Root Cause Analysis (RCA)
Root cause analysis investigates why events happened and why their consequences were severe. The Titanic inquiries illustrate how the questions, evidence, time available, and investigators’ responsibilities shape what an inquiry can establish.
THE IDEA
The Essential RCA Questions and Reflections on the Rigour of the Inquiries
As with all inquiries or root cause investigations, it is essential to recognise the question you are asking and answering. The Titanic inquiries were not simply looking at ‘What happened and why did the Titanic sink?’; they were also asking, ‘Why did the Titanic sink so quickly, and why did so many people die?’ By paying attention to the consequences of what happened, you can appreciate why prevention, detection and recovery measures might all be relevant.
If you read just a few pages of either inquiry, you get a sense of the diligence with which they tried to find out the ‘what, where, when, who, how and why’ through witness testimonies. However, several caveats need to be added:
- The public and newspapers at the time were looking to find someone responsible for the Titanic tragedy, and you sense, during the inquiries, a great deal of focus on who did or did not do what.
- The plight of the third‑class passengers was not a significant focus of either inquiry, even though this is where the bulk of the passenger casualties occurred (along with the crew members).
- The inquiries were expedited for understandable reasons, but that meant the significance of some issues (such as the condition of the hull and rivets and optical effects due to the freezing water) were only fully understood many years later (and even now several mysteries remain).
- The British Wreck inquiry operated under the Board of Trade, which was responsible for the relevant maritime laws and regulations and had overseen the Titanic's design, construction and sea trials. That relationship raises a question about the inquiry’s independence.
Despite these limitations, the inquiries produced several important findings:
- There was no compelling evidence any of the crew of the Titanic did anything deliberately to damage the ship or harm the passengers.
- The root causes of the Titanic tragedy went far beyond what happened that night.
- There were a range of problems with maritime customs and practices and relevant laws and regulations, and how these were supervised at that time, that needed to be addressed.
The same questions apply when leaders investigate problems in their own teams. What outcome needs explaining? What evidence would distinguish the possible causes?
Consider a scenario familiar in many internal audit functions: a Chief Audit Executive (CAE) is disappointed with the quality of audit reports and believes the solution is additional training on report writing or stakeholder management. Before jumping to that remedy, we must ask whether we are addressing the root cause or merely a symptom. When an audit report is lengthy, unclear, or fails to engage stakeholders, that could be a sign of:
- a lack of auditor training;
- a lack of auditor effort;
- the personality and mindset of the auditor; or
- a more general problem with the process for formulating reports and how the audit team works together and with stakeholders.
These possibilities need investigation before choosing a remedy. Lean and agile ways of working encourage auditors to share initial observations with stakeholders early. That gives the team a chance to test interpretations, hear objections, and improve the report while work is still in progress.
A Bowtie or modified fishbone diagram can help an audit team organize possible causes and identify where more evidence is needed.
When to use it
Conducting a post-incident review in healthcare to identify systemic issues rather than blaming individuals.
Analyzing a product recall in manufacturing to determine root causes across the supply chain.
Performing a post-mortem of a software failure to improve processes and prevent recurrence.
Investigating a business process breakdown to implement better controls and training.
Diagnosing why audit reports are consistently unclear or lengthy.
Understanding why stakeholder relationships are strained despite training on communication.
Identifying the real reasons behind low auditor engagement or turnover.
Evaluating whether a process change (e.g., introducing agile) will address underlying team dynamics.
FROM THEORY TO EVERYDAY LIFE
In practice
Titanic Disaster Inquiry
The Titanic inquiries asked not only why the ship sank, but also why it sank so quickly and why so many died, leading to a focus on systemic issues beyond individual actions.
Limitations of Expedited Inquiries
The Titanic inquiries proceeded quickly. Later investigations examined technical questions about the hull and proposed explanations involving optical effects. An initial inquiry can produce useful findings while leaving questions for subsequent investigation.
Improving Audit Reports
When an audit team produces lengthy or unclear reports, instead of assuming only a training need, consider whether the issue stems from individual mindset, team process, or stakeholder interaction. Using RCA, the team might find that the root cause is a lack of early stakeholder calibration, which can be addressed by adopting lean or agile practices rather than just report-writing training.
Applying Fishbone to Team Challenges
A CAE can use a modified fishbone diagram to explore why auditors struggle with stakeholder management. Categories might include people, process, technology, and culture. The diagram helps identify possible explanations and decide what to investigate; training may still be part of the eventual response.
A MOMENT TO REFLECT
Put it to work.
How might the framing of the initial question in an investigation influence the outcomes and the solutions considered?
What biases might be present in a root cause inquiry, and how can we mitigate them to ensure a systems perspective?
Why is it important to consider both immediate causes and systemic factors when analyzing failures?
How do you distinguish between symptoms and root causes in audit team challenges?
What root cause analysis technique (e.g., fishbone, bowtie) could you apply to a current team issue?
What evidence would distinguish a training problem from a problem in how the audit team works?
CONTINUE THE CONVERSATION
Source texts
- Beyond the Five Whys Root Cause Analysis and Systems Thinking (James C. Paterson)
- Beyond the Five Whys Root Cause Analysis and Systems Thinking (James C. Paterson)