Root Cause

Analysis
Definitions and Challenges
 Table of Contents
Definition of Root Cause Analysis …………………………………………... 3

How to Complete a Root Cause Analysis………………………………… 7

Types of Root Cause Analysis…………………………………………………… 13

Challenges with Root Cause Analysis …………………………………… 24

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 Introduction

Definition of Root Cause Analysis

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 The ASQ defines a root cause as “a factor that caused a nonconformance
and should be permanently eliminated through process improvement.”
However, a root cause isn’t just any contributing factor. The root cause
needs to be an underlying cause so that the person identifying the source of
the problem can prevent it from occurring. Furthermore, the root cause
needs to be identifiable.

If a root cause analysis isn’t turning up a true root cause to the problem, the
analyst should consider leveraging another analytical tool to solve the
problem. The root cause also needs to be within management’s control to
fix. For example, if a change to trade policy resulted in a drop in the only
source of a specific material, that is out of management’s control. They don’t
set government policy! Finally, in order to be a root cause, the issue needs to
have a solution that will prevent recurring issues. If it won’t prevent
recurrences, there’s likely a causal issue versus a root cause to solve.

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 Root cause analysis (RCA) is a tool process engineers in manufacturing, and
other folks across industries can use to identify what, how or why the
precipitating event occurred.

This approach to problem solving is usually used when the consequence

involves a “safety, health, environmental, quality, reliability, or production
impact”.

Identifying the underlying cause of the problem, or root cause, empowers

the analyst to identify a solution to the problem. These solutions vary, and
can include process change or other remedies. Unlike leading indicator
based analysis, root cause analysis is a reaction to an existing or historical
problem. The goal it to prevent it from happening again in the future.

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 CHAPTER 2

How to Complete a Root Cause Analysis

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 Before you can complete a root cause analysis, you must collect as much
data as possible about the events and people involved in the lead up. If
you’re getting testimony to recreate events, it’s important that you get this
information as soon as possible. People can be unreliable and their
memories are vulnerable to suggestion, especially after time has passed.

The next steps you should take to complete a root cause analysis, or
method, will depend on your approach. There are 5 popular approaches to
root cause analysis:

• Events and causal factor analysis

• Change analysis
• Barrier analysis
• Risk tree analysis
• Kepner-Tregoe problem solving

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 Causal factor analysis requires identifying all of the contributing events that
led to the problem. Avoid the pitfall of focusing on the most obvious, final
contributors. One of the ways to delve into all of the causes is by leveraging
the “5 Whys”. The 5 Whys is “an iterative interrogative technique used to
explore the cause-and-effect relationships underlying a particular problem.”

For example, imagine your cost of scrap increased over the last quarter. If
you were creating a causal factor analysis for increase, you might focus on
the most obvious cause. What changed during that time period? The answer
might be that a specific line is producing more scrap. If you ask again–why is
that line generating more scrap?–you might uncover that there has been
significant operator turnover over the last period. Ask why again and you
could learn that a few of your experienced operators retired.

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 Continue this process long enough and you learn a lot more contributing
factors to the increase in scrap that provide more detail than “there was an
increase in scrap”. This line of logical questioning is called the “5 Whys”
because 5 is a number of times someone can benchmark their questioning
against. Using the 5 Whys can help you identify the causal factors that
contributed to the problem you would like to prevent in the future.

For basic challenges, the 5 Whys themselves can be enough to get to the
root cause of the problem. In the non-technical example provided above, a
clear solution to the problem would be to replace the latch so the gate closes
without needing a brick to hold it closed.

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11
 With more sophisticated problems, the 5 Whys might not be enough to
solve the root of the issue. Let’s add some color to the example above. What
happens if you factor in that the plant waited to hire new team members
until a week before the experienced operators retired? What if new
operators usually had a couple months of training before having that same
level of responsibility?

It’s not just the operators that caused the problem. There was a series of
causal factors that influenced the poor performance.

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 CHAPTER 3

Types of Root Cause Analysis

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14
 Before you can complete a root cause analysis, you must collect as much
data as possible about the events and people involved in the lead up. If
you’re getting testimony to recreate events, it’s important that you get this
information as soon as possible. People can be unreliable and their
memories are vulnerable to suggestion, especially after time has passed.

The next steps you should take to complete a root cause analysis, or
method, will depend on your approach. There are 5 popular approaches to
root cause analysis:

• Events and causal factor analysis

• Change analysis
• Barrier analysis
• Risk tree analysis
• Kepner-Tregoe problem solving

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 What is Change Analysis?
Change Analysis is a root cause analysis technique that focuses on a
specific problem or problematic event. This type of analysis seeks to
expose which deviation from regular procedure, or change, drove the
unfavorable event. This is the type of analysis manufacturing folks typically
think of when discussing change analysis.

Change analysis is easy to learn and apply. Looking for a deviation from a
norm also results in a clear corrective action. This provides concrete next
steps for anyone conducting the analysis. Furthermore, it makes it easier to
detect unusual root causes.

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 Consider applying a different type of root cause analysis if your standard
process isn’t well defined enough to provide a good basis for comparison.
Also, depending on how variable your processes are, the number of
moving parts might significantly increase the scope of this type of analysis.

Whether you decide to apply this type of analysis or another form of root
cause analysis, make sure to test your assumptions. In the worst case
scenario, you’ll determine that your hypothesis is inconclusive or fail to find
an actual root cause. This result, while unpleasant, is better than drawing
an incorrect conclusion that causes additional issues in the future.

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 What is Barrier Analysis?
Barrier analysis is a systematic process used to identify failures of physical,
administrative, and procedural barriers that should have prevented the
adverse event. This analysis identifies why the barriers failed and
determines which types of corrective action are needed to prevent it from
failing again in the future.

Start your barrier analysis by identifying all of the barriers that were in
place before the adverse event occurred. Review each barrier to determine
if it was functioning under normal operating conditions. If there was a
deviation in operating conditions, was it performing its intended function
under these conditions? Did the barrier help decrease the total cost of the
adverse event? Was the barrier’s design strong enough to fulfill its
intended purpose? Finally, review whether it was built, maintained, and
inspected appropriately leading up to the event.

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 Use these questions with each barrier to identify how the barriers failed to
prevent the event. Note that this may not be the best type of root cause
analysis depending on what you are investigating and the state of the
existing process or set up leading up to your event.

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 What is Risk Tree Analysis?
Risk tree analysis, like the previous two analyses we’ve reviewed, is used
to analyze the effects of a failed system after an adverse event has
occurred. Event trees were developed during the WASH-1400 nuclear
power plant safety study in 1974. Fault tree analysis under certain
circumstances become large and unruly. The event tree was developed to
help identify which pathway creates the most significant risk for a failure in
a system without requiring each path to be mapped out in the tree.

The risk tree analysis has a few benefits. First, it helps you identify multiple
coexisting contributors to failure. This provides multiple layers of detail. On
the flip side, the amount of detail available in this analysis can make it easy
to overlook subtle differences between branches. Also, this is a more
complex form of root cause analysis. The person conducting the analysis
needs training and some experience to ensure success.

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 Use these questions with each barrier to identify how the barriers failed to
prevent the event. Note that this may not be the best type of root cause
analysis depending on what you are investigating and the state of the
existing process or set up leading up to your event.

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 What is the Kepner-Tregoe method?
The Kepner-Tregoe method of root cause analysis became famous when
NASA used it to bring the Apollo 13 team home. It’s a structured
methodology for gathering, prioritizing, and evaluating information. Like
other forms of root cause analysis, the Kepner-Tregoe method is a
systematic approach to solving a problem and analyzing risk.

The first step in this methodology is to identify problems and classify them
by level of concern. Then, set the priority level by potential impact,
urgency, and growth. Next, decide what action to take or which step to
take next. Finally, make a plan for who will be involved, what they will do,
where they’re involved, and when they take part. Be sure to scope the
extent of each person’s involvement.

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 The next step to applying this analysis is to determine which objectives
must be accomplished, as well as which ones you want to accomplish that
aren’t absolutely necessary. This will help you evaluate your options
against your objectives so you can determine the best possible choice of
action.

The key benefit of the Kepner-Tregoe analysis is the ability to prioritize and
focus the analysis. By weighing and setting objectives, this type of analysis
provides a more direct review of an issue.

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 CHAPTER 4

Challenges with Root Cause Analysis

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 What is a Causal Factor vs a Root Cause
One challenge when conducting a root cause analysis is ensuring you are
identifying root causes rather than causal factors. A causal factor is any
behavior, omission, or deficiency that, if corrected, eliminated, or avoided,
probably would have prevented the event. A root cause is a factor that if
eliminated would definitely prevent recurrence.

Root cause analysis purists focus on identifying a root cause over a causal
factor. However, many of the processes where root cause analysis is
applied generate adverse events because of human error. Removing a
specific manifestation of the error doesn’t necessarily highlight how the
type of mistake can be repeated. Ultimately this specific focus can ignore a
systematic error.

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 Data Integrity
The most basic requirement for root cause analysis is data. Collecting as
much data as possible throughout the process you are examining will
improve the quality and efficiency of the root cause analysis. However, this
is another focus for root cause analysis critics. Oftentimes data collection
about the precipitating event begins after the event. It also requires
multiple testimonies and interviews. This qualitative data collection can be
unreliable, especially if these interviews need to occur days, weeks, or
even months after the event.

Easy vs Lasting Solutions

Unfortunately, solutions to these events can be complex. Instead of
removing a piece from an existing process, the best solution may be a
complete redesign, new technology implementation, or other large scale
adjustment. Even when necessary, administrators, managers, and leaders
tend to look for quick and easy solutions.
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 Prioritizing a solution that doesn’t solve the problem in the long term, while
easier, can lead to event recurrence.

Avoiding Blame
If the root cause analysis is seen as a quest to identify culpability, you
might be in trouble. The data collection process could be compromised if
the root cause analysis looks like a way of finding someone to blame for
the event. Balance identifying who is at fault with whatever system
produced the unintended result. It’s unlikely a single person created the
issue in malice. However, if this were the case, accountability for the
individual and organization would be necessary.

Groupthink
Proponents of root cause analysis often encourage groups to collaborate
and brainstorm during the process.

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 However, some critics argue that this promotes groupthink and stifles
creative approaches and analyses. If you’re building an RCA team, include
team members from different groups and functional areas to promote
fruitful collaboration.

Tools to Overcome Challenges & Apply Root Cause Analysis

Companies use tools like Tulip to collect data from their people, processes,
and machines in real-time. This empowers them to conduct root cause
analysis after smaller events and enables faster, and more efficient
improvement to these processes. Furthermore, precise data on operators,
machines, and changes to procedures makes it easier to avoid the
challenges to root cause analysis highlighted above.

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 Tulip, the Manufacturing App Platform, is empowering the world’s leading
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Learn more and try Tulip risk-free for 30 days at tulip.co.