QUALITY BASICS
Root Cause Analysis
For Beginners
by James J. Rooney and Lee N. Vanden Heuvel
R
oot cause analysis (RCA) is a process
designed for use in investigating and cate-
gorizing the root causes of events with safe-
ty, health, environmental, quality, reliability and
production impacts. The term “event” is used to
In 50 Words
Or Less
• Root cause analysis helps identify what, how
and why something happened, thus preventing
recurrence.
• Root causes are underlying, are reasonably
identifiable, can be controlled by management
and allow for generation of recommendations.
• The process involves data collection, cause
charting, root cause identification and recom-
mendation generation and implementation.
generically identify occurrences that produce or
have the potential to produce these types of conse-
quences.
Simply stated, RCA is a tool designed to help
identify not only what and how an event occurred,
but also why it happened. Only when investiga-
tors are able to determine why an event or failure
occurred will they be able to specify workable
corrective measures that prevent future events of
the type observed.
Understanding why an event occurred is the
key to developing effective recommendations.
Imagine an occurrence during which an opera-
tor is instructed to close valve A; instead, the
operator closes valve B. The typical investiga-
tion would probably conclude operator error
was the cause.
This is an accurate description of what hap-
pened and how it happened. However, if the ana-
lysts stop here, they have not probed deeply
enough to understand the reasons for the mistake.
Therefore, they do not know what to do to pre-
vent it from occurring again.
In the case of the operator who turned the
wrong valve, we are likely to see recommenda-
tions such as retrain the operator on the proce-
dure, remind all operators to be alert when
QUALITY PROGRESS I JULY 2004 I 45
QUALITY BASICS
manipulating valves or emphasize to all personnel
that careful attention to the job should be main-
tained at all times. Such recommendations do little
to prevent future occurrences.
Generally, mistakes do not just happen but can
be traced to some well-defined causes. In the case
of the valve error, we might ask, “Was the proce-
dure confusing? Were the valves clearly labeled?
Was the operator familiar with this particular
task?”
The answers to these and other questions will
help determine why the error took place and
what the organization can do to prevent recur-
Identifying “severe weather”
as the root cause of parts not
being delivered on time to
customers is not appropriate.
rence. In the case of the valve error, example
recommendations might include revising the
procedure or performing procedure validation to
ensure references to valves match the valve labels
found in the field.
Identifying root causes is the key to preventing
similar recurrences. An added benefit of an effective
RCA is that, over time, the root causes identified
across the population of occurrences can be used to
target major opportunities for improvement.
If, for example, a significant number of analyses
point to procurement inadequacies, then resources
can be focused on improvement of this management
system. Trending of root causes allows development
of systematic improvements and assessment of the
impact of corrective programs.
Definition
Although there is substantial debate on the defi-
nition of root cause, we use the following:
1. Root causes are specific underlying causes.
46 I JULY 2004 I www.asq.org
2. Root causes are those that can reasonably be
identified.
3. Root causes are those management has control
to 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 prevent
recurrence.
Root causes are those that can reasonably be
identified. Occurrence investigations must be cost
beneficial. It is not practical to keep valuable man-
power occupied indefinitely searching for the root
causes 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 management
has control. Analysts should avoid using general
cause classifications such as operator error, equip-
ment failure or external factor. Such causes are not
specific enough to allow management to make
effective changes. Management needs to know
exactly why a failure occurred before action can be
taken 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 on
time 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. Recommendations
should directly address the root causes identified
during the investigation. If the analysts arrive at
vague recommendations such as, “Improve adher-
ence to written policies and procedures,” then
they probably have not found a basic and specific
enough cause and need to expend more effort in the
analysis process.
Four Major Steps
The RCA is a four-step process involving the fol-
lowing:
1. Data collection.
2. Causal factor charting.
FIGURE 1 Causal Factor Chart

Burner Part one

Electric
burner
shorts out
CF

Pan
Arcing heats
bottom of Had it
aluminum not been
pan originally charged?
Fire
extinguisher

Pan
Aluminum Had it
melts, leaked?
Jane forming Fire extinguisher,
hole in pan floor
Jane comes
to the door What Had it
exactly been
Conclusion did she see? previously used?
Grease ignites Mary Inspection tag
when it
Jane, Mary contacts Assumed Mary Mary
burner
Fire Mary sees Fire extinguisher
Jane rings
How generates the fire is not
the doorbell
much oil is smoke on the stove charged
used? How Mary
much chicken?
Fire starts
Chicken, on the
pan, oil Mary Mary Jane, Mary Mary Mary Mary
stove
Mary Mary leaves Smoke Mary runs Mary tries Fire extinguisher
begins the frying detector into the to use does not
frying chicken Mary
alarms kitchen the fire operate when
chicken unattended extinguisher Mary tries to use it
5:00 pm CF Mary meets About 5:10 pm CF
with Jane
Pan Mary
10 minutes
Mary Mary pulls
uses an the plug
aluminum on the fire
pan extinguisher
Does Mary
Is "plug" know how
the same to use a fire
as pin? extinguisher?
Mary Mary
CF = Causal factor

Figure 1 continued on next page

QUALITY PROGRESS I JULY 2004 I 47

QUALITY BASICS

Part two

Did she know What is

this was wrong? Jane doing during
Lack of practice this time?
fighting fires?
Did she do Mary, Jane
Mary
anything else? Mary, pan
Mary How long
Fire was a did it take for the Did the FD
grease fire FD to arrive? use the correct
Was Mary
techniques?
trying to do this? FD
dispatcher FD
Mary
Kitchen
destroyed
Mary Kitchen, Mary Mary, FD Observation FD, observation by fire
Mary throws Fire spreads Mary calls the Fire department Fire department
water on throughout fire department arrives puts out fire
the fire the kitchen
CF Other losses
Time? Time? Time?
from smoke and
water damage?

3. Root cause identification. drive the data collection process by identifying

4. Recommendation generation and implementa-
tion.
Step one—data collection. The first step in the
analysis is to gather data. Without complete infor-
mation and an understanding of the event, the
causal factors and root causes associated with the
event cannot be identified. The majority of time
spent analyzing an event is spent in gathering
data.
Step two—Causal factor charting. Causal factor
charting provides a structure for investigators to orga-
nize and analyze the information gathered during
the investigation and identify gaps and deficiencies
in knowledge as the investigation progresses. The
causal factor chart is simply a sequence diagram
with logic tests that describes the events leading up
to an occurrence, plus the conditions surrounding
these events (see Figure 1, p. 47).
Preparation of the causal factor chart should
begin as soon as investigators start to collect infor-
mation about the occurrence. They begin with a
skeleton chart that is modified as more relevant
facts are uncovered. The causal factor chart should
data needs.
Data collection continues until the investigators
are satisfied with the thoroughness of the chart
(and hence are satisfied with the thoroughness of
the investigation). When the entire occurrence has
been charted out, the investigators are in a good
position to identify the major contributors to the
incident, called causal factors. Causal factors are
those contributors (human errors and component
failures) that, if eliminated, would have either pre-
vented the occurrence or reduced its severity.
In many traditional analyses, the most visible
causal factor is given all the attention. Rarely, how-
ever, is there just one causal factor; events are usu-
ally the result of a combination of contributors.
When only one obvious causal factor is addressed,
the list of recommendations will likely not be com-
plete. Consequently, the occurrence may repeat
itself because the organization did not learn all that
it could from the event.
Step three—root cause identification. After all
the causal factors have been identified, the investi-
gators begin root cause identification. This step

48 I JULY 2004 I www.asq.org

involves the use of a decision diagram called the
Root Cause Map (see Figure 2, p. 50) to identify the
underlying reason or reasons for each causal factor.
The map structures the reasoning process of the
investigators by helping them answer questions
about why particular causal factors exist or
occurred. The identification of root causes helps
the investigator determine the reasons the event
occurred so the problems surrounding the occur-
rence can be addressed.
Step four—recommendation generation and
implementation. The next step is the generation of
recommendations. Following identification of the
root causes for a particular causal factor, achievable
recommendations for preventing its recurrence are
then generated.
The root cause analyst is often not responsible
for the implementation of recommendations gener-
ated by the analysis. However, if the recommenda-
tions are not implemented, the effort expended in
performing the analysis is wasted. In addition, the
events that triggered the analysis should be expect-
ed to recur. Organizations need to ensure that rec-
ommendations are tracked to completion.
Presentation of Results
Root cause summary tables (see Table 1, p. 52)
can organize the information compiled during data
analysis, root cause identification and recommen-
dation generation. Each column represents a major
aspect of the RCA process.
• In the first column, a general description of the
causal factor is presented along with sufficient
background information for the reader to be
able to understand the need to address this
causal factor.
• The second column shows the Path or Paths
through the Root Cause Map associated with
the causal factor.
• The third column presents recommendations
to address each of the root causes identified.
Use of this three-column format aids the investi-
gator in ensuring root causes and recommenda-
tions are developed for each causal factor.
The end result of an RCA investigation is gener-
ally an investigation report. The format of the
report is usually well defined by the administrative
documents governing the particular reporting sys-
tem, but the completed causal factor chart and
causal factor summary tables provide most of the
information required by most reporting systems.
Example Problem
The following example is nontechnical, allowing
the reader to focus on the analysis process and not
the technical aspects of the situation. The following
narrative is the account of the event according to
Mary:
It was 5 p.m. I was frying chicken. My friend
Jane stopped by on her way home from the doc-
tor, and she was very upset. I invited her into
the living room so we could talk. After about 10
minutes, the smoke detector near the kitchen
came on. I ran into the kitchen and found a fire
on the stove. I reached for the fire extinguisher
and pulled the plug. Nothing happened. The
fire extinguisher was not charged. In despera-
tion, I threw water on the fire. The fire spread
throughout the kitchen. I called the fire depart-
ment, but the kitchen was destroyed. The fire
department arrived in time to save the rest of
the house.
Data gathering began as soon as possible after
the event to prevent loss or alteration of the data.
The RCA team toured the area as soon as the fire
In many traditional analyses,
the most visible causal factor
is given all the attention.
department declared it safe. Because data from
people are the most fragile, Mary, Jane and the fire-
fighters were interviewed immediately after the
fire. Photographs were taken to record physical
and position data.
The analysts then developed the causal factor
chart (see Figure 1, p. 47) to clearly define the
sequence of events that led to the fire. The causal
factor chart begins with the event; Mary begins fry-
ing chicken at 5 p.m. As the chart develops from
QUALITY PROGRESS I JULY 2004 I 49
QUALITY BASICS

FIGURE 2 Root Cause Map

Section one Start here with each causal factor. 1

1

Equipment difficulty 2

Equipment Equipment Equipment

reliability program Installation/
design problem fabrication misuse
5 problem 6 7 8
2

Equipment Equipment reliability Equipment reliability Administrative/

Design input/ Procedures
records program design program implementation management
output
15 18 less than adequate (LTA) 21 LTA 28 systems 55 111

Design input Equipment No program 22 Corrective maintenance Proactive maintenance

LTA 16 design records LTA 29 LTA 41
Program LTA 23
Design output LTA 19 • Analysis/design • Troubleshooting/corrective • Event specification
LTA 17 Equipment procedure LTA 24 action LTA 30 LTA 42
operating/ • Inappropriate type • Repair implementation • Monitoring LTA 43
maintenance of maintenance LTA 31 • Scope LTA 44
history LTA 20 assigned 25 Preventive maintenance • Activity implementation
• Risk acceptance LTA 32 LTA 45
criteria LTA 26 • Frequency LTA 33 Failure finding maintenance
• Allocation of • Scope LTA 34 LTA 46
resources LTA 27 • Activity implementation • Frequency LTA 47
LTA 35 • Scope LTA 48
Predictive maintenance • Troubleshooting/
LTA 36 corrective action LTA 49
• Detection LTA 37 • Repair implementation 50
• Monitoring LTA 38 Routine equipment
• Troubleshooting/ rounds LTA 51
corrective action LTA 39 • Frequency LTA 52
Note: Node numbers correspond to matching page in Appendix A of the • Activity implementation • Scope LTA 53
Root Cause Analysis Handbook. LTA 40 • Activity implementation
LTA 54

Standards, Safety/hazard/ Product/material Procurement Document and Customer

policies or risk review 72 control 85 control 93 configuration interface/
administrative • Review LTA or • Handling LTA 87 • Purchasing control 100 services 106
controls (SPACs) not performed 74 • Storage LTA 88 specifications LTA 95 • Change not • Customer
LTA 57 • Recommendations not • Packaging/ • Control of changes identified 102 requirements
• No SPACs 59 yet implemented 75 shipping LTA 89 to procurement • Verification of design/ not identified 108
• Not strict • Risk acceptance • Unauthorized material specifications LTA 96 field changes LTA • Customer needs
enough 60 criteria LTA 76 substitution 90 • Material acceptance (no PSSR*) 103 not addressed 109
• Confusing, • Review procedure • Product acceptance requirements LTA 97 • Documentation • Implementation
contradictory or LTA 77 criteria LTA 91 • Material inspections content not kept LTA 110
incomplete 61 • Product inspections LTA 98 up to date 104
• Technical error 62 LTA 92 • Contractor selection • Control of official
• Responsibility LTA 99 documents LTA 105
for item/activity
not adequately
defined 63 Problem
• Planning, scheduling SPACs not used 67 identification
or tracking of work • Communication of control 78 Misleading/confusing 117 Wrong/incomplete 130
activities LTA 64 SPACs LTA 69 • Problem reporting • Format confusing or • Typographical error 131
• Rewards/incentives • Recently changed 70 LTA 80 LTA 118 • Sequence wrong 132
LTA 65 • Enforcement LTA 71 • Problem analysis • More than one action • Facts wrong/
• Employee screening/ LTA 81 per step 120 requirements not
hiring LTA 66 • Audits LTA 82 • No checkoff space correct 133
• Corrective action provided but should be 121 • Wrong revision or
LTA 83 • Inadequate checklist 122 expired procedure
• Corrective actions not • Graphics LTA 123 revision used 134
yet implemented 84 • Ambiguous or confusing • Inconsistency
Not used 112 instructions/ between
• Not available or requirements 124 requirements 135
inconvenient to • Data/computations • Incomplete/situation
obtain 113 wrong/incomplete 125 not covered 136
• Procedure difficult • Insufficient or excessive • Overlap or gaps
to use 114 references 126 between
• Use not required • Identification of revised procedures 137
but should be 115 steps LTA 127
• No procedure for • Level of detail LTA 128
task 116 • Difficult to identify 129 Figure 2 continued on next page

50 I JULY 2004 I www.asq.org

 Start here with each causal factor. 1 Section Two

Personal difficulty 3 Other difficulty 4

Company Contract Natural Sabotage/ External

Other
employee employee phenomena horseplay events
9 10 11 12 13 14

Human factors Immediate Personal

Training Communications
engineering supervision performance
138 163 180 192 208

No training 164 Training records Training LTA 170 Preparation 181 Problem
• Decision not system LTA 167 • Job/task analysis • No preparation 182 detection LTA 209
to train 165 • Training records LTA 171 • Job plan LTA 183 *Sensory/perceptual
• Training incorrect 168 • Program design/ • Instructions to workers capabilities LTA 210
requirements not • Training records objectives LTA 172 LTA 184
identified 166 not up to date 169 • Lesson content • Walkthrough LTA 185 *Reasoning
LTA 174 • Scheduling LTA 186 capabilities LTA 211
• On-the-job • Worker selection/ *Motor/physical
training LTA 175 assignment LTA 187 capabilities LTA 212
• Qualification Supervision during
testing LTA 176 *Attitude/attention
work 188 LTA 213
• Continuing • Supervision LTA 189
training LTA 177 • Improper performance *Rest/sleep LTA
• Training not corrected 190 (fatigue) 214
resources LTA 178 • Teamwork LTA 191
• Abnormal events/ *Personal/medication
emergency problems 215
training LTA 179

No communication or Misunderstood Wrong Job turnover LTA 205 *PSSR = Project scope summary report
not timely 194 communication 200 instructions 204 • Communication
• Method unavailable or • Standard within shifts LTA 206
LTA 195 terminology not • Communication
• Communication between used 201 between shifts
work groups LTA 196 • Verification/ LTA 207
• Communication between repeat back not
shifts and management used 202
LTA 197 • Long message 203
• Communication with Shape Description
contractors LTA 198
• Communication with
customers LTA 199 Primary difficulty source

Workplace layout 140
• Controls/displays
LTA 141
• Control/display
integration/
arrangement LTA 143
• Location of
controls/displays
LTA 144
• Conflicting layouts 145
• Equipment
location LTA 146
• Labeling of
equipment or
locations LTA 147
Problem category
Work environment 148 Workload 155 Intolerant
• Housekeeping LTA 149 • Excessive control system 160 Root cause category
• Tools LTA 150 action • Errors not
• Protective clothing/ requirements 156 detectable 161
equipment LTA 151 • Unrealistic • Errors not Near root cause
• Ambient monitoring correctable 162
conditions LTA 152 requirements 157 Root cause
• Other environmental • Knowledge based
stresses excessive 154 decision
required 158 © 1995, 1997, 1999, 2000 and 2001, ABSG Consulting Inc.
• Excessive
calculation or
data manipulation *Note: These nodes are for descriptive
required 159 purposes only.

QUALITY PROGRESS I JULY 2004 I 51

QUALITY BASICS
TABLE 1 Root Cause Summary Table
Event description: Kitchen is destroyed by fire and damaged by smoke and water.
Causal factor # 1 Paths Through Root Cause Map
Description: • Personnel difficulty.
Mary leaves the frying chicken unattended. • Administrative/management systems.
• Standards, policies or administrative
controls (SPACs) less than adequate (LTA).
• No SPACs.
Causal factor # 2 Paths Through Root Cause Map
Description: • Equipment difficulty.
Electric burner element fails (shorts out). • Equipment reliability program problem.
• Equipment reliability program design LTA.
• No program.
Causal factor # 3 Paths Through Root Cause Map
Description: • Equipment difficulty.
Fire extinguisher does not operate when • Equipment reliability program problem.
Mary tries to use it. • Equipment proactive maintenance LTA.
• Activity implementation LTA.
• Equipment difficulty.
• Equipment reliability program problem.
• Administrative/management systems.
• Problem identification and control LTA.
Causal factor # 4 Paths Through Root Cause Map
Description: • Personnel difficulty.
Mary throws water on fire. • Company employee.
• Training.
• Training LTA.
• Abnormal events/emergency training LTA.
Paths Through Root Cause Map is a trademark of ABSG Consulting.
52 I JULY 2004 I www.asq.org
Event #: 2003-1
Recommendations
• Implement a policy that hot oil is never left
unattended on the stove.
• Determine whether policies should be
developed for other types of hazards in the
facility to ensure they are not left unattended.
• Modify the risk assessment process or
procedure development process to address
requirements for personnel attendance
during process operations.
Recommendations
• Replace all burners on stove.
• Develop a preventive maintenance strategy
to periodically replace the burner elements.
• Consider alternative methods for preparing
chicken that may involve fewer hazards,
such as baking the chicken or purchasing
the finished product from a supplier.
Recommendations
• Refill the fire extinguisher.
• Inspect other fire extinguishers in the
facility to ensure they are full.
• Have incident reports describing the use of
fire protection equipment routed to
maintenance to trigger refilling of the fire
extinguishers.
• Add this fire extinguisher to the audit list.
• Verify that all fire extinguishers are on the
quarterly fire extinguisher audit list.
• Have all maintenance work requests that
involve fire protection equipment routed to
the safety engineer so the quarterly
checklists can be modified as required.
Recommendations
• Provide practical (hands-on) training
on the use of fire extinguishers. Classroom
training may be insufficient to adequately
learn this skill.
• Review other skill based activities to
ensure appropriate level of hands-on training
is provided.
• Review the training development process
to ensure adequate guidance is provided for
determining the proper training setting (for
example,classroom, lab, simulator, on the job
training, computer based training).
left to right, the sequences begin to unfold. The loss
events—kitchen destroyed by fire and other losses
from smoke and water damage—are the shaded
rectangles in the causal factor chart.
Although we read the chart from left to right, it
is developed from right to left (backwards).
Development always starts at the end because that
is always a known fact. Logic and time tests are
used to build the chart back to the beginning of
the event. Numerous questions are usually gener-
ated that identify additional necessary data.
After the causal factor chart was complete (addi-
tional data were gathered to answer the questions
shown in Figure 1), the analysts identified the fac-
tors that influenced the course of events. There are
four causal factors for this event (see Table 1).
Elimination of these causal factors would have
either prevented the occurrence or reduced its sever-
ity. Note the recommendations in Table 1 are written
as if Mary’s house were an industrial facility.
Notice that causal factor two may be unexpect-
ed. It wasn’t overheating of the oil or splattering of
the oil that ignited the fire. If the wrong causal fac-
tor is identified, the wrong corrective actions will
be developed.
The application of the technique identified that
the electric burner element failed by shorting out.
The short melted Mary’s aluminum pan, releasing
the oil onto the hot burner, starting the fire.
The analyst must be willing to probe the data
first to determine what happened during the occur-
rence, second to describe how it happened, and
third to understand why.
Root Cause Analysis Handbook, WSRC-IM-91-3, Department of
Energy, 1991 (and earlier versions).
Root Cause Analysis Handbook: A Guide to Effective
Investigation, ABSG Consulting Inc., 1999.
User’s Guide for Reactor Incident Root Cause Coding Tree, revi-
sion five, DPST-87-209, E.I. duPont de Nemours, Savan-
nah River Laboratory, 1986.
JAMES J. ROONEY is a senior risk and reliability engineer
with ABSG Consulting Inc.’s Risk Consulting Division in
Knoxville, TN. He earned a master’s degree in nuclear engi-
neering from the University of Tennessee. Rooney is a Fellow
of ASQ and an ASQ certified quality auditor, quality audi-
tor-hazard analysis and critical control points, quality engi-
neer, quality improvement associate, quality manager and
reliability engineer.
LEE N. VANDEN HEUVEL is a senior risk and reliability
engineer with ABSG Consulting Inc.’s Risk Consulting
Division in Knoxville, TN. He earned a master’s degree in
nuclear engineering from the University of Wisconsin.
Vanden Heuvel co-authored the Root Cause Analysis
Handbook: A Guide to Effective Incident Investiga-
tion, co-developed the RootCause Leader software and was
a co-author of the Center for Chemical Process Safety’s
Guidelines for Investigating Chemical Process
Incidents. He develops and teaches courses on the subject.

BIBLIOGRAPHY

Accident/Incident Investigation Manual, second edition,

DOE/SSDC 76-45/27, Department of Energy.
Events and Causal Factors Charting, DOE/SSDC 76-45/14,
Department of Energy, 1985.
Ferry, Ted S., Modern Accident Investigation and Analysis, sec- Please
ond edition, John Wiley and Sons, 1988. comment
Guidelines for Investigating Chemical Process Incidents,
If you would like to comment on this article,
American Institute of Chemical Engineers, Center for
please post your remarks on the Quality Progress
Chemical Process Safety, 1992.
Discussion Board at www.asq.org, or e-mail them
Occupational Safety and Health Administration Accident
to editor@asq.org.
Investigation Course, Office of Training and Education, 1993.

QUALITY PROGRESS I JULY 2004 I 53