Ryan Burns — New Contributor

The Problem

The investigation starts before it officially begins.

A senior tech walks past the failed pump, glances at the shaft, and says “Oh, I know what this is — happens every time the humidity drops.” The room nods. Someone opens the RCA template and starts filling in the cause chain. The logic tree gets built around the conclusion, not toward it.

This is tribal knowledge in action. It isn’t malicious and it isn’t lazy. It’s what happens when unwritten, undocumented experience fills the space that objective evidence should occupy. The veteran’s pattern recognition is real and often valuable. The problem is that it goes untested, and the investigation quietly becomes a formality.

The Problem

Confirmation bias in RCA rarely shows up as rushing. It shows up as certainty.

The most experienced people in the room recognize a failure pattern and unconsciously lock onto a familiar explanation. “It’s always that coupling.” “Same bearing issue again.” “We’ve seen this a hundred times.” The investigation might still look rigorous, but it quietly narrows. The team hunts for evidence that supports the veteran narrative, stops asking deeper questions, and lands on a surface-level physical cause.

The Problem

In many plants, the unspoken goal of an investigation is to find a “who” to blame rather than a “why” to fix.

When an incident occurs, the immediate pressure for accountability leads teams to stop at human error. “Failure to follow procedure.” “Lack of training.” The root cause field gets filled, the corrective action says retrain, and the file gets closed.

This pattern is a hallmark of low-maturity programs. It creates a culture where subject matter experts hide critical data to protect themselves, and leadership is left with corrective actions too shallow to prevent recurrence.

The Problem

The spreadsheet has seventeen columns. The template runs six tabs deep. Every box is filled. Every question has an answer. The investigation looks finished before the team has really started thinking.

Static RCA templates were built to bring order to investigations. The problem is that too many of them bring closure instead. When the goal becomes completing the form, the form becomes the investigation. Investigators answer what the template asks next, not what the failure actually demands. The thinking bends to fit the structure.

The investigation closes. The real cause stays in the system.

Reliability programs often suffer from “Catastrophe Bias.” We spin up an intensive RCA for the big turbine failure, but we ignore the pump that trips once a week or the sensor that needs a “quick reset” every shift.

Because these events are small, they don’t trigger a formal investigation. However, when you aggregate the labor, parts, and lost uptime, these chronic issues often cost significantly more than the rare, sporadic catastrophes.

In many RCA programs, investigations consistently stall at the “who” instead of the “why.” A technician misses a step, a operator turns the wrong valve, or a mechanic over-torques a bolt.

The investigation concludes that “Human Error” was the cause, and the file is closed with a recommendation for “Retraining” or “Increased Awareness.”

This creates a revolving door of failure. Leaders see the same incidents recurring every six to twelve months because the underlying vulnerability remains untouched.

If your RCA program relies on people never making mistakes, your reliability system is actually a “fragility” system.

[Read more…]

5-Why is it popular because it’s simple—and that’s exactly where it can fall short.

Teams ask “why” five times, land on a familiar answer, document it, and move on.

The exercise feels efficient, but the thinking is often shallow.

Across every mature RCA program we’ve seen, one pattern is unmistakable: leaders who consistently close the loop win.

Not sponsors who attend kickoffs. Not managers who ask for status updates. Leaders who personally ensure that corrective actions are implemented with the same rigor used to identify root causes have RCA programs that thrive.

RCAs often get marked complete, but teams don’t know whether the investigation was actually effective.

Actions are assigned and work moves on, yet the investigation team rarely sees whether conclusions held up, whether actions prevented recurrence, or whether the same failure quietly showed up somewhere else.