More Root Cause Stories

There was such a great response to the Dwindling Owl Population in India root cause story that I decided to share a few more.

We were initially inspired by Paul Preuss’ book, School Leaders Guide to Root Cause Analysis. He had some sample root cause stories within his book. We kicked off our event with the Boat Accident example. We have participants read the story and then brainstorm root cause. What’s interesting is that folks almost always blame the family – sound familiar? However, if we stop our problem-solving with the family, nothing changes. If we start to see the organization, in this case the coast guard as culpable, is there a chance victims from a future boating accident will be saved?

The point is once we as educators take responsibility for student learning outcomes and focus solutions on items within our circle of influence, we can greatly impact results.

Inspired by the Preuss’ book, we created a few of our own:

Roseto – story centers on the importance of relationships (thanks to Sue Kinney)

Gotham City – RtII and large district reform

Korean Airlines – importance of communication and common language

Thomas Jefferson Memorial – Five Whys (recommended by Don Burkins)

Click here to view our root cause resources. Scroll down to see the examples. Please share your own resources and ideas!


DrBillCorcoran said…
1.0 Improving Any Approach to Event Investigation
[This is the first of a series of more-or-less progressive checklists on event investigation improvement.]

This is for people who already know how to do investigations.

However your organization is doing Business Issue Investigations (BII)[aka "Root Cause Analysis (RCA)"] it can cost-effectively improve by adding incrementally some No-Brainer (NB) Blinding Flashes of the Obvious (BFOs).

If you either a) hoist one of these aboard, b)are already doing it, or c)conclude that it's useless or counterproductive please send an e-mail to and let me know about it.

The vast majority of these improvements can be done without violating any organization's investigation procedure. In some cases, you must be judicious to avoid being accused of deviating from procedures. (To do your job you must keep your job.)

These tactics are not mutually exclusive (if you do one you can also do others) or jointly exhaustive (if you do them all you may not be done). Some may be redundant to others in some cases (if you do one it might cover the other).

1. Use plain English.
1.1 Be honest.
1.2 Avoid euphemisms. Call things by their right names.
1.3 If you have to use words or groups of words that anyone in your audience might not understand the way you want them to understand them, include a glossary.
1.31 If you include a glossary have it include the sources of your definitions. If you made them up out of thin air say so.
1.4 Use consistent terminology. Say the same thing the same way every time. Don't use synonyms or equivalent terminologies for words you already used.
1.5 If your organization has definitions that don't make sense, don't use the defined words. Use synonyms for the defined words.

2. Use active voice. For example,"The worker was not wearing PPE" instead of "PPE was not worn."

3. Be specific, instead of the above say, "The worker who sustained a head injury was not wearing his hard hat."

4. Say who did what. For example, "The work team leader did not walkdown the job" instead of "A walkdown did not occur."
4.1 Leave the names of individual event participants and witnesses out of distributed reports, but include role/position names that the investigation team members and the prospective readers will be able to understand and remember.
4.2 Include a list of event instigators, enablers, victims, participants, and witnesses, i.e., "dramatis personae" early in the report.

5. Show your work. Indicate all of the steps you took to reach your conclusions. Give enough detail so that an independent reviewer can see how you got what you got.
5.01 Take the time to say what you do, do what you say, prove it, and improve it.
5.1 When your conclusion is not the only one that is consistent with the evidence say what the other consistent conclusions are and what persuaded you to select the one you selected.

6. Save all investigations and make this investigation incrementally better than the best similar one, at least in your eyes.
6.1 If this is a repeat investigation be sure to find out the factors that resulted in the previous investigations not preventing this one.
6.2 If this is a repeat investigation don't do it the same way you did the previous one. Don't repeat the same weaknesses.

7. Embed photographs with labels showing important features.
7.1 Include drawings, sketches, floor plans, etc. as necessary for reader understanding.
7.2 Videotape scene walkdowns, inspections, and re-enactments with narration for study by the team and screening for management.

8. Specify the natures,the magnitudes, the locations, and the timings of the important harm (aka consequences).
8.1 Specify the significance of the issue you are investigating, i.e., explain what makes this issue worth the costs of the investigation.

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