Making Sense of Root Cause Analysis


Root Cause Analysis (RCA) is often seen as having short-term impacts, when, in fact, the returns may be long term. Understanding the differences is critical to successful implementation of RCA. The chart below lists some of the differences between RCA in software and RCA in other disciplines. This article will address these differences and how they should shape application of RCA to software.

Items one and four are related and are sometimes misunderstood by those who initiate RCA as a "solution" to software defect prevention (using the "If we get to the root cause of critical customer problems, we can make them go away" train of thought). This confuses the physical realm with the intellectual realm. Three Mile Island, TWA 800, Challenger, and other major disasters could be analyzed to identify operational or physical failures that, once identified, could be prevented by a redesign of a part, system, or operational procedures. When people apply these methods to the software profession and expect analysis of critical problems to prevent future failures, they fail to understand the root causes of software defects.

They falsely assume that something that causes a major customer failure must somehow have been caused by a major oversight or repeatable cause, where the consequence of the fault will always be proportionate or related to the initial error. For software this is not true. Single-character coding errors caused Mariner 1 to crash into Venus and the 800 telephone system to crash back in 1994. This means that RCA of serious failures will not consistently prevent other serious failures, as the root cause of simple failures may generate serious failures in other parts of the product. A simple typographical error can have a minor impact in one case and a catastrophic failure in another case.

 SoftwareOther Engineering Discipline
1Many failures of varying consequenceSingle events with major and often catastrophic results
2Failures caused by "intellectual" shortfallsFailures caused by physical interactions or mechanical fatigue,
operational errors, management failures, or design errors
3Many common-cause faultsTypically unique faults
relation of cause to failure or future failures in many cases
Cause may repeat with similar consequence
5Typically low effort per failureOften significant effort, many times with political overtones
6Prevention may be well into the future; requires investment to prevent future errorsScapegoat and financial responsibility

If we are lucky enough to identify a common process failure related to a specific failure mode, then RCA will have a benefit. This leads us to identifying a common cause for multiple failures, which is the third item in the tabled list. By systematically analyzing multiple failures, patterns of common cause may be identified, leading to a single fix in a requirements, design, or coding process that eliminates multiple faults with one change. A secondary impact of this item is that RCA of single failures is self-defeating, as patterns will not be apparent until multiple failures are analyzed and common causes identified. If you go back to one of the original papers on Defect Prevention and search for "Defect Prevention"), you'll find that the RCA process involves collecting data from multiple failures and analyzing them as a group.

The second item, intellectual vs. physical, is one of the reasons the first and fourth items present their difficulties. Metal fatigue, for example, can be attributed to specific causes that, once eliminated, ensure these failures will not be repeated. The human mind, however, is not so accommodating. If we look at some of the reasons errors get into software, such as communications loss, noisy work environment, multi-tasking impact on short term memory, etc., we need to address the sociological aspects of our profession rather than mechanical or chemical aspects. How many of us work an entire eight-hour day without interruptions? How often do you start a one-hour task in the morning and find that at day's end you have not finished it—and the next day, as you start over, you've forgotten a critical aspect of the program that was your next task the day before.

Item six has multiple consequences. To be effective in software development, the real root cause usually requires the person making the mistake to be involved in the analysis. If there is fear of retribution (scapegoating), the incentive to identify the root cause is eliminated. The second issue is the time relationship between discovery of the root cause and the chance to prevent the problem in the next development cycle.

I came across an organization that was doing RCA on production failures with the expectation of significantly improving quality. Their typical release schedules were twelve to eighteen months. This meant problems found in the requirements or early design activities and eliminated from the next release cycle would have a twelve- to eighteen-month delay before showing up as improved quality in the next release—not what they wanted. To be effective, the time delay between the error introduction, discovery, root cause analysis, repeat of the activity that introduces the error, and impact on the next development or production cycle should be as short as possible.

The third issue with item six is "what to do with the result" of the RCA. For major catastrophes, finding the scapegoat is often the real reason behind RCA, as lawyers and victims get in line for compensation. In software, we are looking to prevent future occurrences, which means we need to change something: process, development environment, work environment, etc. Change means some effort or cost will be incurred to make the change. If this cost is not budgeted, how will it happen? All too often this falls into the "now a miracle occurs" part of the plan—or lack of plan—for preventive action. Whether the preventive action is as simple as a checklist update or complex as changing the development environment or process, allocating some budget for this endeavor is mandatory. Telling your development teams to do something in zero time or at zero cost sends a message that the activity isn't worth much. 

To effectively apply RCA in your organization:

    • Make RCA a formal, budgeted activity
    • Avoid scapegoating
    • Involve the people who made the original error
    • Do RCA on groups of failures, looking for common causes
    • Understand both temporal delay and causality (linkage of cause to significance of the failure)


Side Note:
Typically we use the terms error, fault, defect, and failure in sequence to correctly describe what happens. A person makes an error which introduces a fault in the product. This fault results in a defect when the program executes, which may or may not result in a failure visible to the user. Casual writing quite often uses the terms bug or defect to mean all four. Usually context will tell you which is which, and, hopefully, I (hopefully) was consistent in this article.

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