Root Cause

I was once lucky enough to be employed by the British computer company ICL.

Now Fujitsu Services, (who continue to pay me a good monthly pension), they were a remarkable company to work for.

Unlike all the other companies and organisations, large and small, that I’ve encountered.

You see, when something ‘went wrong’ they behaved in a way that is very different to business and popular culture today.

It seems the first reaction of everyone, when something ‘goes wrong’ or something ‘bad’ happens is “Who is to blame, who can we make ‘pay’ for this?

They then go into ‘seek and destroy’ mode to pin responsibility on to someone, sometimes a group but usually an individual, and hold them to account for their supposed evil or criminal actions.

But not at ICL.

When something went wrong, particularly if it affected a major customer such as one of the key government bodies to which they supplied IT systems, there was of course an investigation.

But not about who was to blame.

What we did at ICL was to seek out the root cause of the problem and correct it.

A ‘corrective action’ team was set up in order to deal with the issue and ensure that it didn’t happen again.

At ICL we had processes and procedures for everything, every operation and every role.

(It was one of the first major UK companies to achieve the ISO9001 quality accreditation.)

Standards and Procedures were continuously reviewed and evolved but sometimes they had faults which caused things not to happen properly.

As a manager or an engineer, you followed the processes and any ‘mistake’ was attributed to the process being wrong, not to the individual.

Even when a mistake occurred due to someone not following the process, again a corrective action would be instigated to discover why;

Had they not been trained properly? – look at the training processes.

Had they not been recruited properly, or not managed properly? – look at the HR processes.

And so on.

Occasionally people were encouraged to ‘clean up their act’ but primarily in terms of keeping their standards and procedures up to date and relevant.

To my knowledge, during the time I was there, no-one was ever personally ‘blamed ’for any incident.

The thing is that ICL had realised early on that people work much better in a blame-free culture.

If anyone made an error then it would be spotted in the detailed processes carried out before a product was released and the root cause of the error identified.

It was never any individual’s ‘fault’, even if it did get through the net, in which case the whole series of processes back to source would be investigated.

Occasionally there was some seriously intricate detective work going on to get at the source of the problem – the root cause.

But what you and I see going on around us today is different. It seems much easier to single out an individual and attribute the whole problem to them personally.

Regardless of whether or not they were actually following the ‘rules’ or the process.

Regardless of whether or not they were conforming to the existing standards and procedures.

Regardless of whether or not they actually had anything to do with the issue in the first place but just happened to be a popular ‘target’ or just ‘in the wrong place at the wrong time’.

Because the ‘system’ is never wrong, the ‘law’ is never wrong, and the processes, standards and procedures are never inadequate or out of date.

It has to be somebody’s ‘fault’.

When something ‘goes wrong’ you and I need to think why, not who.

Why did that circumstance come about, what was the root cause of it happening?

And when we think about it properly, tracing the problem back to source, doing the detailed detective work, we’ll always find that some ‘thing’ is wrong, not some person.

For sure, there may have been a ‘key player’, but the likelihood is that they believed they were doing what they were supposed to do.

And that applies as far as I can see, to everything that happens.

Time I examined some of my processes!

How about you?