Root Cause Analysis: An Overview.

The root cause is the core issue that sets in motion the entire cause-and-effect reaction that ultimately leads to the problems (www.asq.org). Root cause analysis is an approach for identifying the underlying causes of an incident so that the most effective solutions can be identified and implemented. It’s typically used when something goes badly, but can also be used when something goes well.

As an analytical tool, Root Cause Analysis is an essential way to perform a comprehensive, system-wide review of significant problems as well as the events and factors leading to them. If you only fix the deficiency (already identified) then the problem will almost certainly happen again, which will lead you to fix it, again, and again, and again. If instead, you look deeper to figure out why the problem is occurring, you can fix the underlying systems and processes that cause the problem. Root Cause Analysis (RCA) is a technique that helps you answer the question of why the problem occurred in the first place.

The goal is to find out;

1. What happened?
2. Why happened?
3. What can be done to prevent the problem from happening again?

The Root Cause Analysis Process

Root Cause Analysis has five (5) major Steps.

1. Identify the Problem: What do you see happening? What are the visible symptoms?
2. Collect Data: What proof do you have that the problem exists? How long has the problem persisted? 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 Root Cause Analysis, consult everyone who understands the situation. People who are most familiar with the problem can help lead you to a better understanding of the issues.
3. Analyze Cause and Effect: What sequence of events leads to the problem? What conditions allow the problem to occur? What other problems surround the occurrence of the central problem? It is not enough to identify one or two causal factors and then stop, with RCA, you want to dig deeper in order to identify underlying factors. The Cause and effect analysis examines the causes of the Focal Point.

We analyze cause and effect for two reasons:

1) It develops a detailed, evidence-based understanding of the event, and

2) It leads to effective solutions by providing innovative opportunities to eliminate or control the causes of the problem.

A basic premise of cause and effect analysis is that effects are generally the result of multiple causes. A fire, for example, has three causes: Oxygen, combustible material, and an ignition source. Each cause is necessary in order for the fire to exist. And the group of causes together is sufficient to cause a fire — nothing else is needed. Each of the causes of the fire has subsequent causes as well. It can all become quite confusing — therefore we employ a cause and effect chart to help us keep track.

Tools for Identifying Contributing Factors

Pareto Analysis, Fish-bone diagram (Ishikawa diagram), Five-whys analysis, Failure Mode, and effect Analysis are all examples of tools used for identifying contributing factors. These tools would be treated in subsequent publications.

4. Generate Solutions: The cause and effect chart provides the platform for solutions. We solve problems by controlling, altering, or eliminating causes. Therefore, if the cause and effect chart accurately models the causes of the problem, controlling those causes eliminates future similar events (or greatly reduces probability).

One common misconception is that there is a single root cause for any given event. This is rarely the case. Robust solution strategies eliminate causes from different paths on the cause and effect chart. Diversification of solutions helps to reduce the risk of recurrence to a lower level than can be achieved by implementing single solutions.

5. Implement Solutions:

• How will the solution be implemented?
• Who will be responsible for it?
• What are the risks of implementing the solution?

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.

As an analytical tool, RCA is an essential way to perform a comprehensive, system-wide review of significant problems as well as the events and factors leading to them.