What Can a Swedish Warship Teach Us About Root Cause Analysis?

Andy Fox Engagement Manager
Read Time: 4 minutes apprx.

We have had some big stretches in our blog posts applying current or historical events to analytics and supply chain concepts (4 Things Nick Saban Can Teach Us About Inventory Planning, anyone?). This one might take the cake. I must have not fully disconnected my mind from work on a recent vacation, but I couldn’t help but to think that the value of root cause analysis goes back longer than I could have imagined…back at least as far as 1628.

The Vasa was a Swedish warship built in the early 17th century. It was an innovative vessel commissioned by the King during a war with Poland. One mile into its maiden voyage, the ship toppled over in a light breeze and sunk in Stockholm’s harbor. While a disaster for Sweden at the time, it was almost perfectly preserved in the mud at the floor of the harbor for over 300 years, which is how tourists/data scientists can see the magnificent ship and write blog posts about it today.

Immediately following the sinking, Swedish officials held a formal hearing to identify the root cause of the incident. The Captain, responsible for the operation of the ship, reported that the crew sailed the ship to the best of their ability. Another crew member, responsible for the cannons, reported that the cannons were indeed secured and not likely to have shifted the weight of the ship. He was cleared, too. The Boatswain correctly loaded as many cannonballs as would fit in the space below deck. Several more of the ship’s building team and crew were brought in; all proved that they did their part correctly. No root cause was ever identified, and no one held responsible.

This formal hearing, though dealing with more serious consequences, might sound familiar to any operations leader. Something goes wrong; we try to figure out what went wrong; and all process owners report a bright green in-process KPI (if their business unit is even sophisticated enough to have data). When we manage processes, we sometimes lose sight of the end user, customer, or client since it might be difficult to tie them back to our upstream process. But, we should always remember – the Vasa still sank!

Here are 3 lessons from the Vasa that made me think about how to do better Root Cause Analytics:

    1. Focus on outcomes: Executing a process correctly does not mean the process is designed correctly for the customer. In the case of the Vasa, the Boatswain, while not responsible himself, held the answer to the mystery of the sinking ship: a poor design. He loaded all the stones that fit in the space, but the ship wasn’t built wide enough for him to load enough cannonballs to balance the ship. Internal KPIs are useful for managing process teams, but secondary to key indicators of customer success and satisfaction.


    1. Integrate: The Vasa’s root cause hearing was a disconnected, binary, and individual evaluation of crew members (and left out a critical one – the King giving the design orders) that led to no conclusion. In business, doing this better means integrating teams, but also data sources. A distribution center may store its data in a Warehouse Management System, while customer order and delivery data may reside in a different system of record. Connecting these together and to the customer gives the end-to-end visibility needed to reliably analyze the full supply chain.


  1. Be open to discovery: The Vasa was an innovative ship for Sweden; no other ship was built quite like it. Therefore, the officials had difficulty when asking the same questions they may have asked in the past, looking for “the usual suspects”. This is just as hard in business. We don’t know what we don’t know, and manually questioning process owners may not lead to new discoveries. Analytical methods like unsupervised learning are made for this, revealing latent patterns for which we didn’t even know to look.

Once considered an embarrassment and a disaster, the Vasa is now viewed as an inspiration to many types of archaeologists and scientists. It turns out, data scientists can be added to that list. The knowledge Vasa holds goes beyond its history and beyond Stockholm Harbor to affect how we think about what we do in business almost 400 years later.