root cause and Root Cause . . .

There seemed to be endless obstacles… it seemed that the root cause of them all was fear. -Joanna Field

One of the seminal tools in problem solving and process improvement is called Root Cause Analysis.

I found the following useful definition on the website: Bill Wilson’s Root Cause Analysis Site:

Root cause analysis (RCA) is a methodology for finding and correcting the most important reasons for performance problems. It differs from troubleshooting and problem-solving in that these disciplines typically seek solutions to specific difficulties, whereas RCA is directed at underlying issues.

To illustrate the point, in perhaps a slightly absurd way, here is a little example of root cause analysis:

Scenario # 1:  The Plant Manager walked into the plant and found oil on the floor. He called the Foreman over and told him to have maintenance clean up the oil. The next day while the Plant Manager was in the same area of the plant he found oil on the floor again and he subsequently raked the Foreman over the coals for not following his directions from the day before. His parting words were to either get the oil cleaned up or he’d find someone that would.

Scenario # 2:  The Plant Manager walked into the plant and found oil on the floor. He called the Foreman over and asked him why there was oil on the floor. The Foreman indicated that it was due to a leaky gasket in the pipe joint above. The Plant Manager then asked when the gasket had been replaced and the Foreman responded that Maintenance had installed 4 gaskets over the past few weeks and they each one seemed to leak. The Foreman also indicated that Maintenance had been talking to Purchasing about the gaskets because it seemed they were all bad.

The Plant Manager then went to talk with Purchasing about the situation with the gaskets. The Purchasing Manager indicated that they had in fact received a bad batch of gaskets from the supplier. The Purchasing Manager also indicated that they had been trying for the past 2 months to try to get the supplier to make good on the last order of 5,000 gaskets that all seemed to be bad.

The Plant Manager then asked the Purchasing Manager why they had purchased from this supplier if they were so disreputable and the Purchasing Manager said because they were the lowest bidder when quotes were received from various suppliers. The Plant Manager then asked the Purchasing Manager why they went with the lowest bidder and he indicated that was the direction he had received from the VP of Finance.

The Plant Manager then went to talk to the VP of Finance about the situation. When the Plant Manager asked the VP of Finance why Purchasing had been directed to always take the lowest bidder the VP of Finance said, “Because you indicated that we had to be as cost conscious as possible!” and purchasing from the lowest bidder saves us lots of money. The Plant Manger was horrified when he realized that he was the reason there was oil on the plant floor.

Illustrative? Yes.  Absurd example? Maybe not so absurd as it first seems.

I am currently engaged with a division of a large and highly professional US company. Unfortunately this division is currently being plagued with supplier quality problems and customer satisfaction issues.  Like the professional organisation that they are, they are doing all the right things, including root cause analysis to fix these vexing issues.

And here’s where I want to draw the distinction between “root cause” and Root Cause.  In doing the traditional “root cause” analysis they discovered that one of their long time suppliers is suddenly producing sub-quality parts.  Ah ha!  Got it.  The supplier’s fault.  So, like all good purchasing people they both help the supplier with resources and expertise on one hand, and pressure them with consequences on the other hand.  A typical industry practice to get the supplier to improve quality.  And that’s usually as far as it goes.  This particular issue will eventually get resolved and things will go back to normal.  But not really, because there is also Root Cause.

Like the Plant Manager scenario above, what if we kept going on our pursuit of causal factors and went looking for the Root Cause?

If we take our analysis even deeper we find that upper management decided to increase the number of “widgets” produced so they could book more revenue faster and turn in better quarterly numbers.  So they told their trusted, sole-source, long-time supplier to increase his shipments by 2-fold.  The supplier was happy to oblige since it meant more money and larger profits. However, this ramp up demand put severe strains on labor, material availability, management attention and ultimately, product quality.

In addition, to be more profitable, upper management demanded the division cut the number of people assigned to the customer account once it got into full production, again, increasing profits.  The customer started complaining that it took too long to find someone to talk to and their questions and problems weren’t being handled quick enough.  Result, loss of customer confidence.

And here’s where things get really messy.  Those in purchasing and program management knew that upper management’s decision to double production rates and reduce staffing would have a negative impact, but senior management didn’t want to hear it. They tried, got rebuffed, and backed off. They hung their heads, knowing they had not stood their ground. Both morale and trust in leadership suffered.

Root Causes.  Myopic, profit-focused leadership and lack of real courage on the part of management.

We have met the enemy, and he is us!  –Pogo

If we honestly talk about these issues, we can solve them.  Blaming the supplier is just too easy and usually not the whole story.

Tight Lines . . .

John R Childress

About johnrchildress

John Childress is a pioneer in the field of strategy execution, culture change, executive leadership and organization effectiveness, author of several books and numerous articles on leadership, an effective public speaker and workshop facilitator for Boards and senior executive teams. In 1978 John co-founded The Senn-Delaney Leadership Consulting Group, the first international consulting firm to focus exclusively on culture change, leadership development and senior team alignment. Between 1978 and 2000 he served as its President and CEO and guided the international expansion of the company. His work with senior leadership teams has included companies in crisis (GPU Nuclear – owner of the Three Mile Island Nuclear Plants following the accident), deregulated industries (natural gas pipelines, telecommunications and the breakup of The Bell Telephone Companies), mergers and acquisitions and classic business turnaround scenarios with global organizations from the Fortune 500 and FTSE 250 ranks. He has designed and conducted consulting engagements in the US, UK, Europe, Middle East, Africa, China and Asia. Currently John is an independent advisor to CEO’s, Boards, management teams and organisations on strategy execution, corporate culture, leadership team effectiveness, business performance and executive development. John was born in the Cascade Mountains of Oregon and eventually moved to Carmel Highlands, California during most of his business career. John is a Phi Beta Kappa scholar with a BA degree (Magna cum Laude) from the University of California, a Masters Degree from Harvard University and was a PhD candidate at the University of Hawaii before deciding on a career as a business entrepreneur in the mid-70s. In 1968-69 he attended the American University of Beirut and it was there that his interest in cultures, leadership and group dynamics began to take shape. John Childress resides in London and the south of France with his family and is an avid flyfisherman, with recent trips to Alaska, the Amazon River, Tierra del Fuego, and Kamchatka in the far east of Russia. He is a trustee for Young Virtuosi, a foundation to support talented young musicians. You can reach John at or
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