Root Cause Analysis

Information about 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.

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 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
Man
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

Background

The change referred to in this context includes a broad array of topics.
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Risk management is the human activity which integrates recognition of risk, risk assessment, developing strategies to manage it, and mitigation of risk using managerial resources.
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Systems analysis is the interdisciplinary branch of science, dealing with analysis of systems, often prior to their automation as computer systems, and the interactions within those systems. This field is closely related to operations research.
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The five whys is a question asking method used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the 5 Whys method is to determine a root cause of a defect or problem. The following example demonstrates the basic process.
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Failure Mode and Effects Analysis (FMEA) is a risk assessment technique for systematically identifying potential failures in a system or a process. It is widely used in the manufacturing industries in various phases of the product life cycle.
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Pareto analysis is a statistical technique in decision making that is used for selection of a limited number of tasks that produce significant overall effect. It uses the Pareto principle - the idea that by doing 20% of work you can generate 80% of the advantage of doing the entire
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Bayesian inference is statistical inference in which evidence or observations are used to update or to newly infer the probability that a hypothesis may be true. The name "Bayesian" comes from the frequent use of Bayes' theorem in the inference process.
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The Ishikawa diagram (also fishbone diagram or cause and effect diagram) is the brainchild of Kaoru Ishikawa, who pioneered quality management processes in the Kawasaki shipyards, and in the process became one of the founding fathers of modern management.
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In general, diagnosis (plural diagnoses) has two distinct dictionary definitions. The first definition is "the recognition of a disease or condition by its outward signs and symptoms", while the second definition is "the analysis of the underlying physiological/biochemical
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Debugging is a methodical process of finding and reducing the number of bugs, or defects, in a computer program or a piece of electronic hardware thus making it behave as expected.
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Safety engineering is an applied science strongly related to systems engineering and the subset System Safety Engineering. Safety engineering assures that a life-critical system behaves as needed even when pieces fail.
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Security engineering is the field of engineering dealing in developing detailed engineering designs for security systems and for security of spaces. It is similar to systems engineering in that its motivation is to make a system meet requirements, but with the added dimension of
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