Understanding the Root Causes of Failure
My father always encouraged me to understand why something happened, not just a problem. Unfortunately, many managers troubleshoot the problem rather than diagnose it to find the reasons (root causes) for the failures. To increase performance and efficiency, we must go beyond the simple problem or error and try to understand what might have caused it in the first place.
Recently, while working on a training module related to root cause identification, I remembered a specific experience in the Marine Corps. A few days before I joined the unit, there was a significant department inspection, and they failed. It was not your typical failure, but was described as “the worst unit performance ever recorded.” It went unstated that the Commanding Officer would most likely be relieved if they failed again. A re-inspection was scheduled for 60 days.
Being very junior during the larger team debriefing, I sat at the kiddie table in the back of the conference room. The Commanding Officer, whose career was now in jeopardy, was screaming and yelling, demanding to know why they failed and how to fix it. Many ideas were tossed out, including fixing all of the specific defects listed in the report, and if we fixed those, we should at least pass. This is an example of troubleshooting: you know you have a problem and correct a specific defect, but it may not prevent it from recurring. To complicate the situation further, they relieved the department managers and the head of the team that was supposed to manage these record books before the debrief.
While he was ranting away, I tried to quickly read the report when the person beside me nudged me in the ribs, getting my attention. The Commanding Officer asked if I thought he was boring me. I learned you are supposed to give your full attention to senior officers during these moments of rage. I stood, apologized, and told the CO I was trying to read through the report to understand why we failed. He asked sarcastically if I had found the “real problem” besides incompetence. I agreed with the incompetence but told him I saw four root causes. Over my 30 years of consulting, I have seen these same four issues time and time again with failed projects.
Root Cause 1 – Lack of Knowledge and Training – The auditors indicated that most defects were due to one or more of the following:
- Team members did not know that they needed to make a specific entry
- Team members did not know they must have a particular document in the record.
- Team members did not know how to make the entry.
I stated that these defects can easily be corrected through remedial training. I suggested that we retrain the entire team on the requirements of the left and right sides of the record and do multiple audits of 100% of the records post-training to confirm they understood their job, identified all defects, and fixed them before the next audit.
Root Cause 2 – Different Opinion of Requirements—A potentially more significant problem and a harder one to fix was that the team leaders and a few team members knew what to do, but either had a different opinion or didn’t care about the rules.
For example, the auditors noted that 100% of the records lacked a signed rifle requalification exemption. The report indicated that the Admin Officer and Personnel Chief, despite an explicit directive to the contrary, would only add the exemption entry when the Marine leaves the unit. They did not feel the need to make the entry when they joined the unit. The problem with their interpretation is that the Marine is flagged as not rifle-qualified, negatively affecting their promotion score. Whereas if the entry were done and added to the system at the join, they would be exempt, and their previous qualification would be used, enabling them to be in higher consideration for promotion. That defect can also be corrected through an attitude adjustment.
Root Cause 3—Lack of Coordination and Collaboration—There was no coordination or management oversight between departments, enforcing the sharing of training and promotion-required activities. The auditors indicated a further systemic failure of training and administration to ensure the necessary training and promotion information is current.
A significant report flag was the number of missing entries for education, physical fitness tests, and other promotion qualification events. While implementing and monitoring these activities is the training department’s responsibility, it is also the admin department’s responsibility to make the entries in the Marine’s record book and the management system. There is an apparent disconnect in that process. The report indicated that 95% of all completed training events were not entered into the record book or the computer system, with zero indication that training shared them with the admin team. I suggested this be solved by requiring document sharing and periodic reviews between the departments.
Ironically, the Training Operations officer complained that it would add a lot of work for his team to ensure things were updated. “Field training was far more important than pushing paperwork.” My lack of mouth control responded with, “But that is your job as the head of the training department, sir,” further stating that while it may seem to be less critical than combat-related training, it is a required activity and, more importantly, it directly affects the morale and welfare of our Marines. If a Marine is frustrated that he’s not getting promoted or is worried about providing enough money for his family, he may not pay attention to detail or perform at their best, risking lives. This can be fixed with process oversight and an attitude adjustment. Not surprisingly, that officer felt my attitude needed adjustment.
Root Cause 4 – Lack of Process, Oversight, and Governance – The root causes noted in the first three issues are enabled by a lack of governance or process. Because of the number and types of defects, it is clear there was no proper onboarding or routine review process. If there were a formal review process during onboarding or even periodic audits, most of these issues would never have happened.
One of the more egregious failures was that 70% of the records were missing the Marine’s life insurance form, were unsigned, or had an incorrect beneficiary. This could have been fixed at check-in by simply opening the record, verifying the form’s presence, a signature, and date, and asking the Marine for any changes. It would be impossible not to have 100% compliance if that simple process were followed. I further noted that when I checked in, the records clerk said I was somehow interrupting him. He stamped my check-in form and tossed my record book into a file box without any attempt to verify anything while I was standing there.
The Commanding Officer looked at me and said, “Excellent Insights and Plan; you’re in charge of it; go fix it and give me your detailed plan by the end of the day.” After being shocked by the assignment, I presented my complete roadmap for remediation later that day. I asked the Colonel what the metric for success was. He replied, “The only metric you need to care about is being good enough, so I don’t get fired. I’ll support you in whatever you need to make that happen, especially those attitude adjustments.”
The remediation was intense, working 19 to 20-hour days over the sixty days. We retrained all team members, explaining the many use cases, situations, and sample records. I created audit work streams and QA process auditing every record at least twice. We directly fixed or took corrective action with each audit on nearly every record book. In the end, the retraining and the audit process resulted in the team going from the worst audit to one of the best, receiving a grade of outstanding. The Commanding Officer kept his job and received a special commendation for the fantastic turnaround.
It is rare that a company or department simultaneously has all four of these issues. A lack of governance and oversight of the activities will almost always ensure that you have one or more. Don’t just look for an error or singular issue; focus on why something is not working; you can identify a path forward from there. Then, develop ways to measure and monitor ongoing performance, collaboration, and knowledge to ensure it does not go off the rails again.
The team at Bisan Digital uses various methods, including interviews, process reviews, and audits, during our process realignment consulting to identify root-cause issues and work with companies to implement corrective actions.
