RCA is not a Post-mortem Paperwork. Not everyone can do the Real RCA.
The industrial buzzword "Root Cause Analysis" (RCA) is often more about bureaucracy than breakthroughs. In reality, most RCAs are post-mortem paperwork drills that end up blaming the "Doer" rather than fixing the "Design." True RCA is a leadership skill, not a clerical task. Here is why the industry is getting it wrong: 1. RCA is an "In-the-Moment" Reflex, Not a Meeting If you perform an RCA weeks after a failure, you aren’t analyzing data - you’re analyzing memories and assumptions. Real RCA happens parallel to problem-solving. A leader identifies the "why" while the "how" is being fixed. The "Doer" Trap: When done later, the easiest target is the person closest to the error. The Systemic Reality: True RCA looks past human error to the systemic gap that allowed the error to happen. 2. Leadership is RCA in Action Not everyone can do a real RCA because not everyone is willing to "turn their back on the crowd...