ROOT CAUSE ANALYSIS –

TOOLS AND PROCESS

CHARLES COTTER

15-16 MAY 2014

 TRAINING PROGRAMME
OVERVIEW
• Defining the fundamental concepts

• Building a Business Case for RCA

• 10 General Principles of RCA

• 3 Basic types of causes

• Foremost RCA tools and techniques

• The 5-step RCA process

INTRODUCTION
 DEFINING THE FUNDAMENTAL
CONCEPTS

• Root cause

• Root Cause Analysis (RCA)

• Problem-solving

• 8-D Problem-solving process

TYPES OF SOLUTIONS
• Mop-It (Temporary)

• Stop-It (Permanent/Sustainable)
 DEFINING ROOT CAUSE
ANALYSIS (RCA)
• RCA is a useful process for understanding and solving a problem. RCA is a
systematic process for identifying “root causes” of problems or events and an
approach for responding to them.

• Wilson et al. (1993) have defined the Root Cause Analysis (RCA) as an analytic
tool that can be used to perform a comprehensive, system-based review of
critical incidents.

• It includes the identification of the root and contributory factors,

determination of risk reduction strategies and development of action plans
along with measurement strategies to evaluate the effectiveness of the plans.

• RCA is based on the basic idea that effective management requires more than
merely “putting out fires” for problems that develop, but finding a way to
prevent them.

• Essentially, RCA means finding the specific source(s) that created the problem
so that effective action can be taken to prevent recurrence of the situation.
8-D PROBLEM-SOLVING PROCESS
BUILDING A BUSINESS CASE FOR
RCA
• Purpose of RCA

• Goals of RCA

• Benefits of RCA

• Utility value and functionality of RCA

 BENEFITS OF RCA
• Identify barriers and the causes of problems, so that
permanent solutions can be found

• Develop a logical approach to problem-solving, using

data that already exists in the organization

• Identify current and future needs for organizational

improvement

• Establish repeatable, step-by-step processes, in which

one process can confirm the results of another
 10 GENERAL PRINCIPLES OF RCA
• RCA is a diagnostic and analytical tool

• Effective RCA is a systematic process

• Effective implementation of RCA requires a fundamental

shift in attitudes and mindset

• RCA requires supportive organizational and

management cultures

• Persistence and sustainability in the RCA effort

 10 GENERAL PRINCIPLES OF RCA
• RCA is an efficient and economical process

• Effective problem statements and event descriptions are

helpful, or even required

• RCA can help transform a reactive culture into a forward-

looking culture and it also reduces the frequency of
problems occurring over time within the environment

• RCA requires a collaborative, multidisciplinary team effort

• The focal points of RCA are corrective measures of root

causes and not simply treating the symptoms of a problem or
event
The focus of investigation and analysis through
problem identification is WHY the event
occurred, and not who made the error i.e.

“Hard on the problem, soft on the person.”

BEST PRACTICE RCA
(COMPETENCE)

CONTENT

PROCESS CONTEXT
 THREE BASIC TYPES OF CAUSES

• Physical

• Human

• Latent/Organizational
FOREMOST RCA TOOLS AND
TECHNIQUES
 FOREMOST RCA TOOLS AND
TECHNIQUES
• Brainstorming

• Cause Effect Analysis/Fishbone Diagram

• Fault Tree Analysis/Diagram

• 5-Why Analysis

• Force-field Analysis

• Failure Modes and Effects Analysis (FMEA)

CAUSE EFFECT/FISHBONE
DIAGRAM
FAULT TREE ANALYSIS/DIAGRAM
 FTA PROCESS
• Step 1: Define the fault condition, and write down the top level
failure.

• Step 2: Using technical information and professional judgments,

determine the possible reasons for the failure to occur.

• Step 3: Continue to break down each element with additional

gates to lower levels. Consider the relationships between the
elements to help you decide whether to use an "and" or an "or"
logic gate.

• Step 4: Finalize and review the complete diagram. The chain can
only be terminated in a basic fault: human, hardware or software.

• Step 5: If possible, evaluate the probability of occurrence for each

of the lowest level elements and calculate the statistical
probabilities from the bottom up.
SUMMARY OF FTA SYMBOLS
5-WHY ANALYSIS
 5-STEP DMAIC RCA PROCESS
• Step 1: Define (What problem needs to be solved?)

• Step 2: Measure (collect data and evidence to determine

the scope and magnitude of the problem)

• Step 3: Analyze (Identify and classify the root cause/s of

the problem)

• Step 4: Improve (What are the countermeasures/solution

to solve the problem?)

• Step 5: Control (Evaluate the effectiveness, impact and

sustainability of the implemented solution)
DMAIC RCA PROCESS
(ILLUSTRATION)
 STEP 1: DEFINE
• Objective: Identify and define the problem

• Specify the nature, the magnitude, the location/s and the

timing of events

• Use integrated methodology (quantitative and qualitative

techniques)

 Brainstorming

 Fishbone Diagram or FTA Diagram

• Outcome: Definition of a well-formulated Problem Statement

 STEP 2: MEASURE
• Objective: Through the collection of data and evidence,
the determination of the scope and significance of the
problem

• Preferred tools:

 CATWOE or Situational Analysis

 Application of Quantitative and Qualitative data collection

methods

• Outcome: Development of a Scope-Significance Matrix

and an in-depth understanding of the problem
CATWOE ANALYSIS
SCOPE-SIGNIFICANCE MATRIX

High Scope- Low

High Scope-High
Significance
Significance(HIGH
(MODERATE
PRIORITY)
PRIORITY)

Low Scope-High
Low Scope-Low
Significance
Significance (LOW
(MODERATE
PRIORITY)
PRIORITY)
 DATA COLLECTION METHODS
AND SOURCES OF DATA
• The two (2) categories of data collection methods:

 Quantitative – numeric e.g. statistics

 Qualitative – subjective e.g. surveys and focus groups

• The predominant sources of data:

 Electronic
 Documentary
 Experimental
 Human
 DATA COLLECTION PROCESS
• Step 1: Develop a Data Collection plan/strategy

• Step 2: Data Collection

• Step 3: Data Collation

• Step 4: Data Analysis

• Step 5: Data Interpretation

• Step 6: Data Verification

• Step 7: Publication
 STEP 3: ANALYZE
• Objective: To identify the root cause/s of the problem

• Preferred tool:

• 5-Why Analysis

• Outcome: Identification and classification of the

underlying cause that must be addressed to
alleviate/remedy the problem
5-WHY ANALYSIS TEMPLATE
 STEP 4: IMPLEMENT
• Identify countermeasures/solutions for the problem (by means of
creative and analytical thinking)

• Evaluate the proposed solutions (by means of a Decision Matrix)

focused on the following criteria:

 Viability
 Feasibility
 Sustainability

• Apply Risk Mitigation techniques:

 FMEA
 Impact Analysis
 Force-field Analysis

• Implement the solution (by means of an Action Plan)

FORCE-FIELD ANALYSIS
IMPLEMENTATION ACTION PLAN
TEMPLATE
 STEP 5: CONTROL
• Objective: Evaluate the effectiveness, impact and
sustainability of the implemented solution

• Management tools:

 Observe
 Monitor
 Evaluate
 Review
 Amend
 CONCLUSION

• Key points

• Summary

• Questions
 CONTACT DETAILS

• Charles Cotter

• (+27) 84 562 9446

• charlescot@polka.co.za

• LinkedIn

• Twitter: Charles_Cotter