Root Cause Analysis

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 Process es.

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 corrective measures at root causes is more effective than merely treating the symptoms of a problem.
# To be effective, RCA must be performed systematically, and conclusions must be backed up by evidence.
# There is usually more than one root cause for any given problem.

GENERAL PROCESS FOR PERFORMING ROOT CAUSE ANALYSIS

# Define the problem.
# Gather data/evidence.
# Identify issues that contributed to the problem.
# Find root causes.
# Develop solution recommendations.
# Implement the recommendations.
# Observe the recommended solutions to ensure effectiveness.

ROOT CAUSE ANALYSIS TECHNIQUES

5 Whys

Failure Mode And Effects Analysis

Pareto Analysis

Fault Tree Analysis

Bayesian Inference

Ishikawa Diagram , also known as the fishbone diagram or cause and effect diagram

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.

BASIC ELEMENTS OF ROOT CAUSE

Materials

--- Defective Raw Material

--- Wrong type for job

--- Lack of raw material

Machine/Equipment

--- 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

--- No or poor management involvement

--- Inattention to task

--- Task hazards not guarded properly

--- Other (horseplay, inattention....)

--- Stress demands

Methods

--- 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

	CATEGORIES ABOUT ROOT CAUSE ANALYSIS

	quality

	safety

	evaluation methods

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Information About

Root Cause Analysis