By Jack Jager
Understanding the root cause of a problem is the purpose of many or all investigations. However, the concept of “root cause” suggests that there is only one, singular cause that is at the “root” of any problem.
The root cause concept and how it is applied often leads to this perception of a singular cause. For example, the statement “What is the root cause of the problem?”
So what is “root cause” and how is it defined? It can be difficult to find a clear and precise definition. The following well-defined description reveals something very simplistic; “Root Cause can be described as that cause, which if it were controlled or eliminated would make the problem go away. Therefore it may be considered a root cause”.
This is an interesting concept as it can be applied to a number of causes within a cause and effect chart, therefore, it can be said that there are many “root causes”.
Cause and Effect analysis and Reality charting indicates that a problem doesn’t occur from a single cause, but for any problem there can be many cause and effect relationships that can trigger a problem. Therefore how do we know which of these causes is the root cause?
If you were to ask this question to various people, there may be a number of different answers. One person may think the root cause is one thing, while another would consider the root cause to be something else. Each party may in fact be right. So how can a “root cause” be assigned unless we are certain that a solution will prevent the problem from recurring?
Let’s look at the example below:What are the causes of a fire? For a fire to occur there must be certain conditions present. Each of these conditions are a contributing cause of the fire.
- There must be oxygen present (a conditional cause)
- Fuel to burn (a conditional cause)
- An ignition source, such as a match or lighter (also a conditional cause)
All of these causes can exist in harmony with each other and can do so for some time.
It is only when an “action” cause occurs, such as the lighting of a match that the fire will actually occur.
So what is the “root cause” here?
If we apply the definition provided above for “root cause” here, then by eliminating the oxygen, there would be no fire. Therefore “oxygen” is a root cause of the fire.
If you were to remove the combustible material, fuel, then this too will satisfy the definition requirement. The problem would not reoccur. Therefore “fuel” is also the root cause of the fire.
If you were to also remove all of the ignition sources, then there would be no possibility of a fire. This too satisfies the definition requirements. Therefore the “ignition source” is the root cause of the fire.
If no match was to be lit, then there would be no fire. Therefore “the lighting of the match” must be the root cause of the fire as well.
Based on this example, there are potentially four root causes and each of them satisfies the root cause definition. This can be quite confronting in a sense to recognise that there are many potential root causes for a problem. It is, however, liberating too because now you have many potential corrective actions rather than just one.
How often have you heard someone ask “What is the root cause of the problem?” and “you can’t control the problem until you have identified what the root cause is”.
How do we determine which causes to control? In the fire example, who will determine the control or controls to put into place? It’s unlikely that oxygen will be eliminated, as this can be a very costly and difficult process (although we do use this concept in confined spaces).
Can we control the combustible material? If we were to eliminate the fuel then would we have an effective control? This is possible in some cases but not in others.
What about the ignition sources? If there were no lighters or matches present or available, then there would be no fire. Do we have the ability to remove these?
If we could stop the persons action from occurring then we would also have controlled the possibility of a fire happening.
Based on these rationales, which of these controls should be implemented? Is this decision governed by certain criteria? And then the question about what we can control also comes into play.
So what criteria can we use to determine our choices?
- Money - it needs to be cost effective
- Safety - it needs to be safe
- Easy - if possible it should be easy to do
- Quick - being able to do it quickly has merit
- Doesn’t cause other problems – at least not unacceptable problems
- Is an ongoing fix – and is not a band-aid. The solution will fix the problem for today and tomorrow, as well as next week and next year.
and other criteria may also be considered.
The above criteria are taken into consideration when making the decision about which solutions to implement. At the end of the day, it is important to have an understanding of the problem and how many of the causes you need to control to prevent recurrence.
Did the notion or understanding of what the “root cause” is come into consideration when making the decision about which solutions to implement? No, therefore what is the value of identifying “root cause”?
In my mind, it is the concept of “root cause” that is important. Applying this concept requires us to understand the problem as completely as possible, before we make decisions about corrective actions. If we do this, then we are in the best possible position to make good decisions about which corrective actions to implement.
The decision of which solutions to implement is a choice. It is a choice we make according to a set of criteria. It is based on the answers you acquire when applying the criteria questions that allow you to be objective in your decision making process to find the best solution.
In Summary
In many ways the concept of “root cause”, whilst being important in the broader application, is often a misnomer when used to describe the critical cause for a unique incident. It is not the only cause. Other causes must also exist.
At the end of the day it is your choice about which causes you wish to control. Therefore it is important to remain objective in this decision making process, via utilising a set of criteria, and applying them to all possible solutions. Let the answers to the criteria questions determine what the best solutions are, and that will determine what you consider to be the “root cause” of the problem.
