The need to establish the sequence of events during an investigation of an incident is well accepted. It is the process of creating order from chaos; the ordering of facts as they are understood by the participants, observers and managers, simultaneously and progressively filtered and distilled by available expertise. There is often a lack of information and more data needs to be collected. The process is mired in uncertainty about why and how “it” happened.  The intention of creating a fundamental understanding in order to prevent a recurrence is the ultimate goal.

Once the facts of an incident have been established, the sequence typically shows what happened from the very beginning of the event, or the chain of events which lead to the serious negative consequences.  One thing leads to another as defences break down or are circumvented. James Reason’s Swiss cheese analogy is often quoted.

So one begins to understand why an event happened but less how to prevent its recurrence. Where does one break the chain? How do you choose?

Deeper analysis is required – relating the sequence of events is evidently insufficient.

This is usually when other factors are identified as having interrupted existing controls, complicated or otherwise influenced/exacerbated the effects as the event unfolded. The universal expression of inquiry, “why?” is often supplemented by “how come?” How does the change come about? This invites a more forensic explanation which slices the event more thinly, exposing every nuance and slightest degree of change, which, after all, is what the investigation is attempting to determine. What changed and why?

The starting point of the investigation must not be the supposed beginning of the event, but rather the effect at the opposite end of the chain, otherwise the random application of the question “why?” would create more confusion than clarity. The focus would keep changing according to the predilection of the investigators and their informants among the stakeholders. Starting with what you least want to happen and working backwards makes complete sense.

Another expression which leads investigators to a comprehensive understanding of an event-related problem is the “exploded” view. I became very well informed of the inner workings of racing and classic cars in my early teenage years by scrutinising this type of illustration. They make perfect sense. These drawings are grist for the mill in the engineering world, but under-appreciated elsewhere.

This view recognises that all components have their own place and the integrity of the explanation, the analysis, requires the exact location of each component (cause) be identified. It is a graphical representation which shows the precise relationship between the causes. “Everything has its place and there is a place for everything”, I recall my grandmother wisely saying.

As the expression implies, the linear representation of the sequence has to be exploded. Each cause path has its own series of causes in a particular order. The sequence of the whole event is disintegrated by the process of separating each component or cause and then creating a distinct sequence for each one, separate from the others. The objective is no longer about the “what”; it’s about the “why” which has its own graphical form.

This analysis is absolutely not about lists and groups within the lists. Lists serve to constrain the questioning and confine the investigative process to known and familiar paths. Prejudices will prevail. Donald Rumsfeld, a US Defence Secretary of yesteryear, was ridiculed for some memorable quotes but his reference to the “unknown unknowns” was unjustifiably included. “You don’t know what you don’t know “, is a corollary of the classical philosophical axiom “the more you know, the more you realise you don’t know” (Socrates via Plato). It is difficult to disagree with either.

What we must be able to agree on is that the focus of an investigation must change from the “what” to the “why” if we are to expose the causes. Only then can we hope to identify all the opportunities for prevention. The more causes we identify, the more opportunities we have for intervention along the cause paths leading to the undesirable result.

The sequence of events needs to be considered simply as the launching pad of the investigation, on the understanding that exposure of the causes will only occur when separation occurs.

Ned Callahan
Apollo Root Cause Analysis Instructor

About ncallahan

Ned Callahan is an experienced Apollo Root Cause Analysis Instructor and facilitator with 15 years' management experience and over 15 years' experience in education in two stints. In his 3 years at ARMS, he has helped people from over 300 companies become better problem solvers.

4 Thoughts on “Reconciling the Cause & Effect Timeline

  1. Ian Buckland on August 21, 2012 at 12:05 am said:

    Thanks Ned – interesting insights. Gave me a different perspective on information you conveyed in the course

    • Hi Ian. I hope the method is still working for you. Yes, the course content is just the beginning of the journey towards a deep understanding of causality. I am always reaching for better explanations in order to clarify my own understanding and then to communicate same more effectively in class. In my observations and conduct of facilitations I have become aware of the value of “how (does that happen)?” when understanding the sequence of events. Slicing the problem as thinly as possible, given the significance of the problem, of course, should reveal all the action conditions

  2. Agree in full. Regards.

    • Regards to you too, Mina. How is the method working for you? Let me know of your successes or complications even. Maybe I can help out – a neutral view of a problem often reveals a different way of thinking about a complex problem.

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