Tuesday, August 03, 2010

WHY Tree No-No

I recently received an email that I simply must share. It's about the value of WHY Trees (or Cause Maps, or any other form of diagramming). Yes, these tools have value. But don't get pulled into the muck! BEWARE! The following is the email I received.

I recently helped facilitate a Latent Cause Analysis where one of the stakeholders (an engineer!) had to do a cause map in order to communicate what happened and what caused the incident.

The facilitators obliged, thinking it couldn't be much different than a WHY tree, and I learned an important lesson.

When the engineer took it upon herself to do the cause map, she was immersed in it for 2 days (formatting, typing, coloring blocks, printing copies etc) instead of being immersed in the evidence with the rest of the stakeholders.

And what was worse, the other stakeholders were dragged through this map in a 4-hour presentation of causes and possibilities that reached into areas that weren’t supported by evidence.

The end result was a confusing document created by one person’s interpretation of the evidence.

Once the cause map exercise was complete, luckily we were able to save the stakeholder meeting and proceed with the LCA methodology. However, the waters were no doubt muddied by the cause map. But patience and persistence prevailed and we got the investigation back on track.

EVERYONE was discussing the evidence at hand and determined Physical, Human and Latent Causes while not even referencing the cause map.

This experience taught me something important: The answers to our questions come from immersing ourselves in evidence and pulling the causes from it, not focusing on the WHY tree (or cause map in this case).

I know how fun and even constructive it can feel to spend time drawing cause maps and WHY Trees. Believe me when I say I am enamored by them myself. But I also know, through painful experience, how devious they can be to revealing the truth of the causes of an event.