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Arun Hariharan

Management

Generalization: The Enemy of Root Cause Analysis

Keep asking why until you reach the root cause

Published: Wednesday, March 2, 2016 - 15:28

A horrific accident on Dec. 16, 2015, claimed the life of an airline service engineer: He was sucked into the live engine of an aircraft. The engineer had been standing on the ground supervising the aircraft being pushed in reverse from its parking bay.

“No one knew what happened,” said an Air India source. “All of a sudden we hear that the technician has been sucked into the engine. The body had been badly mutilated."

Aircraft can only move forward. Towing vans are used to push aircraft when they need to move in reverse. To supervise this process and be visible to the pilots, an engineer is positioned on the ground in front of the aircraft nose. During a regular startup, once the aircraft has been pushed back and is ready to start taxiing, the ground control gives startup clearance after ensuring that no one is near the engines.

One day after the accident, the Aircraft Technicians Association released a letter directing its members not to give engine startup clearance until further instructions. The letter included this statement: “The incident... has forced us to rethink our working conditions, which [were often] brought to the knowledge of the management, to no effect.”

According to the letter, a majority of the problems pertain to the airline’s severe manpower shortage, especially of pilots, leading to flight delays, thereby putting pressure on engineers—in all, increasing the risk of accidents.

Some people guessed that the pilot didn’t follow the standard operating procedure of waiting for clearance from the service engineer on the ground before starting the engine. Another statement issued to the press was about the shortage of flight attendants, although it’s not clear how this linked to the accident. It’s likely that the issues talked about by various sources are real and need attention.

This article is not about the accident itself, but about the responses to the accident. My point being: How many of these issues have to do with this particular accident? A statement such as “problems pertain to a manpower shortage” is a generalization and not a root cause. At the time of writing this article, no root cause analysis of the accident is evident. There’s no information about what exactly caused this accident. Without knowing the exact cause, how can similar accidents be prevented in the future?

Generalizations can be dangerous because they deflect the focus away from the real root cause(s). At times, vague and general statements pass off as root cause analysis. For example, customer complaints are brushed away with comments like: Oh, some customers will always complain. “Always” is the wrong word to use while trying to identify the root cause. Generalizations can lead to loss of customers and loss of life.

My book Continuous Permanent Improvement (ASQ Quality Press, 2014) contains an entire chapter that explains the technique of root cause analysis through an interesting story. The message is simple: Keep asking why until you reach the root cause; don’t generalize or jump to conclusions.

Discuss

About The Author

Arun Hariharan’s picture

Arun Hariharan

Arun Hariharan, author of Continuous Permanent Improvement (ASQ 2014), and The Strategic Knowledge Management Handbook (ASQ 2015) is a strategic quality, knowledge management (KM), and performance management practitioner with nearly three decades of experience in these fields. He has worked with several large companies and helped them achieve substantial and sustained results through quality and customer focus. He is the founder and CEO of The CPi Coach, a company that provides partnership, consulting, and training in business excellence and related areas. Former roles held by Hariharan include president of quality and knowledge management at Reliance Capital Ltd, and senior vice-president of quality and knowledge management at Bharti Airtel Ltd, India. He is a frequent speaker at quality and KM events around the world. He is also the author of more than 50 published papers on quality and KM.

Comments

No such thing as a root cause

Hi,

Unfortunately your pitch here is fundamentally flawed, which is odd if you come from the aviation industry where the following is "de riguer" in incident investigations.

There is no such thing as "a" root cause.  The minimum number of causal factors is 2...one gap in the controls ("latent condition" in the Reason Model) and one behaviour ("unsafe act" in the Reason Model) that exploited it.  

I commend you to Prof James Reason's two seminal books on the subject and to Dean Gano's small book about Apollo Root Cause Analysis.

This might help as an intro  http://www.clearlineservices.co.nz/SiteAssets/qnewz-articles/1212SolutionsFirstPaperWorldCongress.pdf 

Cheers 

Generalization prevents improvement

Ian, you seem to have missed the whole point of my article.Nowhere have I said that there can be only "one" root cause.

Secondly, the main point of the article is about the "generalization" that sometimes follows such incidents - the article is not about the aviation industry, though a topical example has been used. I am sure your own statement that investigation is "de riguer" is true in "general", but the point I am making is that there is no evidence of any investigation in this particular instance. If you read the reports given as links in the article, they point to general statements (some of which may or may not have any link to the accident), without any investigation into this particular incident.

In my 30 years of working in quality across industries, I have come across a number of instances where there is a tendency to "explain away" a problem (which could be a customer complaint, a product defect, or an accident) with general statements, thus losing the opportunity for permanent improvement.

No such thing as a a root cause

Arun, your last sentence is "The message is simple: Keep asking why until you reach the root cause; don’t generalize or jump to conclusions."  

This is wrong on two counts.  

There as no such thing as the root cause, there are at least 2 causal factors, in fact two groups of causal factors.  Second, simply asking why isn't enough either because it's linear in a binary model.   

What you actually refer to I think, is what I call Solutions First Syndrome, where someone  (or a team) jumps to a conclusion then makes their observations fit.  The classic demonstration is the fishbone diagram, that requires the identification of cause areas first.  In my 40 years, I have never known the fishbone deliver anything other than trivia and obfuscation.

Have a look at my paper..it might help....

Cheers

Focus on results, not jargon

Ian, please read my last reply. I don't think you have still got the message of my article. I have never said that there can be only "one" root cause. This article is also not about the relative merits and limitations of different methods of getting to the root cause (or causes).

The message of this article is "do NOT jump to conclusions or generalize" - I am sure even you will have no quarrel with that.

As far as the technique of getting to the root cause (or causes) of problems is concerned, may I refer you to my book Continuous Permanent Improvement (ASQ 2014) which has an entire chapter on the subject. This is based on actual implementation experience in a variety of companies, and provides actual examples of successful application and results. Again, I am not claiming that the method that the companies in the examples followed is the only method.

I would advise you not to get stuck up on terminology or jargon - what matters is application and lasting results.

No further correspondence in this matter from my side.