Sherlock Holmes described his methods in The Sign of Four as “the curious analytical reasoning from effects to causes.” Working backward from effect to cause, Holmes applied a scientific process to detective work—using data to form a hypothesis and eliminating theories that did not fit the facts of the case. Only after careful application of a logical thought process did the consulting detective jump into action and exclaim, “Come Watson the game is afoot.”
When Kepner-Tregoe founders Ben Tregoe and Chuck Kepner formulated KT problem-solving methods, they created a systematic approach to this Holmesian thinking that’s become SOP in thousands of organizations. From the vantage point of the present, once this critical cause-effect relationship is well understood, the game is afoot: we can design effective action.
With Watson to tell the tale, Holmes stunningly turned the evidence and the culprit over to Inspector Lestrade and returned to Baker Street. Similarly, as troubleshooters, we record issues and solutions for future reference. We recommend corrective actions (as in lock’em up) and when the guilty party is brought to justice, we’ve eliminated the true cause of the problem. Today’s high tech world of constant change and complex problems demonstrates the growing need for this rational process approach. As Holmes writes in A Study in Scarlet, “From a drop of water a logician could infer the possibility of an Atlantic or a Niagara without having seen or heard of one or the other.”
The ultimate goal of most troubleshooting efforts is finding true cause and corrective action. Yet, in many cases, adaptive action is taken as a temporary measure. If, for example, a piece of equipment is leaking oil (effect), adding a drip pan and topping off the oil can limit the effect. But this adaptive action does not correct the problem. If an old, worn-out seal is the cause, it is a corrective action (replacing the seal) that eliminates the source of the effects and their cause.
Adaptive actions play a key role in emergency situations or when the cost of corrective action is too high, such as when machines and products near obsolescence. But it is critical to understand that the problem is not solved (see Figure 1) until true cause is identified and corrective actions are taken.
Figure 1: Corrective and Adaptive Actions
This cause-effect relationship in problem solving is even more challenging for a problem that has yet to occur. To perform at a high level of quality and reliability, we need to devise and implement actions that help deal with the causes and effects of future events. From the vantage point of the present, we need to anticipate potential problems and what could cause them, in order to take action that will prevent them and, if the problems do occur, reduce their effects.
In their classic book, The New Rational Manager, Chuck Kepner and Ben Tregoe wrote, “A problem is the visible effect of a cause that resides somewhere in the past.” Preventive action is future oriented, anticipating and eliminating the likely cause of potential problems before they can generate an effect. It requires anticipating potential “visible” effects and their cause. For example, Lockheed Martin Space Operations had a checklist of more than one million potential problems it addressed before a launch. To achieve quality and reliability, systematic thinking ahead needs to be part of the equation.
Figure 2 shows the two types of actions we can plan or take now with regard to potential problems. Preventive actions are based on an understanding of the likely causes that might lead to a problem. If we eliminate the likely causes, we lower the chances the problem will come about. Contingent actions are taken to reduce the seriousness of a problem if it should occur. They are based on an understanding of the probable effects such a problem would produce. If we implement these limiting actions quickly, we lessen the severity of the problem itself. For example, in considering the threat of fire, a preventive action is to keep combustible material in tightly closed containers while a contingent action is to install a sprinkler system.
Figure 2: Preventive and Contingent Actions
Just as corrective actions and adaptive actions are both valid responses to a problem that has occurred, preventive and contingent actions are valid approaches to a potential future problem. All too often though, we focus on adaptive action at the expense of corrective action and contingent action at the expense of preventive action. In both cases, this results from our common tendency to focus on effects rather than causes.
There is often some conceptual confusion over the distinction between corrective and preventive actions. In Figure 3, the matrix shows how to document actions taken to address problems by separating problem-solving actions by intent. Are we solving the problem or controlling effects? Are we anticipating how we will deal with the effects of a potential problem or are we preventing it?
Through a focus on root-cause detection and corrective action, organizations overcome the pitfalls of constant firefighting and an overreliance on adaptive action. In addition, by incorporating potential problem identification and preventive action, organizations overcome recurring correction and overreliance on contingent action. This “consulting detective” approach of moving from effect to find cause—applied to both current and potential problems—creates a corrective and preventive action system for managing problems. It’s solid, critical thinking and Sherlock Holmes would approve.
KT has a powerful toolkit for root cause analysis and preventing future problems