Tag Archives: Lessons Learned

Root Cause Analysis

Learning lessons from projects is not as simple as you may think! Projects are complex adaptive systems linking people, processes and technology – in this environment, useful answers are rarely simple. Our latest White Paper WP1085 Root Cause Analysis looks at some techniques that may help ‘learn lessons’ and solve problems.

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The limitations of root cause analysis

Learning lessons from projects is not as simple as you may think! Projects are complex adaptive systems linking people, processes and technology – in this environment, useful answers are rarely simple.

Certainly when things go wrong stakeholders, almost by default, want a simple explanation of the problem which tends to lead to a search for the ‘root cause’. There are numerous techniques to assist in the process including Ishikawa (fishbone) diagrams that look at cause and effect; and Toyota’s ‘Five Whys’ technique which asserts that by asking ‘Why?’ five times, successively, can you delve into a problem deeply enough to understand the ultimate root cause. The chart below outlines a ‘Five Whys’ analysis of the most common paint defect (‘orange peel’ is an uneven finish that looks like the surface of an orange):

These are valuable techniques for understanding the root cause of a problem in simple systems (for more on the processes see WP1085, Root Cause Analysis); however,  in complex systems a different paradigm exists.

Failures in complex socio-technical systems such as a project teams do not have a single root cause. And the assumption that for each specific failure (or success), there is a single unifying event that triggers a chain of other events that leads to the outcome is a myth that deserves to be busted! For more on complexity and complex systems see: A Simple View of ‘Complexity’ in Project Management.

Complex system failures typically emerge from a confluence of conditions and occurrences (elements) that are usually associated with the pursuit of success, but in a particular combination, are able to trigger failure instead. Each element is necessary but they are only jointly sufficient to cause the failure when combined in a specific sequence. Therefore in order to learn from the failure (or success), an approach is needed that considers that:

  • …complex systems involve not only technology but organisational (social, cultural) influences, and those deserve equal (if not more) attention in investigation.
  • …fundamentally surprising results come from behaviours that are emergent. This means they can and do come from components interacting in ways that cannot be predicted.
  • …nonlinear behaviours should be expected. A small change in starting conditions can result in catastrophically large and cascading failures.
  • …human performance and variability are not intrinsically coupled with causes. Terms like ‘situational awareness’ or ‘lack of training’ are blunt concepts that can mask the reasons why it made sense for someone to act in a way that they did with regards to a contributing cause of a failure.
  • …diversity of components and complexity in a system can augment the resilience of a system, not simply bring about vulnerabilities.

This is a far more difficult undertaking that recognises complex systems have emergent behaviours, not resultant ones. There are several systemic accident models available including Hollnagel’s FRAM, Leveson’s STAMP that can help build a practical approach for learning lessons effectively (you can Google these if you are interested…..)

In the meantime, the next time you read or hear a report with a singular root cause, alarms should go off, particularly if the root cause is ‘human error’. If there is only a single root cause, someone has not dug deep enough! But beware; the desire for a simple wrong answer is deeply rooted. The tendency to look for singular root causes comes from the tenets of reductionism that are the basis of Newton physics, scientific management and project management (for more on this see: The Origins of Modern Project Management).

Certainly starting with the outcome and working backwards towards an originally triggering event along a linear chain feels intuitive and the process derives a simple answer that validates our innate hindsight and outcome bias (see WP1069 – The innate effect of Bias). However the requirement for a single answer tends to ignore surrounding circumstances in favour of a cherry-picked list of events and it tends to focus too much on individual components and not enough on the interconnectedness of components Emergent behaviours are driven by the interconnections and most complex system failures are emergent.

This assumption that each presenting symptom has only one cause that can be defined as an answer to the ‘why?’ is the fundamental weakness within a reductionist approach used in the ‘Five Whys’ chart above. The simple answer to each ‘why’ question may not reveal the several jointly sufficient causes that in combination explain the symptom. More sophisticated approached are needed such as the example below dealing with a business problem:

The complexity of the fifth ‘why’ in the table above can be crafted into a lesson that can be learned and implemented to minimise problems in the future but it is not a simple!

The process of gathering ‘lessons learned’ has just got a lot more complex.

Lessons Not Learned

Melbourne’s Swanston Street is undergoing a major upgrade to create a primarily tram and pedestrian precinct. This includes new tram stops, but the new Swanston St. stops are dangerous.

The new tram stop outside of Melbourne Central is probably one of the most dangerous pieces of public architecture produced in the last several years. The design ignores basic building standards established for over 100 years and incorporates a small ‘trip’ line of around 4cm in height in the middle of what is otherwise a flat walking area.

The almost invisible ‘trip line’ before the yellow paint line was added.

Steps and kerbs should be a minimum of 10cm in height (preferably 15cm or 6 inches) so walkers can clearly see the change in level. The shallow trip line incorporated into this design is too low to notice but big enough to catch anyone walking normally. I have no idea how many people will need to fall and then sue the Council for negligent design before this dangerous ‘feature’ is corrected but you can guarantee there will be many accidents and near misses on a daily basis.

Another view of the tripping hazard.

What is tragic is the apparent inability of the designers of this tram stop to learn from similar stops created in other locations in the network or from published design principles. This type of ‘tripping hazard’ was a major consideration in the Bourke St. Mall design a couple of years ago and an elegant solution was developed.

Even without this experience, there is plenty of information available that clearly shows it is dangerous to put a small ‘trip line’ at right angles to the direction of travel of most pedestrians. Good design suggests the ‘trip’ is either eliminated by a small change in level or protected by a hand rail.

This ‘feature’ has apparently been deliberately included in the design to keep the pedestrian footpath and bike lane differentiated by having pedestrians ‘step down’ into another zone. A great idea but the same separation effect could easily have been achieved by using a couple of well placed bollards or even a painted line or change in surface texture – the focus on one aspect of safety without looking at easily learned lessons on another has created a hazard that will cause serious injury to many people if it is not quickly corrected.

Unfortunately a few cents of design effort to review and ‘learn’ appropriate lessons will require $thousands to fix now the stops have been built. The danger has obviously been recognised with a pretty yellow line now painted along the length of the trip line (which it totally useless if you cannot see the ground for people). My guess is nothing further will happen until the council’s insurers force the issue after receiving a barrage of insurance claims. Getting designers, bureaucrats and politicians to admit they have screwed up the design is next to impossible. But until this happens ‘enjoy your trip’ will have a completely different meaning in Swanston St.

Photographs copied from http://treadly.net/2011/12/01/swanston-st-the-upgrade/

Lessons Learned

The London Olympic Delivery Authority’s Learning Legacy is designed to facilitate the dissemination of the lessons learned from the London 2012 construction project for the benefit of future projects and programmes, academia and government with the intention of raising the bar within the construction sector.

The ODA are on the verge of delivering a massive program of works on-time and on-budget, the learning from this major undertaking can benefit everyone.  To browse and download the 250 documents see: http://learninglegacy.london2012.com/

There are four types of reports:

    • Micro reports: Short examples of lessons learned, best practice and innovations from the construction programme.
    • Case studies: Peer reviewed papers on lessons learned, best practice and innovations from across the Programme.
    • Research summaries: Summary reports of research projects undertaken by academia and industry on the London 2012 construction.  These organisations will also publish full research papers as they are finalised throughout 2012.   Over 600 interviews were undertaken by researchers on the ODA and its supply chain as part of the learning legacy research.
    • Champion products: Examples of tools and templates used successfully on the programme.

    The reports have been classified into 10 themes:

  • Programme and project management;
  • Design and engineering innovation
  • Equality, inclusion, employment and skills;
  • Health and safety;
  • Masterplanning and town planning;
  • Procurement and supply chain management;
  • Sustainability;
  • Systems and technology;
  • Transport;
  • Archaeology.

This is a highly recommended rich source of information.

140 PM Tips in 140 Words or Less

A new book, Lessons Learned in Project Management: 140 Tips in 140 Words or Less has just been published by John A. Estrella, the ‘tips’ were contributed by a wide range of authors. Our tips were:

Tip 36: Understand who’s who and who’s playing
Projects attract stakeholders. You need to find out who they are and manage their relationships with the project if you want to succeed.

Only when you understand who the important stakeholders are can you develop and implement a structured communication plan to positively influence their attitudes and expectations. Your stakeholder community is never static! People’s attitudes change, and individual stakeholders become more or less important as time goes by. Routine monitoring is critical, supported by adjustments to your communication plan.

If this sounds hard, it is a lot less difficult than dealing with a failed project, and help is at hand. Take a look at http://www.stakeholder-management.com for a range of resources to support the Stakeholder Circle® methodology. This lets you focus on the right stakeholders at the right time to maximize your chances of success.

—Dr. Lynda Bourne, DPM, PMP
Managing Director, Stakeholder Management Pty Ltd

Tip 37: Treat your schedule as king
Useful schedules are used! The only thing management can influence is the future; the past is a fact, and the present is too late.

Useful schedules are developed collaboratively, are used to coordinate the work of the project team and help management formulate wise decisions. Good schedules are:
• Elegant and easy to understand
• Concise and accurate
• As simple as possible
• Maintained by regular status/updates—all incomplete work MUST be in the future!

To achieve these objectives, you must avoid vast schedules and unnecessary detail—no one understands them, and you can’t maintain them; for guidance refer to the PMI Practice Standard for Scheduling. Only after you understand the flow and timing of the work can you hope to develop accurate resource plans and then cost budgets.

—Patrick Weaver, PMP, PMI‐SP
Managing Director, Mosaic Project Services Pty Ltd

To read the other 138 tips, buy the book form Amazon, see:
http://www.amazon.com/Lessons-Learned-Project-Management-Words/dp/1456357581 for details.

How to Suffer Successfully

How to Suffer Successfully, is the title of chapter four in Alain de Botton’s first book of philosophy, How Proust Can Change Your Life. The same idea is the theme of The Adversity Paradox by J. Barry Griswell and Bob Jennings.

The Adversity Paradox is full of inspiring examples of people who have suffered major adversity and have used the experience to improve their capabilities and gone on to outstanding success. The knowledge they gained from overcoming obstacles has played such a crucial role in their success trajectories that they now consider adversity to be an invaluable friend.

De Botton takes a more philosophical view and recognises there are ‘bad sufferers’ and ‘good sufferers’. Bad sufferers learn nothing from their adversities and react to them by engaging defence mechanisms that compound the problem such as rage, delusion and arrogance. Successful sufferers, including those identified in The Adversity Paradox, use their adversity to gain a better understanding of reality and by rising to the challenge, create a better future for themselves and others.

Whilst no sane project manager would chose to suffer sufficiently to produce their version of Proust’s In Search of Lost Time, only the most naive would expect their project to run without a problem. Projects and their attendant stakeholders are a potential source of much grief and suffering, all be it at a lower level of intensity; schedule slippage test failures, cost overruns and accidents to name a few.

As identified by de Botton, bad sufferers try to hide the problems, blame others and learn nothing. Ethical and effective project managers accept their suffering and use the experience to grow their knowledge and capabilities. Quoting Proust, “Griefs, at the moment when they change into ideas, lose some of their power to injure.”

No one likes a project that fails! However, it is only when you are experiencing the pain of failure, the opportunity to learn from the failure opens up. By using the opportunity to maximise the lessons learned, you minimise the potential for similar problems in the future. The cost of the failure is the coin by which future gains are purchased. The difficulty is developing the level of understanding needed to really achieve valuable lessons learned; finding the ‘cause of the cause’. The second more complex challenge is ensuring the lessons learned are transferred to the organisations store of knowledge and available for others to use and thereby avoid unnecessary pain and suffering.

De Botton suggests being a ‘good sufferer’ does not entail subscribing to the Romantic cult of suffering for its own sake, rather making practical use of the occasions when suffering is unavoidable to create new insights and grow in capability or knowledge. Our addition to this basic idea for the practicing project manager is to then make sure the lessons learned are effectively distilled, recorded and made available to others for the future benefit of the organisation and the profession.

Learning from your Mistakes

I have had to confront a couple of different aspects of people getting things wrong recently. The experience triggered 2 or 3 thoughts……

The first was the advice given last century by (from memory) Fred Daly MP to a new member of parliament ‘always leave the back door unlocked’ – no matter how sure you are of the correctness of your position in an argument always have a way to back out gracefully.

Every one wants to employ experienced people but very few employers tolerate mistakes…. To quote Denis Waitley: “Mistakes are painful when they happen, but years later a collection of mistakes is what is called experience” and Franklin P. Jones “Experience is that marvellous thing that enables you to recognize a mistake when you make it again”. You cannot attempt something new without occasionally making mistakes – the skill is to use your experience to recognise a pending mistake early and short circuit the error.

Lesson’s Learned should be the repository of ‘other peoples’ mistakes that you can draw on to avoid repeating them yourself – as quoted in ‘The Knack’, “A smart person learns from his or her mistakes. A wise person learns from other people’s mistakes.”

And then there is the question of what to do about your mistakes. The generally accepted process for getting over a mistake is:

  • Acknowledge it (“my mistake”)
  • Make restitution if needed (eg apologise)
  • Learn from it
  • Move on, only people who have never made anything have never made a mistake.

In moving on though, make sure you take your enhanced experience with you.

One last thought from Helen Keller: “Life is either a daring adventure or nothing. Security does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than exposure.”  The same idea applies to making decisions; every decision you make may be wrong but in the long run no decisions are usually worse than wrong decisions and your decision may be correct (but it helps if you can leave the “back door unlocked”).