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Are You Looking For Root Cause, Or Someone to Blame? August 15, 2016

Posted by Tim Rodgers in Management & leadership, Operations, Process engineering, Quality.
Tags: , , , ,

When I worked as a quality manager in my first career I was often required to investigate quality failures to determine the cause. There were times when it was pretty easy to figure out, but in an uncontrolled business environment it can be hard to identify a simple dependent relationship between cause and effect. There are usually multiple contributing factors. Sometimes a small thing (the cause) can become a big thing when it’s overlooked (another cause).

Most of the other managers I worked with didn’t have much patience with the complexities of root cause analysis. They wanted a simple, actionable outcome: this is the cause, and if we eliminate this cause then this problem will never happen again (right?), so let’s eliminate the cause. The people who were impacted by this quality failure want answers, and they want to feel confident that the business has taken decisive and effective action. They don’t want to endure an extended period of uncertainty and exposure to risk while the business figures out what to do in order to prevent re-occurrence.

Most of the managers I worked with wanted to find someone to blame. After all, businesses rely on people to perform tasks and provide oversight, so just about any root cause can be assigned to an individual or group of individuals. If the process went out of control, or the instrument wasn’t calibrated, or the incoming material had the wrong composition, or the operator didn’t do their job correctly, then can’t we reasonably blame the people responsible? If the supplier didn’t deliver on time because their truck broke down, or because there’s an earthquake in Japan, can’t we blame the supply chain team for not having a contingency plan? If the production yield is low because the design isn’t manufacturable, can’t we blame the design team or the production team (maybe both)?

Isn’t there always someone to blame?

We look to blame someone because that’s a cause that seems easy to address. Let’s fire that person and replace them with someone who knows what they’re doing. Or, if we’re more interested in correcting the behavior, let’s discipline them and perhaps re-train them. Now we can tell people that we isolated the cause and we’ve taken swift action to ensure that it won’t happen again. If it does happen again, then let’s blame the person who was supposed to deal with it the first time.

Yes, quality failures can usually be attributed to actions taken (or not taken) by real people. However we rarely try to understand why people take those actions. I don’t believe companies are being undermined by embedded saboteurs. Is there something about the business environment itself that’s causing poor quality? In many cases there are mixed messages, or an internal culture that rewards immediate results over protecting the company from future risks. The real root cause may be much harder to address, and means it might not be addressed at all.

Businesses need processes and systems that make it harder for people to do the wrong thing, and thereby reduce the probability of quality problems in the future. Otherwise, replacing or punishing or blaming people won’t improve quality, even if they make managers and customers and stockholders feel better in the short term.




1. Claudia Bach - August 15, 2016

Great post Tim. I sometimes wonder if the move towards risk management is an attempt to put a more realistic system in place. What do you think?

2. Tim Rodgers - August 15, 2016

I think that’s correct, at least in some cases. I do think many companies are now developing more robust risk management plans, perhaps because of the new ISO9001:2015 requirements, perhaps because of their own quality crises (learning the hard way). Either way, it’s better than “figuring it out when we get there.”

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