By Ed Wells, Chief Strategy Officer, What Caused This
After many years of working with water professionals involved in Root Cause Analysis, I hear the same comment time and again: “We don’t have an investigation problem. We have a communication problem.”
Every year, water companies invest significant time and expertise investigating pollution events, operational failures, health and safety incidents, and customer complaints. The people leading these investigations are knowledgeable, committed and genuinely motivated to prevent repeat events. Yet remarkably similar problems continue to occur.
In my experience, there are two reasons why…
The first is that many investigators have never been taught a common method of Root Cause Analysis. Most have developed their own approach through trial and error. As a result, investigations vary considerably in structure, depth and language. One investigator may stop at human error or equipment failure, while another explores the organisational conditions that allowed those failures to occur. Without a shared framework, collaboration becomes inconsistent and learning is difficult to transfer across teams.
The second challenge is technology. Even well-executed investigations are often recorded in documents and spreadsheets that were never designed to communicate complex cause-and-effect relationships. Valuable knowledge becomes trapped within individual reports, disconnected from previous investigations and largely invisible to the wider organisation.
This creates an unfortunate paradox. The water industry has never had more investigation data, yet many organisations still struggle to convert that information into meaningful organisational intelligence. Reports are completed, actions are assigned, files are archived, and recurring patterns often remain hidden.
Why is nobody listening?
One of the most rewarding moments during RCA training comes when delegates realise that incidents rarely have a single root cause. Instead, they emerge from an interconnected combination of technical, organisational and human factors. That shift in thinking changes the conversation. The focus moves away from identifying someone to blame and towards understanding the conditions that made the event possible. It also brings another realisation: a Five Whys template or a spreadsheet populated with predefined fields is wholly incapable of communicating what really happened in anything but the most straight-forward issue.
Training and technology should therefore be viewed as complementary rather than separate investments. Training provides investigators with a common language and a structured way of thinking. That is necessary if organisations are to investigate consistently, but it is not sufficient. Only purpose-built technology can preserve that knowledge, connect investigations across an organisation and help reveal recurring themes that would otherwise remain invisible.
So you created a report. So what?
The purpose of Root Cause Analysis is not simply to explain yesterday’s incident. It is to improve tomorrow’s decisions. Every investigation represents an opportunity to strengthen organisational knowledge. If that learning is not effectively communicated, shared and applied, the investigation may explain what happened, but it will do little to prevent it happening again.
Sound all too familiar?
