ROOT CAUSE

ANALYSIS
DEFINITION
 A root cause is defined as a factor that
caused a non-conformance and should
be permanently eliminated through
process improvement.
 Root cause analysis (RCA) is defined as
a collective term that describes a wide
range of approaches, tools, and
techniques used to uncover causes of
problems.
TRACING A PROBLEM TO ITS ORIGINS

Eg. In medicine, it's easy to understand

the difference between treating the
symptoms and curing the condition. A
broken wrist, for example, really hurts!
But painkillers will only take away the
symptoms; you'll need a different
treatment to help your bones heal
properly.
But what do you do when you have a
problem at work? Do you jump straight in
and treat the symptoms, or do you stop to
consider whether there's actually a deeper
problem that needs your attention? If you
only fix the symptoms – what you see on
the surface – the problem will almost
certainly return, and need fixing over, and
over again. However, if you look deeper to
figure out what's causing the problem, you
can fix the underlying systems and
processes so that it goes away for good.
 Root Cause Analysis (RCA) is a popular
and often-used technique that helps
people answer the question of why the
problem occurred in the first place. It
seeks to identify the origin of a problem
using a specific set of steps, with
associated tools, to find the primary
cause of the problem, so that you can:
 Determine what happened.
 Determine why it happened.
 Figure out what to do to reduce the
likelihood that it will happen again.
RCA assumes that systems and events
are interrelated. An action in one area
triggers an action in another, and
another, and so on. By tracing back
these actions, you can discover where
the problem started and how it grew
into the symptom you're now facing.
 You'll usually find three basic types of causes:

 Physical causes – Tangible, material items failed

in some way (for example, a car's brakes stopped
working).
 Human causes – People did something wrong, or
did not do something that was needed. Human
causes typically lead to physical causes (for
example, no one filled the brake fluid, which led to
the brakes failing).
 Organizational causes – A system, process, or
policy that people use to make decisions or do their
work is faulty (for example, no one person was
responsible for vehicle maintenance, and everyone
assumed someone else had filled the brake fluid).
THE ROOT CAUSE ANALYSIS PROCESS

RCA has five identifiable steps.

Step One: Define the Problem

 What do you see happening?
 What are the specific symptoms?
 Step Two: Collect Data

 What proof do you have that the problem exists?

 How long has the problem existed?
 What is the impact of the problem?

You need to analyze a situation fully before you

can move on to look at factors that contributed
to the problem. To maximize the effectiveness of
your RCA, get together everyone – experts and
front line staff – who understand the situation.
People who are most familiar with the problem
can help lead you to a better understanding of
the issues.
 Step Three: Identify Possible Causal Factors

 What sequence of events lead to the problem?

 What conditions allow the problem to occur?
 What other problems surround the occurrence of
the central problem?

During this stage, identify as many causal factors

as possible. Too often, people identify one or two
factors and then stop, but that's not sufficient.
With RCA, you don't want to simply treat the most
obvious causes – you want to dig deeper.
 Use these tools to help identify causal
factors:
 Appreciation – Use the facts and ask "So
what?" to determine all the possible
consequences of a fact.
 5 Whys – Ask "Why?" until you get to the
root of the problem.
 Drill Down – Break down a problem into
small, detailed parts to better understand
the big picture.
 Cause and Effect Diagrams – Create a
chart of all of the possible causal factors, to
see where the trouble may have begun.
 Step Four: Identify the Root
Cause(s)

 Why does the causal factor exist?

 What is the real reason the problem
occurred?
Use the same tools you used to identify
the causal factors (in Step Three) to look
at the roots of each factor. These tools
are designed to encourage you to dig
deeper at each level of cause and effect.
 Step Five: Recommend and Implement
Solutions

 What can you do to prevent the problem from

happening again?
 How will the solution be implemented?
 Who will be responsible for it?
 What are the risks of implementing the solution?
Analyze your cause-and-effect process, and
identify the changes needed for various systems.
It's also important that you plan ahead to predict
the effects of your solution. This way, you can
spot potential failures before they happen.
 One way of doing this is to use
Failure Mode and Effects Analysis (FMEA). This tool
builds on the idea of risk analysis to identify points where
a solution could fail. FMEA is also a great system to
implement across your organization; the more systems
and processes that use FMEA at the start, the less likely
you are to have problems that need RCA in the future.
Impact Analysis is another useful tool here. This helps
you explore possible positive and negative consequences
of a change on different parts of a system or organization.
Another great strategy to adopt is Kaizen , or
continuous improvement. This is the idea that continual
small changes create better systems overall. Kaizen also
emphasizes that the people closest to a process should
identify places for improvement. Again, with Kaizen alive
and well in your company, the root causes of problems can
be identified and resolved quickly and effectively.