Prevention Details

Judgment should not get in the way of solutions

Flight 1549
Flight 1549

On Jan. 15, 2009, U.S. Airways Capt. Chelsey Sully Sullenberger ditched Flight 1549 in the Hudson River. No one died, and most of those who were hurt walked away with only minor injuries. Dubbed the Miracle on the Hudson, the event inspires us. The media and most of America lavished him with praise, all of it incredibly well-deserved. Media usually focus attention on the mundane and trivial reality TV starts in unreal situations, dancing celebrities, and the like so it was nice to see coverage of a truly amazing human being. Sullenberger is an example of just how good we can be.

Several weeks later, on the other side of New York State, tragedy occurred. A regional plane went down on their final approach to the airport in Buffalo. Everyone aboard perished. We may remember that it was wintry, not the best weather for flying, and that icing on the plane was a problem. But we really remember that the crew made significant errors. Not only did these pilots make mistake after mistake (pulling down when they should have been pulling up, etc.), they also were inexperienced, low paid, and tired. One had flown across the country from her parents' house in Oregon. The pilots didn't signal any mayday, and they even chatted casually below 10,000 feet, which is against FAA regulations.

Finger pointing ensured. Executives at Colgan Air the regional airline that operated the Continental flight blamed the pilots, who they said didn't properly pay attention to their flight instruments. The public pointed fingers at the corporation. As news tricked out and hearings commenced, people's attention turned to some eye-opening facts. How could they pay entry-level pilots so little? One pilot even took a job at a coffee shop to pay the bills. After reading this, we may have put down the newspaper and thought: You mean the same barista who served me latte may be flying a Bombardier Dash 8 Q-400 on the side?

The National Transportation Safety Board interrogated the executives at Colgan. The executives told the NTSB that entry level pay is within market norms, and that pilots are told what the pay scales are before taking the job. Many of us reading the news had the same emotional reaction: You've got to be kidding me.

Narrative and Emotion

The previous section shows how opinion and emotion crop up in our writing and conversation. It is part of storytelling and journalism (especially now). Even the most objective journalist (if there is one nowadays) comes to an event with at least some preconceptions.

Storytelling revolves around human experience what a person did. This means that when we talk of a bad experience, we easily fall into the finger-pointing trap. And though blame may have its place in criminal court, newspaper editorials, and water cooler conversations, it has no place in a root cause analysis. Such a hostile environment may hinder the discovery of details, and more details are almost always better. When conducting a root cause analysis, it's not about who did it, but what happened and why.

During casual conversation, you may find it extremely difficult to relay a series of events without focusing on the people who committed the acts. This is true for both negative and positive events. Consider Captain Sullenberger again. He certainly deserves accolades. Many view him as a hero, and for good reason. But focusing just on his heroism won't reveal the true system of causes that led to the incredibly favorable outcome. Just being a hero doesn't show anyone how the Miracle on the Hudson was actually accomplished.

Details are everything in root cause analysis. For instance, the pilot knew to keep the wings level and nose up. He had years of training and re-training to accomplish this feat, but he also had training on a glider. Also, the plane landed in calm winds. The aircraft doors opened immediately and without issue, so that every passenger could exit quickly and safely. The floating slides deployed correctly. Because the plane landed on the Hudson River on a weekday morning in New York, ferry boats were on the scene almost immediately.

All of these events and more had to occur for the successful outcome to happen. Yes, Sullenberger played a big part, and all aboard would have perished without his skill. But his skill isn't the root cause that led to the favorable outcome.

Captain Sully actually has conducted many accident and safety investigations for the NTSB and the U.S. Air Force. As he has said during his numerous public appearances, the Miracle on the Hudson wouldn't have happened without everyone on his crew, not to mention the maintenance personnel who made sure emergency systems operated smoothly.

Causes, Plural

That's Sully's way of saying that his skill wasn't the only cause. In fact, his point also debunks some typical jargon used in quality circles: the root cause and contributing factors. The thinking goes that the principal root cause is the major factor that led to an event. If you want to avoid it, you must eliminate the root cause. Contributing factors also led to the event, but they weren't essential for the event to occur.

This follows logic, until you ask this simple question: How is oxygen related to fire? Is it the root cause of the fire, or is it a contributing factor of fire? Most would say oxygen is a contributing factor because, on its own, oxygen can't cause a fire.

That's fine, but if there is no oxygen, can there be fire? Of course not. So, is oxygen the root cause? That's a trick question, because in reality no one root cause exists for any incident. Every event has a system of causes plural.

It's human nature to pinpoint one cause as more important than others. But in reality, fire can't occur without heat, fuel, and oxygen. All three have to be there, or the fire just won't light. Having three causes not only means that all must occur, but also that there are different ways to prevent the fire from occurring. Some solutions are better than others, but no one cause is more important than others, because they're all required for an incident to occur. Put another way, there may be a best solution, but there is no such thing as the best cause.

The Importance of Visual Tools

Again, to uncover the system of causes requires details. Writing details and making them visible to everyone on the incident investigation team encourages people to focus on what happened the details and not who committed the act. The most obvious benefit occurs when investigating negative outcomes, when details shown visually point the conversation toward what happened and away from the blame game and finger-pointing. Although less obvious, visual tools benefit positive-outcome investigations too, like the Miracle on the Hudson. Focusing on the captain's heroism doesn't reveal many details. Without sufficient detail, others would not gain much knowledge from the incident and, thus, would not be able to apply that knowledge during situations down the road.

The Cause Map Approach

To capture essential details, an incident investigation team can use the Cause Map approach, which occurs in three parts:

  1. Define the problem.
  2. Find out why it happened (the analysis).
  3. How to prevent it.

Defining the problem isn't as straightforward as it sounds. People have different opinions about what the problem should be. Consider a worker who breaks his leg by tripping over a cord connected to a machine. Some may think the problem is cord placement; cords should be run above on a cable tray, not on the floor. Others may feel the machine was placed in a bad area. Others may blame the fact that the worker has to walk to and from the machine all day to fetch a tool; why isn't that tool kept at the machine? All this is good information. They all make up the system of causes that led to the event and, as such, they should be captured on the Cause Map.

But it's not where the conversation should start.

Instead, it should start at a point where everyone agrees and is on the same page. We call these an organization's overall goals. Everyone agrees that no one should be injured on the job, so zero injuries should be the overall goal that wasn't met.

The Cause Map approach applies the same way to events with positive outcomes, like the Miracle on the Hudson. What was the problem? It was widely reported that birds flew into the engine. It's true that the bird strike caused both engines to fail, which led to the ultimate incident. But the bird strike isn't the one root cause. There's more to the story.

Again, so that everyone is on the same page, a root cause analysis should start with the impact to the overall goals. In this case, the incident impacted, among other things, the organization's safety goal: zero fatalities. That goal was thankfully met but why, exactly?

This is where the second part the analysis begins. At this point the root cause analysis team starts to build the actual Cause Map. This involves a series of connected boxes with why questions, reading from left to right, describing specific events. When one cause is established, the group discusses the causes that led to it.

The incident investigation team starts by placing the overall goal, Safety Goal Impacted: zero fatalities on the ground, on the left. The team then draws the Cause Map, moving box by box to the right, by asking why questions:

There were zero fatalities on the ground. Why? Because the pilot guided the aircraft clear of populated areas. Why did this happen? It's because the aircraft was at a sufficient altitude and because he decided to ditch in the Hudson River. Why did he do this? Because he was unable to maintain altitude. Why? Because the aircraft lost both engines. Why? Because of a bird strike.

Notice how awkward these sentences read, yet how simply the Cause Map shows the incident details that may get missed in straightforward conversation. The visual map forces people to stop thinking in narrative form: essentially, to stop storytelling. Yes, the plane had to ditch into the river because birds struck the plane. But there are more details, and the Cause Map helps people uncover them.

The team starts with a simple, top-level (or basic) Cause Map. But a mid-level and detailed Cause Map show more details important for many in the organization to know: the importance of good maintenance when it comes to emergency evacuation systems, for instance. (To view a detailed Cause Map, click here.)

Written beneath each cause is supporting evidence. Causes without sufficient evidence remain on the Cause Map but have a question mark by them, showing them as possible but still an unproven cause. Proposed solutions are also posted above certain causes, after which the team determines the best solutions.

The third part of the Cause Map approach involves prevention, or what has to be done to carry out those identified solutions. In a root cause analysis of a negative outcome, this includes identifying action items, who needs to accomplish them, and the deadlines all to prevent the incident from happening again. Analyzing an incident with a positive outcome, the team identifies the solutions that led to it. They then can communicate those solutions to improve training and work processes throughout the organization.

And none of it would be possible without details. Details are vital to prevent future problems, even after positive outcomes. Imagine any situation in which a team of extremely competent, qualified professionals avert disaster. Other people in the organization could gain a lot of knowledge and improve their own work processes. But none of it would happen without revealing the details about how a job was accomplished so well.

A Place for Names

Consider again the tragedy near Buffalo in early 2009. Talk about pilots' pay blanketed the news. It spurred our emotions, and made for a compelling, emotional story. But in an incident investigation, pilot pay may or may not enter into the discussion. The objective approach starts with the overall goal that was impacted zero safety incidents and goes from there, asking why questions to reveal an array of causes.

All problem-solving methods, including the Cause Mapping approach to root cause analysis, focus on an event's details, not people. Judging people in either a good or bad sense has no place in a root cause analysis.

This isn't to say there's no place for judgment anywhere, particularly when loss of life enters the picture. There's truth to the phrase, The buck stops here. Taking responsibility is important. Captain Sullenberger should be admired, just as the people who lost loved ones have a right to admonish executives at Colgan Air.

But root cause analysis isn't a criminal investigation. It's about solving a problem and developing better work processes to minimize the risk of recurrence.

The bottom line: With better work processes, people are less likely to err. Put another way, to err is human, to prevent is process, and to accomplish it all requires details.