Root Cause Analysis (RCA)

The document discusses Root Cause Analysis (RCA), which is a method used to determine the underlying cause of failures or problems. RCA aims to identify issues and discuss possibilities for change rather than just fixing problems. The RCA process involves defining the problem, creating a timeline, developing a fault tree, and identifying effective solutions to prevent recurrence.

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Root Cause Analysis (RCA)

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Root Cause Analysis (RCA)

1
Root Cause Analysis (RCA) is an
effective method for determining
the basic cause(s) of a failure or
problems and preventing a
recurrence

2
Why RCA?
“Root Cause Failure Analysis should have learning rather
than fixing as its goal. Failures should not be
approached with the expectation of finding the single
“root” cause of the problem, nor is there a “solution” to
the problem. Instead, a root cause analysis should
become an occasion to identify and discuss issues, to
encourage new insights, and to explore possibilities for
change and their consequences.”

John Carroll, MIT Sloan School of Management

3
RCA comprised of the following steps

6
RCA initiated by an event that
“triggers” a RCA
7
• Problem definition

8
 Time line development

9
 Fault tree development

10
 Fault tree development with human and
systemic cause

Butterfly valve
Physical Cause
partially closed

Operator did not

Human Cause
open valve fully

Operator performing
Latent Cause
task as task has been
performed for years

11
 Identification of effective solution(s) to mitigate
problem recurrence – pursue appropriate
solutions and consider not pursing all solutions
12
• Implementation of and tracking of solutions

13
5 Whys

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Root Cause Analysis (RCA)

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Root Cause Analysis (RCA)

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Root Cause Analysis (RCA)

John Carroll, MIT Sloan School of Management

Operator did not

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