Let ye without failure cast the first stone.

I am involved in a workgroup at work that is exploring Root Cause Analysis in the hopes that we can come up with a way to help everyone improve their RCA process and procedures.

I believe it is important in our RCA recommendations to strive to build a culture around RCA. To borrow from a theme brought up by a workgroup member, culture building should be extended to retrospectives and all of our continuous improvement processes in general.

Just Culture

For RCA to be most effective we should instill the idea of the “blameless postmortem” into how we envision RCA. Blameless postmortem is an awesome concept that defines a culture around failure called a “Just Culture” that was introduced to me in a blog post by John Allspaw, Web Operations guru at Etsy. It’s a way to encourage team members to own their failures without fear in the hopes that a less hostile environment towards failure will encourage fast, detailed, feedback in active issue resolution and postmortems. We want team members to volunteer to report an issue as soon as they see it or cause it.

Owning Failure

In terms of RCA, this boils down to instilling the idea that finding who’s at fault, what team missed this or that, is not important. The only thing important is how, when, and why an issue was leaked and “who” is not under investigation. Granted who is at fault will most likely come out, and it should, but there should be no condemnation or negative side effect to owning a failure. We want “who” to come from failure owners themselves, not a lot of intricate detective work. We want the team to freely offer their actions that may have contributed to a failures in hopes that we can compile a timeline of multiple narratives of the failure from various perspectives. When we can freely own failure without retribution we are more apt to own up to a failure and share details that led to the failure so that it can be corrected.

Remove Managerial Blockages on RCA

There are managers that want to know who to blame so that they can monitor who is causing issues. If there is a problem with someone continuously failing, it will be evident without having to expose personal failures in the RCA process formally or as a part of team culture. Root cause is usually deeper than one person or team’s failure There are usually multiple stories that contribute to failures. There are managers that use hindsight to amplify the negative effect of failure to try to shame someone into being better. Highlighting what should have been done is not helpful as it doesn’t lead to change. Often times hindsight is disguised as a solution without ever understanding why the actions were taken that caused the failure or even how the manager’s mismanagement may have contributed to the failure. I only add this because I have seen many RCA or postmortems fail because of a manager trying to place blame and using their limited hindsight to declare the problem solved.

And More

There is a lot of good that comes from a Just Cause Culture. Since I saw some things in the RCA practices at work that may lead to the blame game, I thought that a blameless postmortem should be explicitly built into our RCA process in the hopes that it affects the culture. Just something to think about if you are going down this same road.