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

Minutes

50

Data shows strong positive

correlation.

40

30

20

10

0
0

10

15

Cases/Hour

20

25

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

Training
Class
Cancelled

Trainer not
prepared

New trainer assigned late

No time
to learn
Turnover
Flexibility

Materials not
completed

Late changes

Changes up
to class date

Floating due date

Training Dept other projects

This projectlow priority

More info needed

Current

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

Incident
Reason for investigation

Events
Actions that lead
to incident
Person
steps in hole
in parking
lot

Person
walks to car

Person
treated at
ER

Person
sprains
ankle

CF
Leaves work late
(after dark)

Usual parking
spot in company
lot

No barricades or
markings for hole

Parking lot
lighting
not working

Conditions or Causal Factors

Amplifying information explaining
the event

CF

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

4
3

Compare

Comparable activity
without undesired
result

Identify
differences

5
Analyze differences for
effect on undesired
consequences

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

Procedure

Occurrence

Barriers Analysis
Start

Tagout Tagout
Process Process
Step 1 Step 2

Barrier Barrier
Holds Holds

Barrier
Holds

Communications
Process
Interface
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