manipulating valves or emphasize to all personnelthat careful attention to the job should be main-tained at all times. Such recommendations do littleto prevent future occurrences.Generally, mistakes do not just happen but can be traced to some well-defined causes. In the caseof the valve error, we might ask, “Was the proce-dure confusing? Were the valves clearly labeled?Was the operator familiar with this particulartask?”The answers to these and other questions willhelp determine why the error took place andwhat the organization can do to prevent recur-rence. In the case of the valve error, examplerecommendations might include revising theprocedure or performing procedure validation toensure references to valves match the valve labelsfound in the field.Identifying root causes is the key to preventingsimilar recurrences. An added benefit of an effectiveRCA is that, over time, the root causes identifiedacross the population of occurrences can be used totarget major opportunities for improvement.If, for example, a significant number of analysespoint to procurement inadequacies, then resourcescan be focused on improvement of this managementsystem. Trending of root causes allows developmentof systematic improvements and assessment of theimpact of corrective programs.
Although there is substantial debate on the defi-nition of root cause, we use the following:1.Root causes are specific underlying causes.2.Root causes are those that can reasonably beidentified.3.Root causes are those management has controlto fix.4.Root causes are those for which effective rec-ommendations for preventing recurrences can be generated.
Root causes are underlying causes.
The investi-gator’s goal should be to identify specific underly-ing causes. The more specific the investigator can be about why an event occurred, the easier it will be to arrive at recommendations that will preventrecurrence.
Root causes are those that can reasonably beidentified.
Occurrence investigations must be cost beneficial. It is not practical to keep valuable man-power occupied indefinitely searching for the rootcauses of occurrences. Structured RCA helps ana-lysts get the most out of the time they have invest-ed in the investigation.
Root causes are those over which managementhas control.
Analysts should avoid using generalcause classifications such as operator error, equip-ment failure or external factor. Such causes are notspecific enough to allow management to makeeffective changes. Management needs to knowexactly why a failure occurred before action can betaken to prevent recurrence.We must also identify a root cause that manage-ment can influence. Identifying “severe weather”as the root cause of parts not being delivered ontime to customers is not appropriate. Severe weath-er is not controlled by management.
Root causes are those for which effective recom-mendations can be generated.
Recommendationsshould directly address the root causes identifiedduring the investigation. If the analysts arrive atvague recommendations such as, “Improve adher-ence to written policies and procedures,” thenthey probably have not found a basic and specificenough cause and need to expend more effort in theanalysis process.
Four Major Steps
The RCA is a four-step process involving the fol-lowing:1.Data collection.2.Causal factor charting.
Identifying “severe weather”as the root cause of parts notbeing delivered on time tocustomers is not appropriate.