We might be doing a Shallow Cause Analysis (SCA) if …
1. We blame and discipline the violator and that concludes the investigation. There is no attempt to try and understand the intent of the decision.
2. ‘Compliance’ is our only definition of success (not a direct correlation to a measurable improvement in Reliability, Safety safety or some other meaningful bottom-line metric)
3. We don’t have time to do RCA right, so we just do it quickly
4. ‘Hearsay’ is a valid form of evidence in our analysis
5. Our team leader has anything to lose or gain by the outcome of the analysis
6. Our analysis is linear and concludes there is only one (1) root cause
7. We keeping picking from a drop down list of potential cause choices, until we have reached a predetermined conclusion that is acceptable to reviewers
8. We are a one (1) person team
9. We are only using a ‘one-size-fits-all’ RCA form to complete our analysis because we feel it has a better chance of being accepted due to the format
10. We cannot quantitatively measure the effectiveness of our analysis using lagging and/or leading indicators (e.g. – quality of RCA process, use of evidence, bottom line impacts, etc.)
11. We find ourselves doing an ‘RCA’ on the same issue, over and over again (e.g. – definition of insanity?)
Do you know if Shallow Cause Analyses are being conducted at your place?
Thought provoking list, Bob. Another possible sign of a SCA is that it fails to answer the question, What in our system allowed this defect to occur? This questions tends to shift the focus to higher level decision makers.