Facilitating Causal Factor Timelines: Bring the Texts and Emails
Emotions and defenses run high when a significant failure occurs in physical assets or environmental operations. Mid- and senior-level technical leaders gather in a room to perform a root cause analysis (RCA), and the process almost immediately bogs down in a debate over sequence: Who knew what, and when did they actually know it?
Memory alone will not settle that debate. Timestamped texts and emails will. Yet most facilitators never require them in the meeting.
From the Real World
The department had a reputation as one of the best in the company. However, several events over the previous six months suggested its performance was slipping. Three of those events were eventually referred to the company's root cause evaluation program.
“I don't know why we had to spend so much time printing our emails and texts from 30 days before and after each event,” said one of the junior engineers.
“Because JD told us to,” countered one of the managers. “Plus, all three events overlapped. I didn't realize that until I looked back at each one.”
“What do you mean?” I asked.
“Well, two of the events happened the week Jerry was on vacation,” he explained. “Jill and I were in training that week and the following week. The third event happened during that second week of training.”
“I don't remember it that way,” the junior engineer replied. “I don't think all three events happened in those two weeks.”
“My texts show they did,” the manager bristled. “My emails show we were diagnosing the problems later, but the texts definitely show Jerry was on PTO and we were in training.”
“OK,” I interjected. “That's a good start, and it's exactly why I asked everyone to go through their texts and emails. Does anyone have anything that confirms or contradicts that account of what was happening in parallel with the failures?”
Why Memory Is Not Enough
Human memory is reconstructive and defensive by nature. People rebuild events after the fact. Once they know the outcome, they subconsciously reshape the sequence so that it seems more predictable and their own actions seem more logical. I often see participants place a notification in the morning when it actually arrived in the afternoon or the following day.
Communication records also reveal causal factors that memory tends to smooth over. This includes things like one team had critical data four hours before another team was notified. Or a text said “check the valve” but did not say which valve. Sometimes an email sat in an unmonitored inbox during a shift change.
In most organizations, the failure mechanism is frequently a breakdown in information transfer.
Timestamped records move the discussion from personal recollection to documented history. That alone lowers the temperature in the meeting.
How to Bring the Texts and Emails Into the Discussion
Asking for records is easy. Using them well takes some facilitation. Here are five steps I use.
1. Make It Required Pre-Work and Size the Window to the Scenario
Ask every participant to arrive with their emails, text threads, chat messages, and call logs for a defined window before and after the event. Printed copies work best in the room because you can lay them side by side and mark them up.
There is no magic number for the window. A sudden equipment failure may need only a few days. A slow degradation, or a cluster of related events, may need several weeks. I often start with 30 days before and after and adjust from there. The goal is to capture the conditions leading up to the event and the response that followed.
Ask for system records such as SCADA alarm histories, operator logs, and work order timestamps from the maintenance management system. System records anchor the clock. Communication records explain what people knew and did in between.
2. Build Micro-Timelines First, Then Put Them Together
Complex failures often run on parallel streams of action, decision-making lags, and concurrent troubleshooting.
Have each individual or sub-team build its own micro-timeline before anyone touches the master timeline.
Putting the micro-timelines onto the master timeline exposes overlaps and blind spots that no single participant could see from their seat.
3. Mark Every Entry as Recorded or Recalled
Not every entry will have a document behind it. That is fine, but the difference should be visible. Use one color for entries backed by a record and another for entries based on recollection.
Recalled entries are hypotheses to be tested. The goal is to convert as many as possible into recorded entries as the session progresses or remove them.
4. Let the Record Settle the Conflicts
When memory and a record disagree, the record wins unless someone can show why it is wrong. When two records disagree, find out why before moving on. Clock settings, time zones, and forwarded messages all create honest discrepancies.
One note of caution. A timestamp shows when a message was sent, not when it was read or acted on. That gap is often where the causal factor hides, so ask about it rather than assume it.
Letting the record settle conflicts also takes rank and personality out of the debate. In the session above, the discussion moved from whose memory was better to what the texts showed.
5. Look Across Events
Lay their timelines side by side when more than one event is under review. Shared conditions such as staffing gaps, training schedules, vacations, contractor changes, and shift rotations rarely show up within a single event's timeline. They surface only when events are compared.
That is exactly what happened with the three events above. Each RCA on its own might have pointed to a local cause. Together, they pointed to a department that was thin on experienced people for two specific weeks. That is the kind of underlying condition that drives lasting management system improvements.
Bring the Texts and Emails
Insist on evidence if you want your RCAs to drive lasting improvements rather than surface-level fixes. Make time-stamped communications required pre-work. Size the window to the scenario. Build the micro-timelines, mark what is recorded and what is recalled, let the record settle the conflicts, and look across events.
Replacing narrative recollection with hard communication records lets you control the session's tempo, reduces defensive arguments, and produces a causal factor timeline that reflects reality. Is your timeline built on memory or on evidence?
This article is part of a series on the three core tools of FAST root cause analysis: block diagrams, work process diagrams, and causal factor timelines. Read the first installment, “Facilitating Reliability Block Diagrams: Follow the Drop.”
JD Solomon is the founder of JD Solomon, Inc., the creator of the FINESSE Fishbone Diagram®, and the co-creator of the SOAP criticality method©. He is the author of Communicating Reliability, Risk & Resiliency to Decision Makers: How to Get Your Boss’s Boss to Understand and Facilitating with FINESSE: A Guide to Successful Business Solutions.
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