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Root Cause Analysis

The document discusses root cause analysis (RCA), which aims to identify the underlying causes of problems in order to minimize the likelihood of recurrence. There are different schools of RCA from fields like safety, production, and systems analysis. RCA uses techniques like 5 Whys, fishbone diagrams, and barrier analysis to systematically trace the causal relationships between root causes and the defined problem. Performing effective RCA involves following general principles like addressing root causes rather than just symptoms, and using documented evidence to identify multiple potential root causes.

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John Brix Balisteros
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2K views18 pages

Root Cause Analysis

The document discusses root cause analysis (RCA), which aims to identify the underlying causes of problems in order to minimize the likelihood of recurrence. There are different schools of RCA from fields like safety, production, and systems analysis. RCA uses techniques like 5 Whys, fishbone diagrams, and barrier analysis to systematically trace the causal relationships between root causes and the defined problem. Performing effective RCA involves following general principles like addressing root causes rather than just symptoms, and using documented evidence to identify multiple potential root causes.

Uploaded by

John Brix Balisteros
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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Root Cause Analysis

Mc Kevin L. Teodoro
Joanne S. Perez

Root cause analysis

Root cause analysis (RCA) is a class of


problem solving methods aimed at identifying
the root causes of problems or events. The
practice of RCA is predicated on the belief
that problems are best solved by attempting to
correct or eliminate root causes, as opposed to
merely addressing the immediately obvious
symptoms. By directing corrective measures at
root causes, it is hoped that the likelihood of
problem recurrence will be minimized.
However, it is recognized that complete
prevention of recurrence by a single
intervention is not always possible. Thus, RCA
is often considered to be an iterative process,
and is frequently viewed as a tool of
continuous improvement.

RCA, initially is a reactive method of problem detection and solving. This


means that the analysis is done after an event has occurred. By gaining
expertise in RCA it becomes a pro-active method. This means that RCA is able
to forecast the possibility of an event even before it could occur.

Root cause analysis is not a single, sharply defined methodology; there are
many different tools, processes, and philosophies of RCA in existence.
However, most of these can be classed into five, very-broadly defined
"schools" that are named here by their basic fields of origin: safety-based,
production-based, process-based, failure-based, and systems-based.

Safety-based RCA descends from the fields of


accident analysis and occupational safety and health.
Production-based RCA has its origins in the field of
quality control for industrial manufacturing.
Process-based RCA is basically a follow-on to
production-based RCA, but with a scope that has been
expanded to include business processes.
Failure-based RCA is rooted in the practice of
failure analysis as employed in engineering and
maintenance.
Systems-based RCA has emerged as an amalgamation of
the preceding schools, along with ideas taken from
fields such as change management, risk management,
and systems analysis.

Despite the seeming disparity in purpose and definition among the various
schools of root cause analysis, there are some general principles that could
be considered as universal. Similarly, it is possible to define a general process
for performing RCA.

General principles of root


cause analysis

Aiming performance improvement measures at root


causes is more effective than merely treating the
symptoms of a problem.
To be effective, RCA must be performed
systematically, with conclusions and causes backed up
by documented evidence.
There is usually more than one potential root cause
for any given problem.
To be effective the analysis must establish all known
causal relationships between the root cause(s) and
the defined problem.
Root cause analysis transforms an old culture that
reacts to problems to a new culture that solves
problems before they escalate, creating a variability
reduction and risk avoidance mindset.

General process for performing and


documenting an RCA-based
Corrective Action
Notice

that RCA (in steps 3, 4 and 5) forms the most critical part of
successful corrective action, because it directs the corrective action at the
root of the problem. That is to say, it is effective solutions we seek, not root
causes. Root causes are secondary to the goal of prevention, and are only
revealed after we decide which solutions to implement.

Define the problem.


Gather data/evidence.
Ask why and identify the causal relationships
associated with the defined problem.
Identify which causes if removed or changed
will prevent recurrence.
Identify effective solutions that prevent
recurrence, are within your control, meet
your goals and objectives and do not cause
other problems.
Implement the recommendations.
Observe the recommended solutions to ensure
effectiveness.
Variability Reduction methodology for
problem solving and problem avoidance.

Root cause analysis


techniques

Behavior Justification A program designed to


teach critical thinking skills for problem
solving. The program teaches that "cause and
effect" is a relative term, meaning that
depending from what direction through time
one is observing a fact determines its input
"cause" or "effect." This means that each fact
is actually both except for the root causes. A
process is used to construct a Gestalt model
using the facts of an event. This model mimics
the human thought process for organizing and
connecting information that is causally
related. The model is a solution path from the
problem to the causes. The application of this
program induces culture change for
improvement.

Cause and effect analysis A technique that


organizes the analyst's knowledge into a cause
and effect chain. For every effect, there is a
cause. There is a fairly long chain of
relationship between the cause and its effect.
In theory, if the lowest cause on the chain is
removed, the problem will not re-appear. Root
Cause is a variability reduction methodology for
problem solving and problem avoidance. Root
cause mindset transforms an old culture that
reacts to problems to a new culture that solves
problems before they escalate, creating a cost
effective variability reduction and risk
avoidance mindset.

5 Whys
Kepner-Tregoe Problem Analysis - a root cause analysis
process developed in 1958, which provides a fact-based
approach to systematically rule out possible causes and
identify the true cause
Failure mode and effects analysis Also known as FMEA.
Pareto analysis
Fault tree analysis
Bayesian inference
Ishikawa diagram, also known as the fishbone diagram
or cause and effect diagram
Cause Mapping - root cause analysis problem solving
method that draws out, visually, the multiple chains of
interconnecting causes that lead to an incident. The
method, which breaks problems down specific causeand-effect relationships, can be applied to a variety of
problems and situations

Barrier analysis - a technique often used in particularly


in process industries. It is based on tracing energy
flows, with a focus on barriers to those flows, to
identify how and why the barriers did not prevent the
energy flows from causing harm.
Change analysis - an investigation technique often used
for problems or accidents. It is based on comparing a
situation that does not exhibit the problem to one that
does, in order to identify the changes or differences
that might explain why the problem occurred.
Causal factor tree analysis - a technique based on
displaying causal factors in a tree-structure such that
cause-effect dependencies are clearly identified.

Event and Causal Factor Charting - Another


technique, where each event is enclosed in a
rectangle. A series of events are enclosed in
rectangles with lines inter connecting the
rectangles. Events progress from left to right,
just like in a text. Striking of a match stick is an
event. If there is possibility of the
interconnection, the rectangles are connected
with the dotted lines. The 'Causes' are
identified for each event. In order to
differentiate the Causes from Events, Causes
are enclosed in ellipse. The 'Presence of
inflammable Gases' can be a 'Cause'. Both
'Event' and 'Cause' put together may lead to the
accident, e.g., 'explosion'.

TapRooT

- A structured root cause analysis


system built around a problem solving process
with six embedded techniques to guide
investigators beyond their current knowledge to
the root causes of human performance and
equipment failure related incidents.
ARCA; Apollo Root Cause Analysis - A unique
problem solving process characterized by a
structured cause and effect chart known as a
Reality chart which allows all problem
stakeholders to own the problem and its
corrective actions.
RPR Problem Diagnosis - An ITIL-aligned method
for diagnosing IT problems.

Common cause analysis (CCA) common modes analysis (CMA) are


evolving engineering techniques for complex technical systems to
determine if common root causes in hardware, software or highly
integrated systems interaction may contribute to human error or
improper operation of a system.
Systems are analyzed for root causes and causal factors to determine
probability of failure modes, fault modes, or common mode software
faults due to escaped requirements.
Also ensuring complete testing and verification are methods used for
ensuring complex systems are designed with no common causes that
cause severe hazards.
Common cause analysis are sometimes required as part of the safety
engineering tasks for theme parks, commercial/military aircraft,
spacecraft, complex control systems, large electrical utility grids,
nuclear power plants, automated industrial controls, medical devices
or other safety safety-critical systems with complex functionality.

Basic elements of root cause

Materials

Machine / Equipment

Defective raw material


Wrong type for job
Lack of raw material
Incorrect tool selection
Poor maintenance or design
Poor equipment or tool placement
Defective equipment or tool

Environment

Orderly workplace
Job design or layout of work
Surfaces poorly maintained
Physical demands of the task
Forces of nature

Management

Methods

No or poor management involvement


Inattention to task
Task hazards not guarded properly
Other (horseplay, inattention....)
Stress demands
Lack of Process
No or poor procedures
Practices are not the same as written procedures
Poor communication

Management system

Training or education lacking


Poor employee involvement
Poor recognition of hazard
Previously identified hazards were not eliminated
4ME (Man, Machine, Materials, Method and Environment).

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