The Journey to Root Cause

By Patrick Kinane

I was giving a presentation on “The Psychology and Physiology Behind Mistakes” in front of a number of AMTs recently. It was an interesting presentation, at least in my eyes, but when I was finished I was approached by one of the attendees and asked what course of action I would recommend because the employees where this person worked are continually not compliant with procedures and causing errors. I wish I could just say “take these two quality tools and see me in the morning.” Unfortunately, there is no magic pill or 10-step plan, so I could not provide a concise answer that would put his mind at ease. The reason is that noncompliance with procedures is a symptom and not a cause. If you fix the symptom, the cause will eventually rear its ugly head and bite you again. “That root cause analysis stuff is just too time consuming,” you say. “Let’s just fix it and move on.” It isn’t that simple.

We do a pretty good job at the short-term fixes. This is an in-your-face, fix-it-now scenario. The water pipe burst in the basement of your house and you instinctively know to run and turn the water supply valve off. This is short-term action. Its purpose is containment, intended to keep the present situation from progressing and making things worse. This is not typically a sustainable fix. You can’t live in your house with the water supply shut off. You need to fix the broken water pipe. Now you fix the broken water pipe and this is your long-term corrective action. Right? Wrong. You are still in the short-term corrective-action mode because you have not done a root-cause analysis. Short-term corrective actions may be the long-term solution, but typically they are targeted at resolving symptoms. Modern medicine can’t cure a cold, but you can take medication that will ease the symptoms. Your cold will go away on its own in a week, but if you take the medication it will be gone in seven days But you say, “I fixed it.” Pipe broken – fixed pipe – done. Not so fast there, rocket man.

Asking why

Why did you have water in the basement? A water supply pipe broke. Why did the pipe break? It must have had a weak spot. You might say, “Who cares? I fixed the pipe, there is no more water leak, let’s get back to work.”  But why did it have a weak spot? It’s been in the house for 50 years and is probably just old. Why did only this pipe break? This is probably not an isolated incident. Why is this not an isolated case? Due to the age of the pipes, others might be ready to break. Asking why again will not provide any additional information that is directed at the original problem, so we can stop asking why.

We could ask why ad infinitum but it will not yield any value. Your three-year-old will ask why way past the point where the desired answer was received. This is overkill, and your three-year-old finds it interesting to continue asking because it continues to get a response until you get to the point of replying “because I said so” to end the dialogue. (If you have a particularly tenacious toddler, the “why” discussion may continue — but that is another matter and I digress.)

The business world thinks conversely and has a tendency to stop asking why too soon. We would see that a pipe is broken, fix the pipe and call it quits. We never got past the first why. We “fixed” it. Then, a while down the road, another pipe breaks and we have another leaky basement. Maybe this time we don’t catch it in time and the water does significant damage. The cost of just replacing that pipe now gets expensive. What do we do? We replace that broken pipe and move on. We “fixed” it … again.” Time passes and we think we’re safe. Then a pipe breaks upstairs and causes damage to the upstairs floors, walls and ceiling, let alone furniture damage. This time we call in a plumber and he tells us that we need to re-plumb the house, and we also need a person to dry out the house, repair the walls, paint, fix the warped floor, and replace the damaged furniture. The damage is so extensive that we have to vacate the house so repairs can be accomplished.

Add up the cost for all three water leaks as compared to doing a thorough root-cause analysis and re-plumbing the house from the beginning. It’s considerably more expensive, let alone the inconvenience as the problem progressed. Why wasn’t this done in the first place? Granted, it initially feels like overkill to re-plumb the house over a simple water leak — but why didn’t we investigate further after the second leak? We suffer from short-term decisions (STDs). We look for victims and quick resolutions so we can return to production. Time is money.

Analysis levels

I agree that doing a thorough root-cause analysis is time consuming and eats up valuable resources. Although you must do a root-cause analysis for all actions, there are certain levels of root-cause analysis depth. You can do an instant corrective action and root-cause analysis for some issues, a medium investigation for others, a thorough dive for others, and a robust in-depth analysis for the chronic, imbedded and latent problems.

How do you decide how in depth you should go? Start by developing a defined threshold for your business. What is your pain tolerance? If you go to the doctor with pain, he or she will typically ask, “On a scale of one to 10 with 10 being the worst, what is your pain level?” This is subjective as we are going to have different pain tolerance thresholds. A level three for one person might be a level eight for another. That is perfectly OK because that is how you feel it and that’s what is important. As each individual is unique, so are businesses unique.

The duration factor

Now let’s say that you tell the doctor your pain is level two. Normally that is the end of the discussion on pain, but how long are you willing to accept a level-two pain? Duration is also a factor in pain but is rarely considered because pain is mostly transitive and will dissipate over time. A level two might not warrant medication (or maybe just aspirin), but a level six or above might require more aggressive treatment. A level two is tolerable for a short duration but not for an extended time. However, even minor pain for a long duration signifies that something is systemically wrong and requires investigation.

If you have a level-two pain of long duration and it’s diagnosed as mild arthritis, you might find over-the-counter treatments acceptable. If the pain level increases, you know something has changed and you need to revisit the doctor for re-evaluation. If you have a level-two pain that is diagnosed as a charley horse, you accept that it is only temporary. If the pain continues beyond a reasonable period, you revisit the doctor for re-evaluation. In both cases, there is a change from the accepted status quo.

Getting back to individuality, some people would rather have their bandage removed quickly and others slowly. Some are partial to a small amount of pain for a longer duration versus a lot of pain for a shorter duration. Neither is right or wrong. It is a matter of personal preference.

Determining risk

What I am getting at with all this is determination of risk. What risk are you willing to accept in your business? What level of pain or risk does your business determine is acceptable? You may come back and say zero is the only acceptable criteria for safety and quality errors. I have to agree in the ideal world, but in reality there is risk in everything we do. Nothing is perfect. For practicality’s sake, we set certain levels that we can still operate within. This does not mean that once they are set that they are set in stone. You continually work toward the ideal of zero. It’s like tearing a piece of paper in half — it never ends. You will never get to nothing, or zero, but you strive continually towards that goal by improving continually.

I have introduced the risk matrix in previous articles and I will delve into its formulation and utility in subsequent articles. The important thing is to recognize the root cause and not just symptoms — but that is still not the starting point.

Getting back to the AMT at the seminar, the question should be, “Why are the employees continually non-complaint?” and not “How do I get the employees to be complaint?” This skips over some important problem-solving steps ... namely, that understanding the problem is first. In the mean time, I’ll leave you with this:

Taxonomy of Problem Solving

1. Understand the problem

2. Brainstorm the problem

3. Data collection

4. Data analysis

5. Root cause(s) identification

6. Brainstorm solutions

7. Root cause(s) elimination

8. Solution implementation/prevention

9. Monitor activities

Patrick Kinane joined the Air Force after high school and has worked in aviation since 1964. Kinane is a certified A&P with Inspection Authorization and also holds an FAA license and commercial pilot certificate with instrument rating. He earned a bacherlor of science degree in aviation maintenance management, MBA in quantitative methods, Master of Science degree in education and Ph.D. in organizational psychology. The majority of his aviation career has been involved with 121 carriers where he has held positions from aircraft mechanic to director of maintenance. Kinane currently works as Senior Quality Systems Auditor for AAR Corp. and adjunct professor for DeVry University instructing in organizational behavior, total quality management (TQM) and critical thinking. PlaneQA is his consulting company that specializes in quality and safety system audits and training. Speaking engagements are available with subjects in critical thinking, quality systems and organizational behavior. For more information, visit www.PlaneQA.com.