I just finished a lunch and learn at the company I work for on Root Cause Analysis. The ‘root cause’ behind this session was the output of an Agile self-assessment that suggested, based on our answers, we could get some benefit from using root cause analysis.
I’ll share the presentation as well, however I really stressed the importance of a creating a “no blame society” as when you are talking about problems, different people are going to have different perspectives which is going to influence their understanding of the problem and the causes of the problem. A key statement I learned from Michael Sahota is that people are doing the best they can with the resources they have.
What was interesting was a sample “Cause Map” I created about a slip and fall accident where there were 2 causes:
1) Maintenance didn’t fix a leaky ceiling pipe (I didn’t go deeper into WHY maintenance didn’t fix it quick enough since this was just to get an understanding of what a cause map is.)
2) Cheap valves were used because a manager was given an incentive to reduce costs which was mandated by executives. Of course that’s fictitious, if the mandate is to reduce cost would there really be an incentive put on top of it?
Our CEO made a slightly defensive comment about the root cause being an executive deciding to reduce costs since there are other ways to reduce cost they wouldn’t jeopardize people’s safety by using cheaper values. I made a point to raise that observation in a safe way. I said “I sensed a bit of defensiveness there, that seemed to hit home for you.” He agreed and we used that a discussion point to re-enforce the value of creating a safe environment when you start to talk about real problems.
I asked the group to imagine the impact had this fictitious scenario been real and stressed that when we start applying this tool, it’s important to talk about what personal safety means and the importance of making it very clear we are here to solve problems and it WILL be un-comfortable.
The moral of the story is, if you’re a coach, manager, executive or team member, perspective on problems matter. Put yourself in the shoes of the other person and try to understand their perception, that’ll go a long way into forgetting about what doesn’t matter (blame) and focus on what matters (fixing the problem).