Think of the story of the RMS Titanic. What’s the first thing that pops into your head? Iceberg. But do you know that there were additional factors that led to the sinking of the Titanic and 1,514 deaths? Using a problem-solving technique called root cause analysis, we can identify at least five causes.
First, the ship was going too fast. Behind schedule and trying to make up some time toward the end of the trip, the captain ordered the engine room to bring the ship to full speed. Was the captain also eager to see how fast his new state-of-the-art ship could go? We can only speculate.
Second, some rare meteorological events occurred that year. The unusually warm gulf-stream water in the northern Atlantic caused more Arctic icebergs to melt and drift southward into the area of the Titanic’s route.
Third, the helmsman initially turned the ship the wrong way. He thought that he had been told to “make the ship turn right,” rather than “push the tiller right to make the ship head left.” Even though the mistake was quickly rectified, the iceberg probably could have been avoided if time hadn’t been lost because of the error.
Fourth, as metallurgists later discovered, the steel plates of the bow and stern were held together by low-grade iron rivets—perhaps because high-grade rivets were in short supply at the time, perhaps because the company that owned the Titanic was in financial difficulty. The hull would have ripped apart more easily with the low-grade rivets, causing the ship to sink faster.
Fifth, when the first officer ordered the engine room to slow down, it was impossible for the ship to slow down quickly enough. So he gave the order to reverse thrust, which caused the steering propeller to stand still for several seconds, making turning the ship more difficult. Even though the first officer thought that reversing thrust was the correct action to take, the seconds when no propeller was turning could have led to the ship’s collision with the iceberg.
In addition to these five widely accepted causes, there are two theories. One is that second officer David Blair, who initially planned to be on the voyage and had the key to the storage compartment for the watch-tower’s binoculars, was replaced just before the ship sailed. As a result, the people responsible for looking out for icebergs had no binoculars. That could have been kind of important, right?
Journalist Senam Molony has proposed yet another theory. He noticed in photos taken of the ship before it sailed a mysterious thirty-foot-long black spot on the ship’s hull. According to Molony, there was a coal shortage in England at the time due to a labor strike. This forced management to find other ways to keep the ship’s boiler running prior to the maiden voyage. Modern metallurgy experts say the wood-burning fire, rather than a coal fire, inside the ship could have weakened the hull by as much as 75 percent.
Thus the seemingly straightforward story of the Titanic becomes more complex when root cause analysis is applied. Sure, the iceberg sank the ship. But understanding the many additional causes and possible causes of the disaster, provides a more complete and accurate picture of what happened. When you think about it, it’s amazing how many things went wrong at the same time and contributed to the sinking of the ship.
Root cause analysis was also applied to a different disaster, the Columbia disaster in 2003. The space shuttle Columbia broke apart while re-entering the Earth’s atmosphere on February 1, 2003, destroying the spacecraft and killing its seven astronauts. The cause of the tragedy wasn’t immediately clear. The investigation team had to study every aspect of the disaster to consider every possible cause. Video footage of the shuttle’s takeoff—which had occurred sixty days before the disaster—revealed that a piece of foam insulation broke off the shuttle and grazed its left wing, damaging the heat shields—which are what normally protect the shuttle during re-entry. The eventual consequences of that foam hitting the wing were catastrophic. Thanks to the technique of root cause analysis, investigators concluded that this piece of foam’s damage to the craft’s left wing was the root cause of the disaster.
Now that you’ve seen root cause analysis in action, let’s talk more about the technique. The best way to describe it is using the metaphor of a weed. The most obvious parts of the weed are the leaves, because they can be seen above the ground. But the leaf isn’t the reason for the weed’s existence; there’s a complex system of roots beneath the surface that the weed wouldn’t exist without. Root cause analysis breaks a problem down into its various parts, so that all the contributing factors to a problem can be understood.
The consulting firm ThinkReliability, described it this way: “Root cause analysis is about digging beneath the surface of a problem. However, instead of looking for a singular ‘root cause,’ we shift your problem-solving paradigm to reveal a system of causes. . . . Most organizations mistakenly use the term ‘root cause’ to identify one main cause. Focusing on a single cause can limit the solutions set, resulting in the exclusion of viable solutions.”
Here’s how to go about conducting a root cause analysis.
Step 1. Develop a problem statement.
The problem statement is usually pretty straightforward, but you need to write it down to make sure that it remains the focus of the analysis. In the Titanic example, the problem statement would be “The ship hit an iceberg, resulting in the death of more than 1,500 people.” In the Columbia example, it would be “The Columbia disintegrated upon reentry, resulting in the death of seven astronauts.”
Step 2. Identify multiple factors that contributed to the problem.
Start by identifying the sequence of events surrounding the actual problem. Ask yourself what happened before the problem occurred. Think about how far back to go. The low-grade rivets were used during the shipbuilding process, for example, long before the Titanic sank. And the root cause of the Columbia disaster occurred sixty days before the tragedy occurred. Identify as many factors as you can. Using the five whys technique here, to brainstorm multiple causal factors, can be very useful.
In addition, think about the values and culture related to the factors you identify. Which of the organization’s beliefs allowed each particular factor to play a role in the problem? For example, in the face of financial troubles, it’s likely that the company that owned the Titanic relaxed some of its materials standards to save time and money. And investigators of the Columbia disaster recommended that NASA make significant changes to its processes and organizational culture.
Step 3. Identify the root causes.
Remember why the Titanic watchman wasn't using binoculars? It was probably because he didn't have the key to where they were stored. Not having the key was one of multiple root causes. Once you think you've identified one of the root causes, there is an easy way to test if it truly is one. If you had been able to fix the cause, would it have eliminated the problem? For example, if the watchman had been able to use binoculars that night, would he have spotted the iceberg in time to avoid it? Probably. And if the piece of foam had not caused damage to the heat shield, would the disintegration of the Columbia have been avoided? In all likelihood. That's how you know you're onto a root cause.
Step 4. Connect the root cause to the problem statement.
Now that you have identified the root cause (or causes), go back to the problem statement you created in step one. You'll want to connect each root cause back to your problem statement. Using the Columbia example, it would go something like this: the shuttle disintegrated upon entry because the heat shield was compromised when a piece of foam came off and hit the left wing at takeoff.
Root cause analysis is a very powerful technique. It does take time, however. Don’t be surprised if you find yourself frustrated while searching for the root causes of problems. You might even think there isn’t a root cause to find. But keep on going. Eventually, your analysis will uncover what's really going on.
Here’s an example of root cause analysis that is closer to the business world. I used to work for a company called U.S. Satellite Broadcasting (now DirecTV). USSB helped launch the eighteen-inch satellite dish that has been popular for the past twenty years. When I started working there, we had about 500,000 customers (there are more than 21 million today). I worked in the corporate marketing department, in the customer retention division.
One day, the company’s customer service call centers started hearing from a lot of unhappy customers complaining about their reception. Naturally, the call center reps thought the problem had to do with malfunctioning equipment, so they followed the protocol of troubleshooting over the phone to get the customer's satellite service back to normal. But the usual troubleshooting wasn’t working.
What was really going on here? What was behind the problem?
It turned out to be solar storms. The technical term for these large emissions of energy from the sun is “coronal mass ejections.” When this massive amount of energy hits the geosynchronous satellites that are more than 22,000 miles above the earth, TV reception suffers.
After solar flares were identified as the root cause of the problem, we handled customer communication in a completely different way. We proactively sent customers messages about approaching solar storms to explain what was going on and let them know to expect minor service interruptions. Once the customers understood why their satellite reception wasn’t perfect, they could just accept having poor service for a day or two and move on.
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