The title of this paper and presentation, "There Is No Root Cause" is lifted directly from Sydney Dekker and his book, The Field Guide To Understanding Human Error. As was Dekker's intent when he wrote this as a section heading in his book, our discussion here is not intended to make the point that investigating incidents to find the root cause should be abandoned. Our purpose here is to explore what Dekker and others are telling us about causation, and the process by which we construct a narrative about what is believed to have occurred. It is this process of constructing or developing the basis for the narrative where care must be taken. Author Erik Hollnagel, in his recent book, Safety I and Safety II, writes, "A problem with root cause analysis as well as most other methods used … is that providing a definitive answer rules out any alternative explanation or even motivation to search for ‘second stories.’"
Investigating workplace incidents is a fundamental skill for safety professionals. It is our job to gather the facts, identify what happened and why, and to find ways to keep it from happening again. However, most of us have received limited training in the investigative process, and even less in how to uncover the multitude of contributing factors that could be material in determining causation. We have learned what we know by reading articles, listening to speakers at conferences, attending seminars, and applying what we have learned on the job. Functionally, we know the fundamental process for investigating well enough. At least well enough to gather information for filing workers' compensation claims and OSHA recordkeeping, and to prescribe corrective measures.
Depending on our experience and the complexity of the situations faced, we may have also been exposed to advanced analytical tools and methods to find the root cause, including the "5 whys," Pareto charts, fishbone diagrams, fault-tree analysis, MORT, HFACS, and others. Depending on who you read or hear, and your level of experience, each has its strengths and weaknesses. In the end, they all start at the beginning and attempt to find a defining cause for what happened.
