Extracts from Dekker’s work about the ontological and empirical shakiness of ‘root causes’.
I’ve taken material from two versions of The Field Guide to Understanding Human Error (Investigations).
In Dekker’s view:
· “There is no ‘root’ cause” (or ‘root causes’)
· Given the multiple angles and interactions in complex systems, you “can really construct “causes” from everywhere”
· “What you call “root cause” is simply the place where you stop looking any further”
· Hence in Dekker’s view, “any policy or standard that gets you to identify root causes, or probable causes, is of necessity:
1) Selective. There are only so many things you can label “causal” before the word “causal” becomes meaningless
2) Exclusive. They leave out factors that were also necessary and only jointly sufficient to “cause” the failure
3) Oversimplified. They highlight only a few hotspots in a long, twisted and highly interconnected, much finer-grained web that spreads far outside the causes you come up with
· “Since there is no such thing as a root cause … there is technically no such thing as the beginning of a mishap”
· E.g., you can always go one step deeper, hence ‘root cause’ is more about stop rules, sociopolitical factors, resourcing and more, whether recognised by the investigator or not
Since people inevitably raise RCA in defence – RCA is irrelevant. This argument isn’t about whether or not you find RCA useful, and whether RCA finds/constructs causes or contributing factors, nor whether it chooses to use the term ‘root’, it’s about whether some causes are ontologically distinct from ‘root causes’.
Does it ultimately matter? Who knows. But people seem to like these posts, so here we are.
Refs: Field Guide to Understanding Human Error (2014) & Human Error Investigations (2006). Ashgate
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