Reports and quality
Analysing why something happened
The difference between fixing a case and fixing the cause.
A failure is fixed in minutes: the document is redone, the supplier is phoned, the send is repeated. What is hard is stopping it recurring, and for that you need to know why it happened — which is almost never what it looks like at first sight.
Going down a level, three times
The technique is simple: ask "and why?" three times about the previous answer. Almost always the third produces something changeable, while the first produces only a person.
| Level | Typical answer | What can be done with it |
|---|---|---|
| First | "Someone forgot" | Nothing. That is a name, not a cause |
| Second | "There was no way to know it was due" | Now you can work with it |
| Third | "That document had no expiry marked" | This is fixable, and for everyone |
Important
If the conclusion of an analysis is a person's name, the analysis is not finished. People make mistakes; what you are looking for is what allowed that mistake to produce consequences with nothing stopping it earlier.
How to check the fix worked
- 1
Define what should stop happening
In one concrete, measurable sentence, not "improve control".
- 2
Set a date to look
Three months is usually enough to know whether it recurs.
- 3
Close only then
Closing on the day the fix is applied is closing without knowing whether it worked.
Watch out
Beware the corrective action that consists of asking someone to be more careful. That is not a corrective action: it is the same situation with a more pressured person, and it fails identically on the first bad day.
Worth knowing
Analyses that work usually end in a small, dull change: marking an expiry, changing a request title, assigning an owner. Those ending in a new ten-page procedure rarely change anything.
›Does it have to be done for every incident?
No. For those with consequences and those that repeat.
›Who should do it?
Someone not directly involved, if possible.
›What if the cause is outside our company?
Document it the same: the action is then about the relationship with that third party.
A real case
The situation
A company concludes that an insurance policy lapsed "because the purchasing lead missed it".
What you do
- Goes down two more levels: that document type had no expiry marked
What you get
Fixes the configuration and the problem can no longer recur with anyone, not just her.
The situation
Something happens and the analysis is done from memory two weeks later.
What you do
- Checks the recorded sequence with its dates
- Identifies which specific step failed
- Records the cause and the action with a review date
What you get
The analysis starts from facts and the action can be verified months later.
The situation
A culprit is sought instead of a cause.
What you do
- Looks at which process step allowed it
What you get
The action corrects the process rather than a person.
The situation
The cause is identified and nothing changes.
What you do
- Records the action with an owner and a date
What you get
The analysis produces a change.
The situation
The same problem returns six months later.
What you do
- Checks whether it had happened before
What you get
The cause is tackled rather than the symptom.
The situation
The analysis ends up in a document nobody opens.
What you do
- Records it in the incident's file
What you get
It is found when it is needed again.
This article answers
- root cause analysis
- why does the same failure repeat
- effective corrective action
- investigating an incident