Tag: #rca #matthewsyed #abrahamwald #problemsolving #data #jordanellenberg #hownottobewrong #solutions #business


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
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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.


Finding The Stamina to Fail

Much has been written about the importance of learning to fail, and fail well. So much so that in recent years it’s become the mantra of almost each and every tech start-up around the world. But beyond the rallying cries, motivational slogans and glib sound-bites what does this really mean? And how can it be achieved?

In my experience, the answer to both these questions can be found largely by looking at how successful organisations create a culture of collaboration and energy to address their problems.

photo of group of people in a meeting
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Almost without exception, every effective and successful organisation we at Sologic work with views complex problem solving as a collaborative activity. They commit to providing the necessary resources, skills and tools required to promote, and reward, effective group-orientated problem solving. No matter the experience or ability of any given individual they know that solutions are always stronger when shaped by teams. In addition, the entire process is energised when problems are viewed objectively, seen as systemic opportunities and addressed free from the toxicity of blame.

Broadly speaking, we see that all cutting-edge organisations really do share a set of positive behaviours. They implement a process that closes the gap between what happened and what should have happened, and alongside that, they develop and support an environment that maximises the opportunity to learn from the overall event.

In summary, great organisations:

  • Solve in teams
  • Define their problems clearly
  • Promote analysis over narrative
  • Start with ‘what’ never ‘who’
  • Evaluate all possible solutions
  • Learn from the event
  • Share that learning quickly and freely

In practice, these behaviours can only come from top-down acceptance that a) problems will always occur, that b) many of these are worth solving, and c) that in the longer term, a structured and sharable process is always going to outperform any ad-hoc one.

In the workplace the painful truth is that solving complex problems as an individual, or trapped within an organisational silo, is very stressful, seriously fatiguing and worse still, it’s damned ineffective. Under these conditions, precious stamina, be it physical or mental, is quickly exhausted. Energy that would be best directed towards long-term solutions is reoriented towards quick-fixes, work-arounds, denial, blame and, in some circumstances, even cover-ups. Left unaddressed, problems become engrained, they increase in size, they multiply, and inevitably the cycle of failure becomes more and more difficult to break. That’s why only a process and not another slogan will make the difference.

The 60 Minute RCA Investigation

RCA has a reputation for being an in-depth, formal and collaborative way to investigate significant events.  But what if time is not on your side…

The 60 Minute RCA.

We know the drill all-too-well.  Something has gone wrong and there’s unanimous agreement that the issue has to be to be tackled. We either have to solve the current problem or ensure it doesn’t happen again.  Most likely both!


But here’s the big dilemma.  Even though we know that the problem is serious, and it is already generating some pain (with the potential for still more), we’re struggling to gather a team or allocate enough time to conduct a fully-blown Root Cause Analysis investigation – which it clearly requires. On top of all this, we know it’s now or never – for as time ticks by data gets lost, memories fade, and impact is forgotten. Furthermore, if we don’t act now there is a very real chance that the problem could recur – moving up, or downstream, or increase in magnitude. Frankly, right here and now it’s impossible to say precisely what might still happen.

And to make things worse, we’re all fighting the old habits of jumping to conclusions, plumbing in a previous “half-decent” fix or go looking for someone to blame.  Despite the obvious temptations, we know it’s almost certainly this type of behaviour that contributed to the problem occurring in the first place.


So…what on earth do we do?

One effective option is to run a 60-Minute “micro” RCA.  With some solid training in formal RCA, a little up-front planning, plenty of discipline and a crisp agenda, 60 minutes can provide some truly effective solutions.


Okay, so how do we do it?

Firstly, it pays to assemble a micro squad of potential team members. For the RCA top out at a maximum of 3 people in total.

Where possible you should aim to involve RCA trained colleagues!  This is sometimes tough because we need both RCA trained people who are also knowledgeable about the event, and those two don’t often align.  If time is absolutely of the essence, and you are well trained and experienced in Root Cause Analysis consider a solo RCA.  As a well-practiced solo problem solver, you should be able to solve some problems in under 45 minutes.

Expert Tip: You can always run your results past colleagues or other experts to augment or correct your findings, especially if some earth-shattering new info is found.


Getting Started.

When a problem occurs that does demand a team RCA, be prepared to send a quick and clear heads-up in advance of any meeting.  This gives space for a preliminary opportunity to discuss & share data requirements.  This is also the time to agree on the precise nature of the problem the team will be analysing.  This can be done by email or your preferred collaborative tool.

Expert Tip: Individuals or teams often need grab data fast.  Even if you are seriously short on time allow maximum available time for gathering all available data.  Without this you are going be hurting very early on in the RCA process.


How should you organise your 60 mins?

Firstly, for a 60-minute RCA itself be sure that it is punctual, whether it is an in-person meet-up or held via a remote collaboration tool.

Agendas may vary but a good, workable template looks like this:

  • 5 mins. Introductions and small talk.
  • 5 mins. Confirm EXACT Problem to analyse and the impacts it had.
  • 30 mins. Run a Cause & Effect charting exercise.
  • 10 mins. Brainstorm Solutions.
  • 5 mins. Measure Solutions agree set criteria.
  • 5 mins. Agree and assign actions.

Take a look at the Sologic 5-Step RCA Method

Tip: Share this agenda in advance.

When you get started, be clear and remind everyone that there is an absolute maximum of 60 minutes available and you really have to stick to that strict timetable.  Keep the pace crisp and don’t allow anyone (including yourself), to become bogged down in granular details. Fine details, evidence and ‘unknowns’ can be addressed after the RCA itself they warrant it.


What can you expect to achieve?

A well briefed, undistracted team should be capable of a great deal in an hour.  Of course, a 60-minute RCA is never going to be a substitute for a formal fully-collaborative investigation, but it will almost always generate many more solutions than any ad-hoc method used to try to solve a complex problem.

Through a good 60-minute RCA you can expect to reveal:

  • Some early glimpses of ‘systemic’ causes you would otherwise have missed.
  • A surprising number of opportunities for good quality solutions that will control, change or eliminate a problem.
  • The true scale of the problem for the first time, allowing problem solvers to reassemble at a later date, for a full RCA, and focus on where further vulnerability is truly lurking.
  • The first indications of problems yet to occur.
  • A dramatic uplift in institutional learning and corporate memory.

Sologic’s Causelink RCA problem solving and reporting software helps teams collate and maximise efficiency in their investigations, manage progress and share findings. See the features HERE.

Expert Tip: If you are an organisation that often finds yourself needing to run RCA type investigations, then there will be a huge return in investment in training more key line employees in order to stem the continual fire-fighting. 

For more information on conducting effective RCAs, improving investigations and developing problem solving skills, contact the Sologic team today.

A Monumental Mystery? The Apocryphal tale of The Jefferson Memorial.


There is a story, so beloved of professional problem solvers that it has become a virtual “article of faith” in the problem solving community. A tale so compelling, that although the story predates Google by almost a decade, and despite never warranting an official publication, there are reportedly more than 100,000 pages online which reference the study in some way.

The story, which addresses the woes of the Jefferson Memorial in Washington DC, is used as a method to extol the virtues of the 5-Whys method of structured problem solving. To recap, 5-Whys is a simple, stripped-down method of root cause analysis (RCA) in which the investigator repeatedly asks, “why?” in order to drill down from higher-level symptoms to the underlying root cause of a problem.  The parents amongst you will have encountered this from your kids (they stop doing at around age 25 I’ve been reliably informed).


Our story begins back in the late 1980s, when US National Parks managers noticed that the Jefferson Memorial was crumbling at such an alarming rate that it would quickly become dangerous to visitors. When they asked why (1) this could be, they were informed that it was being washed with strong chemicals far more frequently than any of the other DC memorials. For most teams, the investigation would stop here. The solution has been found, of course. Reduce the cleaning frequency to match those of the other memorials.

Unfortunately, that solution wasn’t acceptable. It would have resulted in a filthy, unhygienic Jefferson Memorial. This clearly wouldn’t cut it in Washington DC, a city of such national and international significance.  By employing classic 5-Whys thinking the team could surely find out what else could be done?

Next up the investigation team enquired as to why (2) the memorial was being cleaned so frequently?  They discovered it had an exceptionally large amount of bird droppings deposited on it every day. What’s the solution now? Use scarecrows? Fly hawks? Bring in Elmer Fudd or the Duck Dynasty crew and declare open season on pigeons?

Luckily (for the pigeons, anyway), the Parks managers kept inquiring. When they asked why (3) the birds seemed to prefer the Jefferson as a toilet, compared to monuments like Kennedy or Lincoln, they discovered that the Jefferson harboured an incredibly large population of spiders and similar insects upon which the birds were eagerly feasting. Why (4) on earth was this?  An eminent entomologist from Baltimore, Prof. Don Messersmith was contacted, and he discovered that the population of spiders had exploded because of an abundance of midges and similar insects that had made the area around the monument their home.

When the Parks managers asked Prof. Messersmith why (5) so many midges congregated on the Jefferson memorial, Messersmith told them what any  fresh water fisherman already knows – Midges are triggered to emerge and mate by a particular level of light.  And it just so happens that the Park managers had been inadvertently creating this unique quality of brightness by turning the memorial lights on just before dusk.

So, according to our tale, this one variable (light levels) caused this pattern of cause and effect; lots of midges, lots of spiders, lots of pigeons, lots of droppings, lots of chemicals during lots of washing – all leading to the inevitable deterioration of the statue.

Expressed as classic 5-Whys we can illustrate this in the following way:

ProblemOne of the monuments in Washington D.C. is deteriorating.

Why #1 – Why is the monument deteriorating?  

  • Because powerful chemicals are frequently used to clean the monument.

Why #2 – Why are powerful chemicals needed?

  • To clean off the excessive volume of bird droppings on the monument.

Why #3 – Why is there an excessive volume of bird droppings on the monument?

  • Because the large population of spiders in and around the monument are a food source to the local birds.

Why #4 – Why is there a large population of spiders in and around the monument?

  • Because vast swarms of flying insects, on which the spiders feed, are drawn to the monument at dusk.

Why #5 – Why are swarms of insects drawn to the monument at dusk?

  • Because the lighting at the monument in the evening attracts the local insects.

Solution:  Change how the Jefferson is illuminated at dusk to prevent the arrival of swarming insects.

The tale tells us that, by using 5-Whys, the solution ended up being incredibly simple and actually saved the Parks Department a great deal of money on chemicals, labour and administration, namely to just wait until dark to turn on the lights.

What more could we ask for?…

The Alternative Take.

Except, what if it was never as simple as this?  What if, after 30 years of teaching this example, emboldening thousands upon thousands of 5-Whys problem solving disciples, leading to tens of thousands of articles, we discover that the 5-Whys method didn’t actually uncover the layers of this problem and that the solutions chosen were not quite as simple, nor as effective as we have been led to believe all these years?

Let us investigate further via a series of challenges assembled from information that is readily available in the public domain (after all, there are 100,000 articles to purvey!).

Debunk 1.  Although the tale speaks of the unique nature of the Jefferson Memorial official reports, published in 1989, state that several memorials across in DC were a similar condition, regardless of their unique environmental conditions.

Debunk 2.  The investigations undertaken throughout 1989 and 1990 were not undertaken by plucky amateurs as implied by most iterations of the tale. In fact, they were part of an in-depth multi-disciplinary investigation performed by a team of highly trained problem solvers hired by the National Park Service (to the tune of $2 million, as you ask) to perform a year-long study of the widely acknowledged deterioration of DC memorials.

Debunk 3a.  Most versions of the story cite the harsh chemicals required to remove bird droppings as the ‘root cause’ of the problems effecting the monument’s stonework. Documents produced back in 1989/1990 state clearly that although chemicals did contribute they only contributed in combination with other factors. Most significantly the ‘excessive’ quantity of water used throughout the cleaning process, and the pressure at which it was applied.

Debunk 3b. Furthermore, acid rain, air pollution and littering tourists were also cited as contributing factors of note. News articles published at the time stated that the Parks Service must “dramatically reduce the volume of water used to wash the monuments”, even going so far to say that they would need to “educate the public to understand that these buildings may not appear as pristine white in the future as they once did” because of the reduction in water used to clean them.

Debunk 4.  Reports also stated that the majority of the discolouration was not caused by bird droppings.  It was, in fact, the midges and bugs themselves that discoloured the stonework.  It is true, nevertheless, that the lighting used, did attract a substantial percentage of the insects to the buildings.

Debunk 5a. The impact of the Jefferson Memorial story is delivered by the fact that the chosen solution (to delay lighting till full darkness, and reduce overall brightness) was more effective, quicker and far lower in cost than any other consideration.  In the first instance, this solution was extremely effective, reducing bug communities by 85% within just a few weeks.  However, the replacement lighting systems across the city took a full 5 years to implement and eventually cost upwards of $25 million in public money.

Debunk 5b. Although the solution was extremely effective (and ultimately saved on energy costs too) it was never implemented beyond an initial 6-week trial period!  After several years of lobbying from various public bodies and complaints from residents, businesses, tourists and photographers, fearful of being robbed of their stunning images of great monuments glowing next to the mighty Potomac River, the government finally abandoned their decision to permanently restrict lighting levels in the early evenings. A timely reminder that in the real world some solutions can be extremely effective as well as offer an undeniable return on investment but, due to strategic, environmental or cultural (and unforeseen) obstacles they can never be implemented.

Debunk 6. In place of the highly effective, but short-lived decision to change the lighting policy there are now a host of solutions in place to dissuade birds, spiders and midges from congregating on the memorials. These reportedly include the installation of wires, metal spikes, netting, scarers and clear plastic.  The cleaning processes have also changed; the quantity of water has been reduced and the way in which it is applied has changed. And, crucially, the chemicals that are used are now far less aggressive.  Fundamentally though, the demands of the viewing public have changed, leading to a more realistic and pragmatic expectation of the appearance of the monuments.

What have we learnt here?

Firstly, Satirist HL Mencken, from nearby Baltimore, couldn’t have been more apropos when he wrote half a century earlier that ‘For every complex problem there is an answer that is clear, simple, and…wrong’. The answers delivered in this story were clear, they were simple, and they were, alas, also wrong.

But like all good debunked stories, there is still much to be learnt from the apocryphal tale of the Jefferson memorial. Just maybe not exactly what we thought.  Perhaps what we really gain here is a more realistic picture of the huge difficulty of solving complex problems under real world conditions.  And that only via a genuine understanding of cause and effect do we discover the wider spread of solutions that we almost always need to apply in the real world.  But crucially, we are reminded that when a lesson is this plausible, almost all of us are blind as to its questionable validity.

So, let us keep sharing the Jefferson Memorial story, but no longer as an encouragement to adopt 5-Whys, but rather as a warning not to be seduced by its compelling simplicity.