Digging Beneath the Surface
In every organisation, we encounter problems that seem persistent—repeating with frustrating regularity despite our best efforts to fix them. Projects stall. Performance dips. Clients churn. Safety incidents reoccur. Most people respond by patching the surface. But true systems thinkers dig deeper.
This is where Root Cause Analysis (RCA) earns its place as a foundational discipline in systems and strategic thinking. It’s not just about solving problems—it’s about preventing them from happening again.
🪓 The Core Idea: Symptoms vs. Causes
RCA challenges us to distinguish between symptoms (what we see or feel) and causes (what drives those symptoms).
“Every system is perfectly designed to get the results it gets.”
– W. Edwards Deming
If we’re unhappy with the result, RCA asks: What part of the system is causing this? What lever, if adjusted, would stop this issue from reappearing?
🔁 The Cyclical Nature of Systems Problems
In systems thinking, problems are rarely isolated. They’re usually feedback-driven, meaning today’s “solution” can become tomorrow’s problem if you haven’t addressed the root. RCA integrates beautifully into this worldview. It is not just reactive; it becomes a learning mechanism, helping your organisation adapt and evolve.
🧰 Tools of the Trade
Several frameworks support RCA. The most common include:
- The 5 Whys: Start with a problem and ask “Why?” five times, drilling deeper into underlying causes.
- Fishbone Diagram (Ishikawa): Categorise potential root causes into themes such as People, Process, Equipment, Environment, and Management.
- Fault Tree Analysis: A top-down deductive diagram showing how multiple failures or conditions contribute to a problem.
- Causal Loop Diagrams: Ideal for complex systems where variables reinforce or balance each other.
Each of these tools pushes you to pause and think more deeply. They make visible what is usually invisible.
🧠 Strategic Implications
For leaders and capital project managers, RCA is not just a technique—it’s a mindset.
- It forces clarity: What are we really trying to solve?
- It informs strategy: Are we optimising for the wrong variable?
- It unlocks transformation: Can we redesign the system so this problem can’t exist again?
Strategic RCA means we stop firefighting and start fireproofing.
⚙️ RCA in Action: A Project Scenario
Imagine your project pipeline repeatedly experiences delays during design handovers. A superficial fix might be to “remind the design team of deadlines” or add extra checklists.
But Root Cause Analysis might reveal:
- The initial scope brief is incomplete (first why).
- Because the business development team doesn’t consult delivery teams during bid writing (second why).
- Because they’re measured only on contracts won, not delivery success (third why).
- Because there’s no integrated feedback loop between BD and project ops (fourth why).
- Because the org chart structurally separates them with no accountability pathway (fifth why).
Now your fix isn’t a memo—it’s an org design change.
🧭 A Discipline for the Long Game
Root Cause Analysis demands patience. It delays action in favour of insight. But that delay is what protects you from the trap of “fixes that fail.”
Great leaders ask better questions. RCA institutionalises this questioning into every layer of strategic execution. It builds resilience, reduces waste, and sharpens your competitive edge.
🏁 Closing Thought
When something breaks—don’t just fix it. Ask why. Then ask again.
Your organisation is a living system. To lead it well, you must become fluent in seeing not just events, but the hidden causes behind them. Root Cause Analysis is your flashlight.
Illuminate wisely.
Missed out on the over all series?
Murray Slatter
Strategy, Growth, and Transformation Consultant: Book time to meet with me here!
