Keep asking why: Root cause analysis of a contemporary tragedy
Performing a root cause analysis on a contemporary tragedy can provide insight into how to use the process within law enforcement
This article originally appeared in The Chief’s Chronicle; New York State Association of Chiefs of Police. Reprinted with permission.
Law enforcement leaders are familiar with discussing tragedies in our own industry. Such discussions are necessary to identify “what went wrong.” As I’ve written in a previous article, how we conduct the conversation will determine whether we get at the true root cause of the event or simply end our analysis at the proximate cause.
It’s equally instructive to look at incidents outside our industry. Removing the emotion we may associate with law enforcement incidents can more clearly illustrate the process of root cause analysis. So let’s look at one such example.
Shooting on the Set
You’ve likely heard about the tragedy that unfolded on the set of the low-budget, independent movie "Rust." Here are the essential facts at the time this article was written in late October:
The film crew had just returned from lunch and was rehearsing a scene in a wooden church on an “Old West” movie set.
- An assistant director walked outside the church and was handed a prop gun from the film’s armorer.
- He brought it inside and yelled “cold gun,” which indicated the gun was unloaded.
- He then handed it to actor Alec Baldwin, who practiced a “cross draw,” pointing the gun at the camera and the people around it.
- The gun fired, and a live round passed through the body of cinematographer Halyna Hutchins and then struck director Joel Souza. Hutchins died from her wounds and Souza was injured.
- The lead armorer was 24 years old, and "Rust" was only her second film. Some media accounts report she allegedly mishandled weapons on the first film she worked on.
- Many media reports indicate that 500 rounds of various types of ammunition, including live rounds, were found on the set during the execution of a search warrant even though the armorer allegedly told investigators that live rounds were never allowed on the set.
- Additional unconfirmed allegations claim the guns on the set were used by the staff for live target practice during breaks.
A promising young cinematographer is dead, another person is seriously wounded, and multiple lives have been impacted and changed forever. In the days following the shooting, media accounts were frequent and the sensational coverage predictable. Legal experts discussed the possibility of criminal prosecutions. Experts in the film industry explained how it should not and would not have happened on sets they have worked on. Within two days, a state legislator called for a law to ban live guns and ammunition on movie sets. After all, this incident proves guns are just too dangerous to have on movie sets, right? If such laws are passed, then everyone on movie sets will be safe, right?
But wait, is it possible this tragedy is an indicator of larger, more expansive problems lying in wait? Will prosecuting those responsible and passing laws end such tragedies on movie sets forever?
I do not profess to know all the answers to these questions. In fact, I need to make a critical point: A successful root cause analysis requires subject matter expertise. Those without such expertise can begin an analysis and contribute to it, but it will remain incomplete. In the "Rust" example, my subject matter expertise is limited to experience and training with weapons. I could use that knowledge to pronounce, very confidently, how flawed the handling of the weapons was and why therefore we need to require every actor to attend gun safety training and only allow proven and qualified armorers on sets. But that would be a perfect example of the problems that arise after such tragedies. We focus on the proximate cause – the numerous safety violations pertaining to firearms on set – and then stop the discussion. A more thorough process must be undertaken to determine the root causes that could be hiding beneath the surface. And in this case, the process requires expertise in the film industry.
So, because I do not know enough about the film industry to answer all the questions that need to be answered, our analysis will be incomplete. But it will nevertheless illustrate the process and the benefits of a more thorough root cause analysis.
A Primer on Human Error
Dr. James Reason is a nationally renowned expert on human error; I frequently refer to his publications. Reason explains the difference between errors and mistakes that will be helpful in our examination of the "Rust" tragedy.
An error occurs when an action by a person does not go as intended. It may have been the proper choice by the person, but the execution leads to an unintended result. These are generally called “slips and lapses” and can occur when the person’s planned action sequence is drawn away from task at hand and their attention is captured by something else. An example is when an officer decides to deploy a TASER device on a person but instead draws their firearm and shoots the person. The intent was correct, but the execution was flawed. Slips and lapses are generally skill-based and are typically best addressed through training.
A mistake occurs when there is a failure in planning and the actor selects a path that is inappropriate for the present circumstances and the desired outcome. Mistakes can be rule-based (e.g., the organization requires a certain act or response that may be inappropriate) or knowledge-based (e.g., the actor is basing decisions on flawed beliefs or assumptions).
It is also necessary to distinguish errors and mistakes from violations. While errors and mistakes will generally involve the cognitive processes of individuals, violations may have social contexts to consider. A violation is a deviation from a necessary procedure. It may also involve an error if the violation was not deliberate (there was no intention to commit the violation). Violations can be exceptional in that they only occur during a particular set of circumstances, or they can be habitual. Habitual or routine violations can occur because of the natural human tendency to take the path of least resistance. If enforcement of rules is generally lax and there is no reward for doing things the proper way, violations occur. For purposes of law enforcement liability, these types of errors could rise to the level of a “pattern and practice,” which can result in municipal liability.
Root Cause Analysis
Now that we have briefly reviewed the concepts of errors, mistakes, and violations, we can begin the [incomplete] analysis of the "Rust" incident. Based upon the available facts, it does not appear that any form of slip and lapse occurred. Rather, it appears that mistakes and violations will be the most implicated.
To determine root causes, it may be helpful to think of asking “why” until you can proceed no further. Where you end is where your answer may lie. The “whys” may need to be supplemented with requests for additional information. Understanding that my responses may prove inaccurate once the investigation is concluded, let us begin:
Why did one person die, and another person suffer injuries?
- Because Alec Baldwin was practicing a cross draw, pointed the gun in the direction of the camera crew and pulled the trigger on the prop gun, causing it to fire with the bullet striking the victims. (This is a proximate cause.)
Why did the gun discharge and strike the victims when it should have been safe?
- Because the gun was loaded.
- Because Baldwin thought the gun was safe and pointed the gun in the direction of people and pulled the trigger.
Now you should see that we need to start branching our inquiry and start to split the analysis even though there will be some overlap. I will start with the shorter branch first.
Why did Baldwin point the gun in the direction of people and pull the trigger? Specifically, why did he violate several basic tenets of gun safety in that you (1) treat every gun as if it is loaded; (2) never point a gun at a person under any circumstances; and (3) always personally verify the safety of a weapon even if you just watched the person giving it to you check it?
- This is where we now approach the first root cause determination specific to Baldwin’s actions, but we do not have enough facts to complete it. It will, however, most likely be the result of a habitual violation bred from complacency on the set. Why an experienced actor failed to check the weapon needs to be explored and could result in mutual causation – the production management itself and Baldwin’s personal responsibility.
Why was the gun loaded when live rounds were not supposed to be anywhere near the set?
- Because live rounds were found on the set even though the armorer said there wasn’t any. This is likely to be determined to be a habitual rule violation.
- Possibly because crew members were allowed to use the same guns for target practice with live rounds. This would be another habitual rule violation.
Why was Baldwin given a loaded gun when the armorer and assistant director inspected it and declared it was safe?
- Because the armorer was young and inexperienced and she clearly did not properly check the weapon.
- Because the armorer allegedly mishandled weapons on the first set she worked on and was hired anyway. (If this proves to be true, this could result in a separate branch of “why.” If this producer knew about it, why did they hire her? If they did not, why isn’t that important information available to future employers?)
- Because the assistant director should have checked all the rounds in the gun and failed to do so. Again, more rule violations.
- Because the production had been delayed in the morning when multiple crew members walked off the set due to working conditions and the assistant director may have been pressed for time.
Why were so many apparent habitual rule violations allowed to occur on a set with so many inexperienced crew members? This is definitely a question for film industry experts, so I turn to one of many published accounts for some possible answers:
- Because the dramatic increase in the demand for streaming content has stretched the industry thin.
- Smaller companies are attempting large productions without the proper staffing or experience.
- Low-budget productions result in producers cutting costs in areas such as armorers, believing they can do it themselves or going with the least expensive person they can find.
- The sheer volume of produced content can lead to a sense of complacency and misplaced confidence in the overall management of a production.
This root cause analysis is far from complete, but it brings us far enough along to see that a much larger picture is beginning to emerge. Essential to this process is not to stop at the proximate cause. The farther we go the more possibilities we uncover to prevent future tragedies. Is it possible the state of the film industry is such that on this set and others there could be more corners being cut? Should the response from the industry and legislatures only address the use of real guns on a set?
Is this tragedy proof that guns are so dangerous they must be banned, legislatively or otherwise, from all movie sets? Our analysis, while incomplete, indicates the gun could have been used successively in this movie and many others in the future, with proper handling and training. Instead, a deeper analysis of the causation points to a culture that allowed numerous mistakes consisting of habitual rule violations. Further analysis suggests this dangerous culture may be pervasive in the industry.
Investigations and decisions on how to address the larger issues need to be based on the possibility that while this tragedy involved a gun, the next one may involve poorly maintained equipment or vehicles, or poorly managed stunts, or some other problem lying in wait that we can’t yet see. The severity of this incident has led to voluminous news coverage, but how many other near-misses have occurred on sets that could be traced back to the same root causes that we have identified here? That is the value of root cause analysis.
While the set of "Rust" is far from the streets our officers patrol, examining the incident that occurred on the set is instructive in demonstrating the process that should be followed to determine root cause after any law enforcement tragedy. The key is to keep asking questions until you run out of answers, and there will typically be the answer. The process can be very short or very long, with one answer or several.
A final key: Don’t wait until a tragedy strikes your agency. Instead, look at current events and ask, “Could that happen here?” To prevent similar tragedies, we must identify what type of failure, or failures, occurred. Without such a process, blame and overreaction can leave many problems lying in wait, with the clock ticking toward another tragedy.
1. Reason J. (1990). Human Error. Cambridge University Press, Cambridge.
2. Littleton C. (10/23/21) ‘Rust’ Tragedy Reflects Troubling Trends on Movie and TV Sets: ‘We Did This to Ourselves.’ Variety.