Root Cause Analysis: Why? Why? Why?

William A. Lindley April 6, 2001

Why Do Root Cause Analysis?

Just fix it, there is too much to do. We dont have time to think, we need results now.

Reality - fix symptoms without regard to actual causes Root Cause Analysis - structured and thorough review of problem designed to identify and verify what is causing the symptoms

Definitions
Cause (causal factor): a condition or event that results in an effect Direct Cause: cause that directly resulted in the occurrence Contributing Cause: a cause that contributed to the occurrence, but by itself would not have caused the occurrence Root Cause: cause that, if corrected, would prevent recurrence of this and similar occurrences

How Is Root Cause Analysis Done?

Teams identify all possible causes

The actual root causes are identified and verified

Corrective action(s) are identified to reduce or eliminate the problem

RCA Process
Relationship between cause and effect

Need for creative thought to identify all possible causes Collect data about the problem Analyze data Verify causes

Root Cause Tools

Cause and Effect Diagram Scatter Diagram - prove cause-effect relationship Control Chart - process stable? Five Whys Tree Diagram Change Analysis Barrier Analysis Event and Causal Factor Analysis Management Oversight & Risk Tree Analysis (MORT)

Cause Effect Diagram

Visual display of possible causes Cause categories include materials, machines, methods, and people Reveals gaps in existing knowledge Helps team reach common understanding of why loss exists

Cause Effect Diagram

Procedures People

Problem

Equipment

Materials

Cause Effect Diagram

Danger:
The Cause Effect Diagram is a list of potential root causes. This includes both probable causes, real causes and guesses.

After The Cause Effect Diagram

Identify likely candidates for root cause(s) by one of the following actions:
Look for causes that appear repeatedly within or across major cause or process categories Look for changes or other sources of variation in the process or environment Use consensus decision-making to select Collect data to confirm a potential root cause as real

Scatter Diagram
Test for possible cause and effect relationships Some variation should be expected Relationships being tested must be logical Visual depiction of relationship

Patterns of Correlation

Quality Improvement Tools Juran Institute, 1989

Correlation Coefficients

Quality Improvement Tools Juran Institute, 1989

Scatter Diagram
70

Relationship Between Time to Admit from ER and Cases Entering ER/Hour

60

50

Minutes

40

Data shows strong positive correlation.

30

20

10

0 0 5 10 15 20 25

Cases/Hour

Statistical Process Control

Process Variation - Common Cause & Special Cause Is the process stable? Points outside LCL/UCL warrant investigation Alert for problems

Five Whys
Describe the problem in specific terms For each likely cause ask, Why did this happen? Continue for a minimum of five times Show logical relationship of each response to the one that preceded it Stop when the team has enough information to identify the root cause

Tree Diagram
State the problem Causes are listed as branches to the right of the problem Continue to clarify causes, drawing additional branches to the right Repeat until each branch reaches its logical end

Tree Diagram Example

Too much work Not enough students signed up No reward Schedule not communicated No time to learn New trainer assigned late Turnover Flexibility Materials not completed Late changes Changes up to class date

Training Class Cancelled

Trainer not prepared

Current

Floating due date Training Dept other projects This projectlow priority

More info needed

Cautionary Note
Its impossible to solve significant problems using the same level of knowledge that created them!
Albert Einstein

Cautionary Note - Part 2

Cause and effect analysis cant get past existing knowledge - must have either observed (or considered) that the cause produced the effect in the past

Why not just ask Why?

Need to systematically organize and analyze data First understand What happened then Why Typically multiple root causes Blame is an obstacle Guidance needed to investigate human performance problems Need to ask right questions to completely understand why Some RCA techniques may provide easy answers that are either incomplete or wrong (but easy to find)

Event and Causal Factor Analysis

Used for multi-faceted problems or long, complex causal factor chains Cause effect diagram that describes time sequence Anything that shapes the outcome recorded Identifies what questions to ask to follow path to root cause

Event and Causal Factor Analysis

Condition
Condition Condition Condition Condition
Conditions that may exist, but not identified

Condition

Condition Condition
Found or existing state that influences outcome

Event

Event

Potential Event

Event
Sequence of happenings

Events and Causal Factor Chart

Events Actions that lead to incident

Incident Reason for investigation

Person walks to car

Person steps in hole in parking lot

Person sprains ankle

Person treated at ER

CF Leaves work late (after dark) No barricades or markings for hole CF

Usual parking spot in company lot

Parking lot lighting not working

Conditions or Causal Factors Amplifying information explaining the event

Change Analysis
Used when problem is obscure Generally used for single occurrence Focuses on things that have changed Compares trouble-free process with occurrence to identify differences Differences evaluated for contribution to occurrence

Change Analysis Steps

Occurrence with

undesirable consequence

5
Analyze differences for effect on undesired consequences

Compare

Identify differences

Comparable activity without undesired result

Integrate information relevant to the causes of undesired consequence

Change Analysis Steps

Answer the following:
What? When? Where? How? Who?

Barrier Analysis
Systematic process to identify barriers or controls that could have prevented the occurrence
> Physical > Administrative > Procedural

Determine why these barriers or controls failed What is needed to prevent reoccurrence

Barrier Analysis
Sequence of events:
System Tagout Tag Hung Electricians Given Assignment Electricians Follow Procedure Reactor Trip

Barriers Analysis
Start Tagout Tagout Process Process Step 1 Step 2 Communications Process Interface Procedure Occurrence

Barrier Barrier Holds Holds

Barrier Holds

Barrier Fails

Barrier Fails

Barrier Fails

Management Oversight and Risk Tree (MORT)

Used to prevent oversight in the identification of causal factors Specific factors listed Management factors that permit these factors to exist listed Questions for each factor on the tree are included