What a Tangled Web We Weave

Root Cause Analysis is skill and a process – but it is also mindset. There are defined actions (the skills and process) that take place but in order for these to be effective there are distinctive patterns of thought that govern the implementation of the RCA process.

Malcolm Sparrow in his book The Character of Harms illuminates this with a discussion of the cognitive habits which frame an effective approach to problem solving. These habits can be visualised through the relatively mundane task of undoing knots. This will be a familiar analogy to any of us that who have tried to untangle that drawer full of wires and connectors or clear out the sewing basket!

So visualise a knotted ball of string…

When you hand this knotted mass to an adult who has developed all the relevant cognitive skills you will see them hold the ball of string and look at it closely. They will most probably turn it around and around and examining it from all sides. They may be careful not to pull or tug strands or make matters worse until they feel they are beginning to understand the structure of the thing itself. As they begin to understand where the strands are coming from and going to so the steps of a plan to untangle the knots begin to form in their minds…

‘….maybe if I can loosen this strand first, it will loosen that one…in turn this will free up the main one – at which point I’ll need to pass this tangled mass here through the opening that should develop….’

And so on.

If they have understood the structure correctly and fashioned the plan accordingly the knot eventually falls apart and is no more.

So this analogy of an effective problem solving mindset illustrates beautifully, in my opinion, the need to:

• Gain an understanding of what it is you are dealing with.
• Understand how the differing component parts are interacting with one another.
• Understand how acting on one part of the knot will have an impact on other component parts and on the knot as whole.
• Then decide on your course of action.

And this can only be done by taking the unravelling of the knot in stages – much like an effective RCA process.

By contrast give the same knot to a child, who has yet to develop this set of cognitive skills.

Observe their behaviour…

See them randomly tug and pull at the strands in the knot. Witness their frustration as the knot tightens or does not respond and they generally make matters worse. You will notice the relative lack of attention to observation. That there is no time spent on understanding the complexities, causality or the particularities of its structure. There is an alacrity and haste with which the child jumps straight into action applying crude methods that usually fail.

Too often this resembles the corporate approach to problem solving, moving straight from immediate and cursory observation of the problem, into action and as a consequence often making a situation worse or at the very least making us vulnerable to repeat failures.

Next time you or your teams are confronted with complex problems ask yourself which method that you are taking. If the problems are not being solved in a methodical manner that takes into account impact of bad decisions, remind yourself ‘that’s knot the way to do it’.