The SMRT fiasco - identifying the root causes?

In the midst of the chaos surrounding the Committee of Inquiry proceedings, senior management of the SMRT has of course, very predictably, made all kinds of promises to identify the root cause of what went wrong. Mr Ong Ye Kung, an independent director of the SMRT board has been appointed to do this "root cause analysis".

Fancy words, that sound good. The question is, can they?

The ideas of cause and effect go back a very long time in history. But the concept of root cause analysis can perhaps be traced back in more recent times (about 50 years ago) to when Sakichi Toyoda of Toyota fame, introduced the concept of the 5 Whys in identfying what actually caused something to wrong. The idea of asking whys 5 times to arrive at the root cause was perhaps too simplistic, but at least moved the inquiry beyond just fingering the finger that pulled the trigger, to a more fundamental cause.

Root cause analysis has since then become pretty much an industrial standard of identifying the fundamental causes of any industrial or public health incident. But it is not without its limitations. Dean Gano about 20 years ago pointed out some of the limitations in the cause-effect reasoning. He identified 4 principles of causation that we should take note of :

 1. Causes and effects are the same thing only seen at a different point in time.
 2. Causes and effects are part of an infinite continuum of causes.
 3. Each effect has at least two causes in the form of actions and conditions.
 4. An effect exists only if its causes exist at the same point in time and space.

Points 2 and 3 are particularly useful for us to take note of, i.e. that this whole process is pretty much an infinite continuum, and that apart from the action there are conditions that are involved in causation.

When investigating root cause of any event, the assumptions, prejudices and perspectives of the investigator becomes critically important because they determine the conduct of the investigation and interpretation of the events.

Applied to the SMRT conduct of root cause analysis, we can see that the Chairman did the "right" thing in appointing Mr Ong Ye Kung, an independent director of  the board to lead the investigation. However we should note that Mr Ong, although an independent director, is nevertheless a board member. Can we expect that he will be able to properly identify board related deficiencies? Furthermore, he is a PAP member who was on the teams that wrote the Land Transport White Paper, and  that established the LTA in the first place. How objective will he be in drawing that line of causal continuity back to those original ideas? Certainly the conditions for failure are equally important to the actions/inactions that resulted in the failure.

So I am not holding my breath that they will find the answer. The COI has identified the leads. Here's hoping there will at some point in time, be some real experts who will be capable of a truly independent conduct of the root cause analysis.

Curiouser and curiouser..... sharing the skeletons

Image from here

An independent investigation is not always the most intuitive thing to do when a problem arises. The management of an organization will always seek to retain control of the proceedings so that the damage can be contained should any wrong doing be uncovered. Yet we all know that a less than independent investigation will in the end prove to be the least beneficial for the organization in the long run.

A number of recent incidents locally highlight the need for external and independent invistigations or audits.

Late last year, an IVF mistake occured in Thomson Medical Centre. In response, the Ministry of Health held its own investigation rather than to leave it to the TMC to uncover and report its own lapses.

More recently, an accident occured in the Singapore Air Force. Apparent a technician ruptured his liver during an induction exercise. The internal Board of Inquiry, disclaimed any association with the activities during the induction. It was only after the coroner made its findings that the BOI backtracked and agreed to consider that the ruptured liver could have been related to the tunnel crawl during the induction activities.

Now there are allegations of publication fraud and self-plagiarisms at the NUS. One wonders if the NUS sees it as in their interest to keep the investigation 'in house' and secret. Should it not be in everybody's (including NUS's interest), to have an external party audit whatever happened? This is especially as senior members of the faculty are associated with the allegations. Even if the senior members are innocent of any wrongdoing, the perception that the investigations are less than independent is damaging to the credibility of the NUS.

Instead, there is this very bizarre situation where the lead investigator is a Director of Research Admin, in the Office of the Deputy President (Research&Technology) while his boss himself is the subject of certain allegations of self-plagiarism and is associated with two of the Melendez list of publications.

Curiouser and curiouser.