Category: Uncategorized

Man, I don’t envy THAT guy!

Homer Simpson

In an episode of The Simpsons dating back almost a decade, Homer is so overwhelmed with his adult responsibilities that he decides to shirk them by getting drunk. He justifies his choice by stating;

“That’s a problem for future Homer…
Man, I don’t envy that guy!”

Homer’s is a clear choice between dealing with the tough decisions of now, versus kicking them into the long grass for another day. All the while knowing it will be more problematic for him (and others) later.  It’s this kind of decision making that many of us display or encounter day after day in our working lives.  Problems come along and we do our best to ignore them, deny they’re really a problem at all, patch them with a quick fix, or if we possibly can, bump them upstream or downstream for as long as we can.

Many of us just don’t feel confident that we have the time, resources or support to manage big problems in an effective or structured way. We’re used to hearing objections like ‘we just don’t have time for this’ or ‘let’s just get it up and running for now’ or ‘we are already way too busy for this’.  But deep down we know that this is faulty logic and that these problems are always going to catch up with us in the end.

Arguably most of us do this because our decision making is based on a major oversight – namely that we ARE already dealing with these problems.  BUT we’re dealing with them in the least efficient, least predictable and least effective way that our organisations could possibly tolerate. It’s only because many problems are so drawn out, so thinly and widely spread across an organisation that we can somehow compartmentalise and delude ourselves that the problems are anything but massive.

In fact, it’s not uncommon for us to become so conditioned to the problems around us that even though we’re fighting exactly the same fires over and over again, we cannot see them for what they really are.

The tale of the fish and the frog springs to mind:

Two young fish are swimming across a pond and a wise old frog calls down to them from his lily pad. “Hey boys, how’s the water?” he calls.  They look at each other, embarrassed, and swim on by.  Once they are a safe distance away, one fish turns to the other and asks, “So, what’s water?”

You see, when you’re in it, you don’t know what ‘it’ is.

Once we recognise that our problems share root causes that can be addressed, we discover that putting time into solving these problems is NOT more work. On the contrary, it’s the biggest resource saver available. Through a dedicated, effective program of uncovering and tackling root causes we can start to save huge chunks of time and money and use the outcomes for value-added problem solving; for design, for creativity, for improvement, for efficiency and for planning.



All organisations have problems and some of those problems are certainly worth solving. Clearly some teams and some individuals are better at solving problems than others, so what pitfalls can you avoid in order to improve your problem solving skills and outcomes?

Here are the ‘Big Seven’ pitfalls that we know contribute to weaker problem solving:

1) You don’t really know what problem it is that you’re solving.
Question: Have you clearly defined the problem you want to solve?

Being clear about the problem you want to solve is essential. If the problem definition is not clear in your own mind, and has not be coherently stated and shared to your team, how will you or others set about understanding and solving it? Experience demonstrates that individuals rarely have a shared perspective we assume they have when it comes to major issues.

2) You’re not in a problem solving state of mind.
Question: Have you got your inquiring mind set in place?

All too often, problem solvers are judged on speed and not effectiveness – professional perception of a role or profession can imply that good problem solvers should be able to come up with solutions immediately. Expert problem solvers will always put aside any assumptions that they know what caused a problem or that they already know what the solution is. This process prioritises effectiveness over speed.

person holding black and orange typewriter
Photo by on

3) You’re telling stories.
Question: Have you broken down the causes of the problem down into its constituent parts?

Many of us rely too heavily on narrative (aka story-telling) which comes with inherent issues, such as artificial start and finish dates, truncated analysis, focusing on activity (usually the interesting bit), simplified timelines and reduced detail. An effective analysis drills backwards in time from the problem, methodically picking apart the cause and effect relationships at play. Only patient analysis will push us beyond the superficial ‘symptom level’ to the root causes.
4) Your focus is skewed.
Question: During your analysis have you paid attention to the systems and circumstances that have allowed change to take place?

Actions aka ‘points of change’ are usually the most obvious causes, but unless we consider systems and circumstances we will only have part of the picture, at best. Although systems and circumstances are often subtle and are sometimes harder to uncover, they are no less important when it comes to effective problem solving.

5) You’re blaming people.
Question: When ‘Human Failure’ is apparent, have you ‘drilled back’ to really understand what made the person behave in that way?

People are often the aforementioned ‘points of change’ and in that sense their role in a problem is often the most obvious. For many of us it’s easy to become focussed on the actions of individuals and this easily slips into a blame culture. This usually results in less information being shared and a reduced appetite to assess tools, practices and the working environment. In this scenario problems will never be satisfactorily solved. Equally, avoiding accountability altogether by dismissing causes as simply ‘Human Error’ gets us no closer to applying effective solutions either.

6) You’re searching for THE root cause.
Question: Have you taken into account that your problem will have multiple interdependent causes?

If only problems had just a single root cause!  All problems, especially complex problems have multiple causes. Fixation on a single cause leads to a similar fixation on a single solution. Avoid convincing yourself that a solution applied to just one cause, even a major cause, will completely solve your problem.  This is rarely the case. In fact, this pitfall, above all, explains why the majority of problems are frustratingly stubborn.

7) You’re choosing the wrong solutions.
Question: Have you methodically addressed your analysis to select your best solutions?

It’s all too easy to select solutions on criteria that don’t stand up to rigorous scrutiny, or apply solutions that cluster in the part of the problem we are familiar or comfortable with. A systematic evaluation of all possible solutions should help us decide which will offer us maximum effectiveness, provide a strong return on investment and won’t trip us up badly when we’re further down the track.

Lessons Learnt or Lessons Lost

Over 400 years ago, Captain James Lancaster, an English sailor, performed a benchmark experiment in his pursuit of a prevention for a disease called scurvy.  Scurvy was one of the biggest problems at sea at that time, killing or debilitating many individual sailors as well as rendering the operational capability of a crew so diminished that the remaining sailors struggled to man their ships safely.

On just one of four ships in a flotilla bound for India Capt. Lancaster prescribed three teaspoons of lemon juice a day for the entire crew.  By the half way point of the journey everyone on that ship was alive and well. On the other 3 craft, 110 men out of 278 (40%) had died and others were becoming increasingly weak and sick.

sunset ship boat sea
Photo by Pixabay on

This was an incredible finding that directly linked scurvy, a killer disease, with a chronic lack of Vitamin C.  It revealed that relatively modest consumption of lemon juice was a way of avoiding hundreds of needless deaths on future journeys as well as the loss of millions of pounds (in today’s money) of ships and naval hardware.

Despite this discovery, it was to take another 200 years (and thousands more unnecessary deaths) for the British Royal Navy to enact firm dietary guidelines as routine on its ships. This is an adoption rate that can only be described as a ‘glacial’.

One would hope that things have changed and moved on since then, however, many large organisations still struggle to analyse their mistakes and learn from them. And for some, even when learning is identified, these learning opportunities don’t easily flow through the system to the ‘front line’.  For example, adoption rates in global healthcare, in particular, are known for being ‘low and slow’ and have been described as universally sluggish for many years. One recent study examined the outcomes of nine major medical discoveries made at the end of the 20thcentury. The study revealed it took an average of 17 years before the new treatments were fully adopted by the majority of doctors.

But even in this ‘information age’ many differing organisations and sectors continue to struggle with implementing important ‘lessons learnt’. multiple studies clearly show that adoption rates are directly linked to the way that important learning is formatted and distributed to relevant parties. Revealing that necessary knowledge has often not been translated into a simple, usable and systematic format.

Now, although it should be noted that direct comparison between different sectors should be handled with extreme caution, the aviation industry is regularly presented as a sector that has worked assiduously on this issue of sharing learning. Examples being;

  1. In aviation in the aftermath of an investigation the report is made available to everyone.
  2. Airlines have a legal responsibility to implement the recommendations.
  3. Every pilot in the world has free access to the data
  4. Aviation has protocols that enable every airline, pilot and regulator to access every new piece of information in almost real time.

In this sector, data resulting from investigations is universally accessible and rapidly distributed across the world. This enables everyone to learn from the mistake or error, rather than just a single crew or a single airline or nation. Crucially, learning derived from investigations is immediately filtered and refined into targeted guidance. This accelerates the speed of learning and, as a result, the adoption rate in these scenarios is almost instantaneous.

Atul Gawande, Surgeon, Researcher and Author, highlights this challenge of presenting complex information across other organisations and sectors;

“If the only thing people did in aviation was issue dense, page long bulletins…it would be like subjecting pilots to the same deluge of almost 700,000 medical journals per year that clinicians must contend with. The information would be unmanageable. Instead…crash investigators distil the information into its practical essence.”

The crucial lesson to take away is that if an organisation is to generate the maximum dividend from their problem solving and lessons learnt programs then it is imperative that they create a culture that promotes the recognition of mistakes. They must implement a process that investigates mistakes openly and effectively and devise a system that enables the key learning to be distilled, distributed and assimilated as efficiently as possible.

Don’t learn a lesson the hard way, only to lose it.

Which boss are you? Premier League or NFL?


Back in 2013/14 the English Premier League reached an all-time low. Incredibly, the average managerial tenure at a club sunk to just 1.84 seasons per active manager.  And if you had removed Arsene Wenger’s 18 seasons at Arsenal that figure would have plummeted to just 1.05 seasons per head.  Incredible when you consider it for a moment. Just try to imagine any other multi-billion industry where the COO’s of the 20 leading firms had an average of just 1 year in charge.  Consider the impact on corporate memory, continuity, strategy, institutional learning, recruitment, or just about any other metric you’d want to consider.

However, as Martin Calladine points out in his fascinating book The Ugly GameHow football lost its magic and what it could learn from the NFL (Pitch Publishing, 2015) – It’s not just ‘that’ Premier League managers get sacked with alarming regularity but when they are sacked and the reasons why they lose their jobs.  The when is usually after very little time and usually mid-season, and the why is a desperate attempt to conjure up an immediate turnaround in results – rather than part of a wider strategic plan.

But as a Chairman why wouldn’t you?  If the ends justify the means?  Wouldn’t you want to ensure you stave off relegation or make it into a precious European place?  Of course you would!

However, the hard truth is that these decisions rarely play out in the interests of the club. In practice this is a terrible way to address the problems of a failing club, it increases the likelihood of relegation rather than mitigates it, potentially impoverishing the club and serving to start the cycle of hire and fire all over again. The practical impact is that the replacement manager’s first roles are focussed almost exclusively on firefighting rather than planning, restructuring and impartially assessing the road ahead.  Furthermore, the mythical “dressing room” is empowered and the position of Manager is one that is subtly repositioned as a servant of the playing staff, not vice-versa.  Perhaps even more damaging, as in many failing organisations, this ritualistic focus on people and discipline all to quickly becomes an action of “first resort”, not last, and (conveniently) distracts the organisation and its employees from the structural problems hidden elsewhere.

For quantitative evidence of this, Calladine refers to the extensive Bell, Brooks and Markham report of 2013: The Performance of Football Club Managers: Skill or Luck? The report reveals evidence of what club chairman can really expect from their decision to sack a manager in October or February.  Their exhaustive report illustrates that leading clubs who sack managers experience a temporary but altogether fleeting upturn in form at best.  Those that back their managers in times of trouble are statistically far more likely to experience a sustained improvement in results.  Looking at the data in the widest sense, from 700 mid-season sackings over a 30 year period from the 1970s onwards, you guessed it, those clubs performed at a considerably lower level than those who looked towards other methods to improve performance.

So why do it?  These are certainly not evidence-based solutions, after all.  Perhaps it’s as simple as if you sack a manager and improve you can bask in your godlike genius as a chairman.  If the slide continues there are often a myriad of convenient factors to blame this on, ones that do not necessarily reflect too badly on you and the board.  It would seem, therefore, that the risk versus reward ratio for the club is actually quite different to that of the individuals at the top of the pyramid.  Put another way change is almost certainly in the best interests of the board, even when it’s not clearly in the best interests of the club.  And perhaps, Chairman like many successful people suffer from higher levels of survivor and optimism bias.  And finally, let’s not forget, as unpleasant as it is to sack another person, for most people that’s far easier then admitting to their own shortcomings.

Perhaps by now you’re wondering what the NFL has to offer on this debate.  Back to Martin Calladine for this.  He uncovers that the typical time in post for an NFL Head Coach is around 3.2 seasons, a little under the pre 2013/14 average of 3.3 seasons for a Premier League manager.  So, no great difference there. But there are major differences in the why and the when. Firstly, it is rare for Head Coaches to lose their jobs during the season, and when it does happen, it’s only after 80-90% of the season is done and there is nothing to play for.  The practical impact of this is that NFL typically go 3 and Out, while in English football it’s 2.5 or 3.5 and Out.  It’s the impact that the 0.5 has on the clubs that is arguably the root of the toxicity in the system.  Through this crucial difference the NFL franchises are better able to address their systemic failings alongside the obvious human factors at play.

Of course, we can’t discuss this without acknowledging the spectre of relegation, a threat that NFL Head Coaches and Owners simply don’t have to consider.  But this doesn’t fundamentally undermine the point that sacking football managers doesn’t work, nor that chairmen confuse what’s good for them with what’s good for the club.  In other words, it may be true that, were NFL owners to face relegation, they would fall into the same bad habits as English football clubs, but that wouldn’t prove they were right to do so, just that they too hadn’t properly got their organisations operating on a long-term evidence-based footing.

So how does all this relate to Root Cause Analysis?

When it comes to analysing cause and effect within organisations, and especially when firms address the process of creating and selecting effective solutions, Root Cause Analysis encourages them to look beyond the people and stop expecting discipline to be an effective solution. Organisations fixated on hiring and firing often do so in lieu of addressing their systems, tools, hardware, procedures and cultural issues. Evidence reveals that these are the factors that are really defining their performance.

Therefore, an effective RCA culture should force leaders to ask themselves some or all of these questions before they focus on their people:

  1. Do my problems walk out of the door with the sacked individual?
  2. Was the sacking in-line with a pre-acknowledged set of threshold performance criteria? Or were other factors at play?
  3.  Have all the solutions we’ve put in place this year been applied to the previous regime only and therefore walk out the door with them?
  4. Do all my new solutions walk through the door with the next appointment?
  5. Is the replacement manager moving into a system that is improved, the same, or reduced in resilience?
  6. Will discipline (or the threat of discipline) encourage staff and/or management to close ranks – starving me and organisation of vital decision-making information?
  7. Am I basing my decisions on evidence from reliable sources?
  8. Has the organisation used any objective, methodical technique to uncover all possible areas for corrective and preventative actions?
  9. Aka Marginal Gains.Has the organisation successfully uncovered and addressed all areas for systemic improvement?
  10. Is the organisation recording, measuring and sharing improvements both on and off the field?
  11. Are these tied to long term corporate memory/institutional learning/identity/pattern of managerial play?
  12. Do all my officers have undeniable clarity on our targets, goals and objectives?
  13. Who in the organisation is in a position to observe, report and address cultural issues and how?
  14. Is the organisation focussing on immediate effectiveness over long term negative impacts?
  15. Would the organisation’s approach to decision-making and problem-solving change with wholesale change of the board/ownership?
  16. Is the organisation currently imitating or innovating under my governance?

Therefore, if a football Chairman, or any organisational head can answer all these questions in the positive, then there may well certainly be justification for the sacking of [insert failing manager’s name here]. Just as long as, as Martin Calladine suggests, they end their inevitable press conference with these heartfelt words ‘…and if it ever happens again, that we so drastically misjudge an appointment, I will step down too.’ 

Finally, I’d like to personally thank Martin for allowing us to piggy back on his thought provoking work.  I hope that this blog creates as much debate as Martin’s writing did for us at Sologic.