Zero-Based Root Cause Analysis (1)

I recently viewed a slide show about Foreign Material Management, i.e., making sure the wrong stuff doesn't get into our systems. It was based on learning's from past investigations, and was an excellent slide show.

We have learned an enormous amount about why things go wrong through investigating past incidents. Obviously, it is imperative to share what we've learned so that others do not experience needless pain.

As I was viewing the slide show, however, I remember thinking that there’s a difference between what we've learned, and how we've learned it -- a huge, monumental, life-shattering difference! Unfortunately, it seems that many people confuse the two.

Let's suppose, for example, that you have never eaten with with chopsticks. If you went to an oriental restaurant and were unable to use them on the first try, you would probably try another time, and then another until you were finally able to eat. In this simple example, you learned how to use chopsticks by trial and error.

Now let's suppose that you wanted to take your child to the same oriental restaurant, and you wanted him to avoid the frustration you had. You would most probably teach your child how to use chopsticks, based on what you've already learned. I think this would be good, responsible parenting.

We learn from our failues, and then we teach other people how to avoid that same failure. This is life. This is "being responsible." This is good.

But let's suppose your child couldn't use the chopsticks even after you taught him! The tendency, in this simple example, would be for you to compare what he was doing with what you told him to do. "Is he holding the chopsticks the way I suggested?"

We tend to investigate things that go wrong by comparing what went wrong with our predetermined understanding of "correctness." What if our predetermined understanding or correctness is invalid?

In the chopstick example, what if your adult hands were able to hold the chopsticks in a way that was impossible or ineffecitve for your child's smaller hands? Wouldn't it be better to simply look at the evidence in front of you, in this case your child trying to eat with chopsticks, with an open mind about what's going wrong. Even more, might it not even be better to let your child struggle a bit on his own? After all, he might invent a better way?

When we use our past learning’s as a basis of “goodness” when investigating an incident, I believe we’ve biased ourselves in the utmost manner. After all, what is bias? Isn’t it a “preconceived notion?” Isn’t bias the number 1 (or close to it) obstacle to learning something NEW? There’s a difference between how to learn, and how to apply those learning’s. We mix them up all the time.

Is it possible to do a root cause analysis without any reference to our past learning's?

I say YES! Not only do I say YES, I also say this is the ONLY way to grow -- to see what we've never seen, and go where we've never gone.

Beware of those who are asking you to compare what went wrong with a predetermined understanding of correctness.

More later..........