were not so good – perhaps the accountants started to worry about costs?? There was no local contact point provided, no ability to deal with individual issues such as his need to access our business systems (we had to pay for the connection) and only limited communication.

What we find really strange is the time one would have expected communication problems immediately after the engine failure the Qantas service was exemplary, later when one would have expected the situation to be under control the Qantas service collapsed to a fairly low level of customer care.

The lessons to be learned from this experience are twofold. Firstly, good risk response plans really do make a difference, and there may be a place for generic plans at the organisational/PMO level for issues likely to occur across a range of project rather than the individual project each inventing their own. These generic response plans could also identify corporate resources that can be called in to help resolve an issue.

The second, more important lesson is the effectiveness of the initial response can be seriously damaged if the stakeholder communication diminishes before the people inconvenienced by the issue are fully over the problem. The Qantas response was technically efficient, right through to flying a replacement aircraft into Singapore for the journey to continue some 23 hours later; there are only a limited number of aircraft sitting around with nothing to do…..

Where Qantas failed was in personalising the follow through to help stakeholders deal effectively with their individual issues. Just a little extra care and we would have been praising Qantas 100%, as it is we feel rather disappointed in the final outcome: a C+ response rather than an A+ and all of the grades were lost at a time when the organisation had had time to think about its reaction, rather than when the problem first occurred.

Risk response plans need to deal with more than just the technical issues. Managing people’s expectations and disappointments is at least as important if the overall damage caused by a risk event or issue is to be minimised.