Root Cause Analysis (RCA) was developed to resolve defects in manufacturing. When the error rate of a production process is too high, we use RCA to discover why and fix it. In manufacturing, RCA works pretty well. Sometimes it even works with software development and other processes that generate nonphysical outputs. But when we try to apply RCA to problems among people, trouble appears.
A frost-covered spider web. Webs are particularly resistant to single-point failures. That's one reason why the Internet performs as well as it does, and why changing just a few elements of a "causality web" is unlikely to have a material effect on the performance of an underperforming organizational process. Indeed, looking at this Web, it's difficult to discern how the spider might have constructed it. Ask yourself, "In what order would I have put in place the various strands of this web?" It's unlikely that the spider used any "jigs" — temporary structures that were later removed. But in organizational webs, existing structures are often the result of structures that are no longer in place. That phenomenon adds to the complexity of any Root Cause Analysis, because the actual root causes of contemporary problems may have disappeared or been buried by a sequence of acquisitions, mergers, RIFs, reorganizations and other organizational changes. Photo "Frosty Spider Web" by John Brandon, for the "Yellowstone Digital Slide File", 1970. Courtesy U.S. National Park Service.
We're usually unaware of RCA thinking. Some indicators are questions and statements like these:
- Who started this trouble?
- She's the common factor in all these problems.
- I did Y, but only because she did X.
- If we send Jeff to communication training, everything will get better.
Sometimes, RCA thinking does lead to noticeable improvement, but too often, it ends in exasperation or exacerbation.
We can understand why if we remember that RCA makes two critical assumptions. First, it assumes that we'll find causes that have no internal structure. Second, it assumes that these "atomic" causes are independent, adjustable forces. The very term "root cause" captures these two ideas.
In human systems, both assumptions can be invalid, and often are. For instance, consider the assumption of atomic causes. A simple example: our project is late because we keep changing things; so we add resources to speed it up; but adding resources is a change; that change further delays the project.
Because these so-called "causality loops" violate the assumption that we can always find atomic causes, people have extended the method to deal with this situation. But in organizational applications, the term causality loop doesn't quite capture the complexity of the difficulty — causality web is more accurate.
In seeking organizational
improvement, changing just
a few things rarely worksWhen we encounter causality webs, process repair can entail broad organizational change — a process so daunting that we convince ourselves that changing "just a few things" will do the trick. Often, when we do make changes, the web does break temporarily — until the elements we chose not to address can restore its structure.
Assuming independent, adjustable forces also fails from time to time. For instance, in a business unit troubled by toxic, destructive conflict, an objective application of RCA might find causes such as manipulative management, oppressive schedules, or human resource policies that lead to high turnover. Since such environments rarely allow even discussion of these factors, adjusting them is often precluded.
In many cases, even though these causes are independently adjustable, the structure of organizational power can prevent their adjustment. Unable to deal with what everyone can see and nobody can acknowledge, the organization sometimes falls into "analysis paralysis."
It's useful to remember that we seek not the cause of organizational failures, but their elimination. Confusing the two objectives is a cause — if not a root cause — of the misapplication of root cause analysis. 
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