The RCA Phoenix

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Chris Eckert

Feb 19, 2016

Like the phoenix of Greek mythology that emerges from the ashes of its predecessor, Root Cause Analysis programs have been undergoing similar transformations recently.

During the recession, many previously solid RCA programs went into a slow burn, and a good number eventually collapsed entirely. Lack of resources, lack of support, and lack of direction were the culprits--no surprise here. 

Fortunately, this trend began to reverse about a year ago. What changed? In my observation, a major driver was that the incident impacts were becoming so large that more problems started hitting the radar up in the C-suite. The sting was especially poignant because the causes were getting simpler, not more complex as many would probably think. Loss impact had increased ten-fold after all the downsizing and cost cutting from the recession. Brush fires that were previously stomped out quickly went unaddressed. They turned into wildfires. The pain and lost profit companies were experiencing (and tolerating) was incredible, especially in light of the fact that just a few years earlier this had been completely unacceptable. However, it seems Malcolm Gladwell’s “Tipping Point” was reached in 2015. Organizations had seen and tolerated enough and started asking questions such as: 

•          “Why are we having so many major incidents?”

•          “What happened to our RCA program?”, and

•          “Who is in charge of RCA in the business these days?” 

What they heard in response was crickets, mainly. 

Many organizations are now re-establishing their RCA programs. Unfortunately, many have to start from scratch because the entire programs, along with their facilitators, burned to the ground. Adding to the challenge, there are few people left with RCA experience to help the program champion rebuild. Often, the program champion is also new to RCA. 

If you are captain of that ship, here are a few recommendations to help you get your RCA program started:

  1. Identify your key/lead facilitators and have them form a small team to evaluate RCA methods (if you don’t have a standard already). Select one method and standardize on it.
  2. Develop Threshold Criteria (If you want a one page PPT template to build from, send me an email). Make it clear to your team when they need to apply RCA. This also establishes the value proposition for RCA
  3. Figure out where you are going to store the RCA data. This may not seem like a big deal, but it is very important and it will be one of the very first questions all your facilitators will want answered. More on this below.
  4. Provide the necessary training and tools to those who are new to RCA who will be facilitating.   

Of course, there are other things that you should be doing, and those need to be eventually completed, but these should be your initial focus. Send an email if you would like to receive the 14 page RCA Program Development guideline. As you develop your plans, we are always willing to share our thoughts and suggestions on a customized plan to optimize effectiveness while keeping within budget.

A couple thoughts for consideration for your program:

  1. Method:  5-Whys & Fishbone are the class cheerleaders—they look good now, but they won’t age well. That said, if you are under extreme budget constraints, either of these will get you going at essentially no cost, however you will quickly encounter their limitations. Neither are truly methodologies and neither are very accurate. They both are highly susceptible to individual bias, enabling the facilitator to achieve a pre-determined outcome without much trouble. Expect a lot of ‘retrain’, ‘re-communicate…” and “re-inforce the need to…” as solutions. I believe I speak on behalf of all RCA providers when I say that if you pick any of the structured RCA methods and apply it consistently, you will get far better results than 5-Whys or Fishbone. Your payback will exceed training/software investment on the first or second RCA that you tackle. In my experience, 5-Whys and Fishbone miss about 2/3 of the causes that need to be exposed. When causes are missed, problems come back resulting in more being spent on solutions and rework than need be.
  2. Data storage:  While it may not immediately be apparent, a big reason RCA programs fell apart in the recession is because there is no underlying ‘system’ that served as the binding glue while all the turmoil took place. An Enterprise RCA application establishes the consistency needed when turnover is heavy. It demands consistency both in the reports/data generated and the work processes that facilitators need to follow from RCA inception to close out. People move in and out, but systems remain. When systems are missing, your program is totally ‘people dependent’ leaving it exposed to variation, and/or complete collapse when the champion moves on. If there is one lesson the recession made clear, it was that without an underlying system to serve as the stable reference point for the RCA program, such as an enterprise RCA application, your program is at high risk of falling apart. This didn’t just happen to RCA; it happened with many other systems as well. Side point--regarding data, if you allow RCAs to be stored solely as Excel, Word, or PDF, how are people going to retrieve, sort, and use this information in the future? The data needs to be structured and stored in a system so that it becomes accessible and usable knowledge for others. If you want people to leverage lessons learned, you must provide them a system that enables easy retrieval by location, type of incident, key words, etc. People don’t have time to scour though individual Excel files looking for nuggets. They just won’t do it.
  3. Software:  Over the years, I have seen the difference that RCA software makes. 25 years ago when I first got started with RCA, people were drawing cause and effect charts by hand. On average, less than 10 causes made the chart. Then, enter Visio and the Microsoft tools circa 2000. Big improvement for the time. Charts then grew to 10-15 causes. Then, bona fide RCA charting software came on the scene. It drew the boxes and lines for you and auto-arranged things. Even though it was a vast improvement, chart display and output was still clunky, at best, but charts grew to about 20 causes. Today, good RCA software that optimizes chart white space, provides expeditious chart construction and is simple to use has driven the average cause and effect chart to about 30 causes. Right or wrong, people usually only dedicate a fixed amount of time to the RCA—its not open-ended going in. If they have to spend more time drawing boxes, they spend less time thinking about causes and they end up with smaller charts. So, what’s the big deal about having bigger charts? Simple. More causes means more solutions to choose from which means more fast, cheap and easy solutions will be available for the picking. This has driven the ROI of the RCA to very high levels, up to 5,000% in many cases. It has also dramatically improved the quality of the RCA’s as compared to 25 years ago. 
  4.  Facilitators:  Your facilitators make a huge difference on the results you see. I’m old-school (and my co-workers frequently remind me. I believe I am one of 39 remaining people on the planet who doesn’t have a Facebook account). But, this stogy old guy has an insider tip that may surprise you: When choosing your Facilitators, look for the Millennials. Millennials, on the whole, do a great job facilitating, and they generally do a great job running the software and building cause and effect charts. Millennials have RCA software figured out before it is even introduced in class. So, while your Millennials may not yet have the experience or knowledge of all your processes, tap a few for facilitators, and definitely pull one into every RCA. They build accurate cause and effect charts faster than any group I have seen. On the team, they are helping build an accurate chart quickly while also acquiring new knowledge about the processes and systems. They also build new relationships with others in the organization which is very important to the long term success of the individual, and the organization. Word of caution: If you ask a Millennial to build a chart with a Microsoft tool, expect them to look at you like you have a horn coming out of your head. Like it or not, they expect high performance software and training. The good news is that they use them, immediately and you get the benefit right away. It’s money well spent. 

If you are charged with riding the RCA phoenix, feel free to reach out to any of the Sologic offices worldwide for additional ideas, support and solutions. Good luck!