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Where Did Root Cause Analysis Come From?

History of Causal Thinking

By Dean L. Gano

Causal thinking has been with us from the very beginning so when I began the journey to understand it, I was amazed to find that there was no clear structured process I could use to solve every event-type problem every time. I found many simplistic schemes that claimed to provide Root Cause Analysis, but they were all different, each with a different definition of root cause.

So, I spent about 10 years reading and studying everything I could find on cause and effect – from the ancients to the modern gurus. I did not find a single methodology that one could call principle-based, meaning a process that works the same way on every event every time. There was change analysis, differences analysis, hazards analysis, barrier analysis, failure modes and effects analysis, fishbone diagrams, which are often incorrectly called cause and effect diagrams, and all sorts of categorical “root cause analysis” schemes, but none provided an essential or basic principle of causation, known as a principium.

One of the oldest written discussions of cause and effect can be found in the writings of Buddha. In the teachings of Buddha it is fundamentally understood that everything is caused to happen by conditions and causes. Unlike the cause and effect principle, Buddhism does not consider actions and conditions as two different types of causes, rather causes are exclusively actions, while conditions are an undefined something else that just exists. This thinking is still common today is most modern cultures and is a major barrier to effective problem solving. We also learn from Buddha’s teachings that all causes are connected – like a fish net he supposed.

He pondered why we spent so much time focused on the notion of right and wrong and decided it is a simplistic construct created by our inability to understand the infinite set of causes that is the real world. He proposed that the notions of right and wrong, as we use them, are categories used to pigeonhole something such that we can pass judgment on it. What Buddha understood was that by taking this simplistic path of categorizing things into right and wrong we miss the reality that everything has a complex set of causes that can be known. By understanding what cause paths lead to success and what cause paths lead to failure we can know much more than just right or wrong because we know why something happened.

The ancient Greeks and subsequently the western world failed to see the value of conditions and actions and instead embraced a categorical notion of cause and effect. Aristotle had his four categories of cause to include fire, which when viewed by today’s knowledge are such pure dribble they are not worth repeating. Ishikawa and other modern gurus use Manpower, Methods, Machines and Environment as the beginning of their categorical scheme, but having a categorical scheme does not a principle make because every human on the planet has a different reality and thus uses a different taxonomy of cause to understand the world. Instead of establishing a cause and effect principium, the western culture focused on how to categorize causes, reasoning that if they could understand the taxonomy of causes they could control them better – they failed.

The need to understand the world categorically is caused by the biology of the human brain, which uses a pattern recognition scheme with the patterns being stored categorically. We actually store nouns and verbs in different locations in the brain but because we each have a different life experience, we each have a slightly different schema. So it should be no surprise that we would try to use a taxonomy of cause to better understand our world, but it is fundamentally flawed because it does not pass the principle test – it does not work on every problem every time because it is different for everyone.

Another reason our forefathers failed to understand the cause and effect principle is because of the linear nature of language. Because we experience life as a series of events in time, our recollection of our experiences (stories) are communicated as a linear sequence. We simply don’t have any other way to understand or communicate what we think we know. On the other hand, the reality of our world is a set of causes and effects that follows a path similar to starting at the corner of a fish net, branching and interconnecting in many ways as we seek to find causes.

For sure we are able to understand short and simple causal sets, but try to deal with more than 6 or 7 causes and our brains quickly go into overload. We like to keep it simple so our simple minds can properly categorize what we hear or see. In fact, there is a common misconception that all you need to do to find the root cause of a problem is to ask why five times. In light of the infinite set of causes, this is laughable, but this simple minded thinking provides insight into why we have failed to understand and document the cause and effect principle.

In 1987, I began teaching root cause analysis and after teaching for about three years I began to understand and document the cause and effect principle which led to the Apollo Root Cause Analysis problem solving methodology. Unlike any causation model before it, it is based on a principle that holds true for every thing that happens. The Cause and Effect Principle provides four basic characteristics that allow us to understand reality in a simple structured way. These four characteristics are as follows:

Cause and Effect

  1. Causes and effects are the same thing.
  2. Causes and effects are part of an infinite continuum of causes.
  3. Each effect has at least two causes in the form of actions and conditions.
  4. An effect exists only if its causes exist at the same point in time and space.

Learn more about the Cause and Effect Principle.