Lesson 5: Root Cause Analysis (RCA)

A root cause is the most reasonably identified basic causal factor or factors, which, when
corrected or removed, will prevent ( or significantly reduce) the recurrence of a situation,
such as an error in performing a procedure. It is also the earliest point where you can take
action that will reduce the chance of the incident happening.
RCA is an objective, structured approach to identify the most likely underlying causes of a
problem or undesired events within an organization.
Steps for Performing RCA:
1. Define the problem.
2. Identify the contributing factors.
3. Identify the root cause(s).
4. Formulate and implement corrective actions to eliminate the root cause(s).

Benefits of RCA
RCA benefits the organization by identifying cause(s) of an issue. This approach
provides a long term perspective for the improvement of business/control processes.
Without the performance of an effective RCA and the appropriate remediation activities, an
issue may have a higher probability to re-occur.

Required Auditor Skills for RCA

1. Collaboration
2. Communication
3. Business Acumen (strong understanding of business situations)
4. Critical Thinking
5. Creative Problem Solving

RCA Fieldwork Tools and Techniques

Simple techniques such as inquiry and observation are useful for determining the root
cause in many of the issues to be analyzed.
Types:
1. Ishikawa Diagram
The Ishikawa Diagram, also known as the Fishbone Diagram or the Cause-and-Effect
Diagram, is a tool used for systematically identifying and presenting all the possible causes
of a particular problem in graphical format. The possible causes are presented at various
levels of detail in connected branches, with the level of detail increasing as the branch
goes outward, i.e., an outer branch is a cause of the inner branch it is attached to. Thus,
the outermost branches usually indicate the root causes of the problem.
The Ishikawa Diagram resembles a fishbone (hence the alternative name "Fishbone
Diagram") - it has a box (the 'fish head') that contains the statement of the problem at one
end of the diagram. From this box originates the main branch (the 'fish spine') of the
diagram. Sticking out of this main branch are major branches that categorize the causes
according to their nature.
The 4M’s (Machine, Manpower, Methods, and Materials) in Ishikawa Diagram
Manpower (huMan) (Skill, Technology, Organization, Resources)
Do our associates have the skill (and the will) to do what is expected of them safely,
consistently and effectively?
Machine (Equipment)
Are our machines capable of safe and reliable output at the desired quality and rate?
Do breakdowns, defects or unplanned stoppages inhibit their ability to meet that goal?
Method (Process, Schedule, Procedure)
Do we have standard work methods in place which ensure and support consistent,
safe production?
Material (Information, Raw Materials, Consumables, Quality)
Do they meet the required specifications – are there no defects and shortages? Is
excess handling or movement reduced or eliminated? Are they stored appropriately?
Exploring these 4Ms provides us with a structured framework for root cause analysis by
helping us to understand how each one may have contributed to a particular issue.
The Ishikawa diagram uses the “ five-whys” technique in conjunction with the fishbone
diagram. Ask “why” five times about every matter.
1. Agree on the problem statement ( also referred to as the effect). Written at the mouth
of the fish.
2. Agree on the major categories of causes of the problem. Written as branches from the
main row.
3. Brainstorm all the possible causes of the problem. Ask”why does this happen?” Write
it as a branch from the appropriate category.