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.

The Art of Learning

April 3, 2010

I deliver a significant number of training sessions each year through Stakeholder Management and Mosaic Project Services; including both face-to-face classroom courses and using our Mentored Email™ distance learning methodology.

One of the interesting observations is how the rate of information absorption (ie, learning) varies from person to person. The rate of learning does not seem to be correlated to a person’s IQ, industry or role in the workforce. If anything, people who absorb the learning more slowly seem to retain the information longer.

It would appear the ability to learn is a skill that is exercised naturally by younger people, but as one grows older this natural ability seems to fade with only some adults maintaining their innate capability to learn, frequently linked to active practice via university courses, etc. When presented with a large volume of new information (eg, a PMP course) the rest of us need to learn how to learn!

Some of the easier ways to absorb, make sense of, and retain information include:

Using analogies and metaphors

You can learn abstract processes by creating metaphors for more common events. So whenever you learn a fact, ask yourself what the idea is similar to in the tangible world; eg, a data store in a software program may be a cupboard with different things on each shelf.

Build mental pictures

If you break apart a complex mathematical formula into components, you can try to imagine what it would like as a graph or how each component influences each other in a railway switchyard.

Build on the basics

Do a bit of extra research on your most difficult topics focusing on their foundations. You might not understand the more complex theories perfectly, but it makes understanding your testable material much easier.

Become the teacher

The act of explanation creates connections. Ask yourself how would you explain what you’re learning to someone else? Teaching forces you to simplify and break down complex ideas and then re-connect them to build the overall picture.

Stop writing transcripts

Try to free yourself from rigid note taking (the course handouts fulfil this need), instead write down ideas in branches and connections. Add your own thoughts, diagrams and arrows linking ideas so you have a web of information. ‘Mind mapping’ tools are great for this but pencil and paper work just as well.

Draw Diagrams

Most people think in pictures and maps. Research suggests drawing will increase your concentration and help develop the connections between ideas. A picture may not be worth a thousand words, but it can often illuminate the connections that lead to a greater understanding.

There are many more sophisticated memory techniques available in a range of books on the subject but certainly in our areas of teaching, the ability to link ideas and understand the flow of both ideas and information seem to be the key to real understanding.

This opens up a second strand of thought – making the best use of a training course. Some simple tips that will help you to get the most from your training course include.

Before the training course

  • Have a clear picture of what you hope to get from the training course expressed in terms of the benefits to you: a pay rise and promotion is more motivating than a PMP credential.
  • Do any pre-course reading and make a note of any questions to bring along and ask the trainer. You won’t pay extra if you make the trainer work hard……

At the training course

  • Arrive prepared
  • Be open to learning new concepts, even if these challenge your previous understanding
  • Don’t be afraid to ask the trainer to clarify points; remember that if you don’t understand something, it is likely that you are not the only one
  • Share experiences when they are relevant and learn from others in the group, they are likely to be from different industries and have different experiences; take advantage of the fact that you’re surrounded by people with diverse work backgrounds.
  • Dedicate time each evening to completing your homework activities, or reviewing the work covered during the day (our training courses cover a great deal of content in a condensed fashion – reviewing the material each day helps to cement the ideas in your mind).

After the training course

  • Use the resources provided during the training course to help you integrate the concepts into your every day work life (the first 24 hrs after the course are a critical period for reinforcing learning by practice).
  • Make the effort to change if you have discovered better ways of approaching your work, but remember you will need to explain the benefits of the change to people who did not attend your training sessions.
  • Recommend the training to any colleagues that you believe will benefit from it

Learning new things should be an enjoyable process at all stages of life and career, and is becoming increasingly important to stay competitive in a rapidly changing world. Learning how to learn effectively is the first step along the journey.

How to Suffer Successfully

December 7, 2009

How to Suffer Successfully, is the title of chapter four in Alain de Botton’s first book of philosophy, How Proust Can Change Your Life. The same idea is the theme of The Adversity Paradox by J. Barry Griswell and Bob Jennings.

The Adversity Paradox is full of inspiring examples of people who have suffered major adversity and have used the experience to improve their capabilities and gone on to outstanding success. The knowledge they gained from overcoming obstacles has played such a crucial role in their success trajectories that they now consider adversity to be an invaluable friend.

De Botton takes a more philosophical view and recognises there are ‘bad sufferers’ and ‘good sufferers’. Bad sufferers learn nothing from their adversities and react to them by engaging defence mechanisms that compound the problem such as rage, delusion and arrogance. Successful sufferers, including those identified in The Adversity Paradox, use their adversity to gain a better understanding of reality and by rising to the challenge, create a better future for themselves and others.

Whilst no sane project manager would chose to suffer sufficiently to produce their version of Proust’s In Search of Lost Time, only the most naive would expect their project to run without a problem. Projects and their attendant stakeholders are a potential source of much grief and suffering, all be it at a lower level of intensity; schedule slippage test failures, cost overruns and accidents to name a few.

As identified by de Botton, bad sufferers try to hide the problems, blame others and learn nothing. Ethical and effective project managers accept their suffering and use the experience to grow their knowledge and capabilities. Quoting Proust, “Griefs, at the moment when they change into ideas, lose some of their power to injure.”

No one likes a project that fails! However, it is only when you are experiencing the pain of failure, the opportunity to learn from the failure opens up. By using the opportunity to maximise the lessons learned, you minimise the potential for similar problems in the future. The cost of the failure is the coin by which future gains are purchased. The difficulty is developing the level of understanding needed to really achieve valuable lessons learned; finding the ‘cause of the cause’. The second more complex challenge is ensuring the lessons learned are transferred to the organisations store of knowledge and available for others to use and thereby avoid unnecessary pain and suffering.

De Botton suggests being a ‘good sufferer’ does not entail subscribing to the Romantic cult of suffering for its own sake, rather making practical use of the occasions when suffering is unavoidable to create new insights and grow in capability or knowledge. Our addition to this basic idea for the practicing project manager is to then make sure the lessons learned are effectively distilled, recorded and made available to others for the future benefit of the organisation and the profession.