When a company starts out doing root cause analysis, if the analysis is related to the demise of a physical object, they usually mean physical causes.

For example, “Why did it rust?” The answers are expected to be some form of “because some foreign substance was present” or “the wrong material was used.” Beginner root cause analysts will usually stop there. Even if they are using some form of “5 Whys,” the “whys” are usually going to be confined to trying to follow the trail of whatever substance was found to be the problem, rather than expanding the whys to why ANY substance was present. So, one of my colleagues found sodium and chlorine and carbon on a stained part and immediately concluded that one of his co-workers had been eating chips and drinking pop in the part packing room. This is unauthorized. There we have it. A rule was broken, and now there are contaminated parts. The employees are blamed and reprimanded somehow.

A more comprehensive level of root cause analysis for the same situation might look at why the employee thought that it was OK to break the rule that day. Is it because they had been doing it for months and not gotten caught? Is it because they don’t think they are being paid enough to really care about their job? Is it because they are diabetic and got up late and missed breakfast and could not wait until their break without getting faint? Is it because they see others breaking other rules all the time without getting caught? All of these other types of potential “root causes” are left unexplored. A good root cause process allows the company to find more and more comprehensive descriptions of causes as they work with the process in their own situation. More comprehensive analysis is good because it lays the groundwork for more effective responses to the problem that initiated the analysis in the first place. So, more comprehensive analysis, in line with Definition 39, would tend to extend the time between similar events.

We will finish our discussion of this topic next time.