Boomerang Effect in Root Cause Analysis
Root cause analysis can lead back to the actions of people initially seen only as victims. The Titanic lifeboat example asks how to examine missed rescue opportunities while considering survivors’ fear, exhaustion and trauma.
THE IDEA
Recovery Measure: Missed Opportunities to Rescue Those in the Water
We know that many passengers and crew went down with the Titanic. Still, hundreds fell into the sea wearing lifejackets, and we know that there were a number of spaces available in several lifeboats because of how they were loaded, especially at the beginning. A few of those in the water were able to get into the collapsible lifeboats, but after that only a handful of those who fell into the water were hauled into the rigid lifeboats. Jack Thayer was one of the lucky ones who was rescued from the water; he said: ‘The most heart‐rending part of the whole tragedy was the failure, right after the Titanic sank, of those boats which were only partially loaded, to pick up the poor souls in the water. There they were, only four or five hundred yards away, listening to the cries, and still, they did not come back. If they had turned back, several hundred more would have been saved’.68
In the book ‘Unsinkable’, the plight of those who had fallen into the water (in total darkness most of the time), hoping for rescue, was called ‘the saddest act of the entire tragedy’.69
Accounts of what happened in the lifeboats suggest that while some wanted to go back to rescue those who were in the water (and at least one did), most passengers in the lifeboats appear to have been afraid that their lifeboats would be overwhelmed by desperate survivors in the water toppling the lifeboats, so they held back. And there is a heart‐wrenching story of a man in the water being turned away from a lifeboat, saying ‘Goodbye. God bless you all!’ to the passengers; then sinking below the water.70
There is something very poignant about this final twist to the tale. Where spaces were available in a lifeboat, do we want to blame the passengers and crew for not acting? Or can we accept the human factor that many in the lifeboats were tired, traumatised and afraid of capsizing? Viewed from this perspective, it's not a complete surprise that not all were keen to act.
A root cause analysis can begin by looking for a problem in one direction and then rebound, like a boomerang, toward people initially regarded as blameless. Here, examining missed rescue opportunities brings some survivors’ actions into the analysis.
Whatever your own perspective on this final question, it should be clear by now that the root causes for the Titanic tragedy put the simplistic ‘blame the captain’, ‘blame the lookout’, ‘blame the design’, ‘blame the ship owner’, ‘blame the number of lifeboats’ and ‘blame the regulator’ into a completely different light.71
However, I do appreciate that when you come up with this account of what happened, where no one has been identified as responsible, you can be left with a feeling that ‘perhaps someone has got away with it?’ This is always a possibility when you do an RCA; you can't look into the souls of all of those involved and know whether, deep down, malice (conscious or unconscious) was present. But, in any event, this would still not amount to finding a root cause but rather a contributing cause.
When to use it
Applying the boomerang effect to analyze organizational failures where initial blame shifts to include the actions of those who could have intervened.
Using this concept in emergency response planning to anticipate and mitigate psychological barriers to rescue actions.
In project management root cause analysis, to consider how team members' fear of failure might prevent them from taking corrective actions.
FROM THEORY TO EVERYDAY LIFE
In practice
Titanic Lifeboat Rescue Failure
After the Titanic sank, many lifeboats had empty spaces but did not return to rescue hundreds of people in the water due to fear of being overwhelmed, trauma, and exhaustion. Jack Thayer described this as the most heart-rending part of the tragedy, stating that if they had turned back, several hundred more would have been saved.
A MOMENT TO REFLECT
Put it to work.
How might fear and trauma influence decision-making in high-stakes situations, and what can we learn from the Titanic lifeboats?
When conducting a root cause analysis, how can we avoid oversimplifying blame and instead consider the human factors that affect actions?
In what other disaster scenarios have rescue opportunities been missed due to similar psychological factors?
CONTINUE THE CONVERSATION
Source texts
- Beyond the Five Whys Root Cause Analysis and Systems Thinking (James C. Paterson)