I’m a Quality Professional – a Chartered Quality Engineer working on the most advanced airliners flying.
One of the tools we use helps us find why problems occur. It is this tool that I think more people should understand when dealing with any problems in life. Such as why the dinner is cold, why the TV won’t turn on, why your countries industries are failing, why a group of people have been gunned down in a night club. That sort of thing. Anything.
The tool should be used before you go off spouting fixes for problems, when in reality you don’t know what the real problem is. Your fixes are simply sticking plasters over some of the results of the problem, and not fixing the problem itself.
Sometimes the parts we make have faults, and have to be scrapped because they’re not fit for flight.
Scrapped parts mean lost money, time, labour and materials, plus all the overhead costs and facilities required to make the part.
When a part is scrapped we carry out Root Cause Analysis (RCA), because obviously we don’t want to make scrap!
It’s fundamentally a simple process of figuring out the fault, then listing out some of the main causes of the fault, and then figuring out the main causes of those causes, and so on, until you reach the real root cause of the problem.
A simple example would be why the cup of tea (or coffee) you’ve just made is cold.
The water didn’t heat up. WHY?
The kettle didn’t work. WHY?
Was it turned on?
Yes…
Did the switch click?
Yes…
Did the light come on?
Yes…
Did it boil?
Ah… I wasn’t there, but it was left on and when I returned to it and poured my drink, it was cold… So obviously the kettle doesn’t work.
Maybe the heater element failed.
Maybe the fuse blew when you left the kitchen.
Maybe there was a power cut.
Maybe you didn’t click the switch fully.
Maybe someone came in and nicked your hot water for their drink, refilled the kettle and didn’t turn it on again.
Let’s say the switch is faulty… Problem solved.
Nope…
Why was it faulty?
Poor maintenance?
Damaged?
Not made correctly at the factory?
Let’s say it was damaged…
We could ask why you didn’t fix it, but that’s not part of the cause.
Why did it get damaged?
I knocked it off the counter a few weeks ago. WHY?
It was close to the edge. WHY?
The cord won’t reach the socket if it’s moved back.
Okay… Apart from not looking where your going, it appears that had the power cord been longer, the kettle could have been positioned away from the worktop edge and the kettle wouldn’t have been damaged.
That’s a long root cause for something that most people would’ve just stopped at ‘The kettle’s bust… Better get a new one…’
Sure, and in a week, a month, a year, the same thing will happen again because you didn’t fix the real problem… but next time it might have boiled, and your kid runs past and knocks it as it’s close to the edge…
What is my point?
The recent shootings in America have many people calling for tighter controls on guns.
Now whilst America does have very relaxed gun laws, the gun really isn’t the cause, it’s just a step in the root cause. Much like the broken switch… It doesn’t stop there.
Had there been no gun, a homemade bomb could’ve been used, a knife, gas, drive a truck into the crowd… So clearly restrictions on guns would not have stopped this from happening.
The question shouldn’t be HOW he carried out the attack, but WHY?
At the moment the news points to the person having said it was done in the name of ISIS & Islam.
Why was he so adamant on his actions?
What caused him to become this extreme?
Was it his upbringing?
Was it his education?
Was it how he was taught to behave?
Was it how he was taught to believe?
What enabled this to happen?
In this case it is the interpretation of a religion.
Maybe people are looking at restricting the wrong things.
You can take away some of the enablers, but without acting on fixing the root cause, the massacre would still have happened, just by different means.
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