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Prepared By:


Subject Instructor
The concept and methodology of root cause
analysis (RCA) are designed to provide a
cost-effective means to isolate all factors
that directly or indirectly result in the myriad
of problems that we face in our plants and
This process is not limited to equipment or
system failures; but can be effectively used to
resolve any problem that has serious,
negative impact on effective management,
operation, maintenance, and support of our
plants and facilities.

It has the capability to identify initial
problems; isolate the actual cause or forcing
function that directly resulted in the problem,
as well as identifies all factors that directly or
indirectly contributed to the problem.

Uses 10 steps to proceed from problem
identification to resolution in a fashion that
fosters learning, collaboration, and personal

Toyota motor corporation is famed for its
ability to relentlessly improve operational
performance. Toyota uses the A3
The term A3 derives from the paper size used
for the report, which is a metric equivalent to
11 x 17 (or B-sized) paper.

Toyota uses A3 reports for solving
problems, reporting project states, and for
proposing policy changes.
Most problems that arise in organizations are
addressed in superficial ways, what some call
first-order problem-solving
That is, we work around the problem to
accomplish our immediate objective, but do not
address the root causes of the problem so as to
prevent its recurrence.
By not addressing the root cause, we encounter
the same problem or same type of problem
again and again, and operational performance
does not improve.
This helps people engage in collaborative, in-
depth problem solving.

It drives problem solver to address the root
causes of problems.

Can be used for almost any situation.

Whenever the way work happens is not ideal, or
when a goal or objective is not being met, you
have a problem, or, if you prefer, a need.

The preferred source of problem identification is
statistical analysis that tracks the actual versus
design performance of the plant and all of its
functions, for example, sales, production,
procurement, maintenance, and so on.
Observe the work process first hand, and document
ones observation.
Create a diagram that shows how the work is
currently done. Any number of formal process
charting or mapping tools can be used, but often
simple stick figures and arrows .
Quantify the magnitude of the problem.
ex: percentage of customers deliveries that are late,
number of stocks out in a month, number of errors
reported per quarter, percentage of work time,
represented in data graphically

There are multiple diagnostic and analysis
tools that can be used to conduct the RCA.
The guidelines provided will help the
investigator select the most effective tool or
tools for each classification of problem that
will be encountered.

Ex. 5 Whys as a tool for analysis
Countermeasures are the changes to be made to the work
processes that will move the organization closer to ideal,
or make the process more efficient, by addressing root

Recommended countermeasures help the process
conform to three rules:
Specify the outcome, content, sequence, and task of work
Create clear, direct connections between requestors and suppliers
of goods and services.
Eliminate loops, workarounds, and delays.
The countermeasure(s) addressing the root cause(s)
of the problem will lead to new ways of getting the
work done, what is called the target condition or
target state.
It describes how the work will get done with the
proposed countermeasures in place.
In the A3 report, the target condition should be a
diagram, similar to the current condition that
illustrates how the new proposed process will work.
The specific countermeasures should be noted or
listed, and the expected improvement should be
predicted specifically and quantitatively.
In order to reach the target state, one needs a
well thought-out and workable
implementation plan.
The implementation plan should include a list
of the actions that need to be done to get the
countermeasures in place and realize the
target condition, along with the individual
responsible for each task and a due date.
Other relevant items, such as cost, may also
be added.
A critical step in the learning process of
problem-solvers is to verify whether they truly
understood the current condition well enough to
improve it.
Therefore, a follow-up plan becomes a critical
step in process improvement to make sure the
implementation plan was executed, the target
condition realized, and the expected results
You can state the predicted outcome here rather
than in the target condition, if you prefer.
Its vitally important to communicate with all parties
affected by the implementation or target condition,
and try to build consensus throughout the process.
Concerns raised should be addressed insomuch as
possible, and this may involve studying the problem
further or reworking the countermeasures, target
condition, or implementation plan.
The goal is to have everyone affected by the change
aware of it and, ideally, in agreement that the
organization is best served by the change.
If the person conducting the A3 process is not a
manager, it is imperative to remember the
importance of obtaining approval from an
authority figure to carry out the proposed plan.
The authority figure should verify that the
problem has been sufficiently studied and that
all affected parties are within board with the
The authority figure may then approve the
change and allow implementation.
Without implantation, no change occurs.

The next step is to execute the
implementation plan.
Process improvement should not end with
It is very important to measure the actual
results and compare to predict.
If the actual results differ from the predicted
ones, research needs to be conducted to
figure out why, modify the process and
repeat implementation and follow-up (i.e.,
repeat the A3 process) until the goal is met.
Steps in Form Use
Use of the A3 format should begin as soon as the potential
need for RCA is identified.

Business Case. This section should be used to
clearly and concisely define the problem that
is to be investigated.

This definition will define, as well as the
business case , for example, cost benefit
analysis will be complete after the
investigation is complete.
Current Conditions. This section includes a
concise definition of the current conditions
surrounding or as a result of the problem to
be investigated.

The use of graphs, charts, and other
illustrations should be used to clearly convey
the message.

Target Conditions. This section defines the
resultant of the proposed corrective actions
identified by the RCA.

The use of graphs, charts, and other
illustrative materials will permit the inclusion
of much more data as well as provide a more
professional report.

Action Plan. This section is your
management tool during the RCA and
become your next steps following
management approval to implement the
corrective actions.

The use of a Gantt, Pert, or other types of
project schedules or timelines is ideal for this
section. Timelines can be created in MS Visio
and inserted directly into this section.
Metrics. This section should be used to define
the specific return on investment (ROI) or
change that is expected from the
recommended changes.

It should include both the actual values that
represent the change and the source of the
data that will be used.
Root cause analysis takes many forms.
It can range from:
Simple visual inspection of failed parts to a
comprehensive process designed to identify;
quantify the impact of;
develop cost-effective solutions;
and implementation of corrective actions for
complex capacity, quality, cost, and reliability
RCA is a systematic process that is based on
factual data that is free of prejudice,
opinions, or political pressure.

It is a logical, practical process that can be
used by anyone who is willing to follow it.

Many of the equipment-related problems that
plague industrial plants and facilities can be
resolved by visual inspection of the failed parts.

For example, premature failure of rolling
element bearings is a common problem in most
plants and facilities. Too many plants simply
replace the bearing and throw the failed bearing
in the nearest trash bin. This approach does little
to eliminate the real reason that the bearing
failed and there is a high probability that the
failure will recur.
A simple, visual inspection of the failed
bearing, in most cases, will permit plant
personnel to identify the underlying reason,
that is, root cause, of the premature failure.
As its name implies, this simple root cause
tool is an interview process that works best in
a cross-functional group of personnel who
have direct knowledge of the problem that is
being investigated.
The process should be repeated as often as
necessary to arrive at the true root cause of
the problem that is being investigated.
Why is Module A failing to meet it production goals?
Answer: Were forced to use relief operators most of the time?

Why are you forced to use relief operators?
Answer: The regular operators have been in training for the past month?

Why are the regular operators in training?
Answer: Its mandated training and everyone has to attend before the end of
the year.?

Why are all operators being trained at the same time?
Answer: Thats how it was scheduled.?

Why was it scheduled that way?
Answer: We were really being pushed earlier in the year and management
decided to postpone training until demand dropped?

What is the root cause of the problem? The
forcing function was managements decision
to wait on mandated training until it was too
late to do it efficiently, but is that the real
root cause?
How would you correct this problem
remember the objective is to prevent a
similar situation from reoccurring at some
point in the future.
In formal RCA, the investigating team will need input
from all plant personnel who may have direct or
indirect knowledge of the deviation, event, or
problem that is being investigated.

This information input activity may be limited to
interviews, either individually or in groups; but could
entail additional support gathering data, records, and
other pertinent information.

Obviously, the actual level of effort will depend on the
complexity of the problem and the team? ability to
determine the root cause or causes.
The purpose of RCA is to resolve problems
that negatively impact safety, environmental
compliance, asset reliability, and plant
performance, not to fix blame.

Fixing Blame = this approach results in lost
morale and will condition the workforce to
withhold information that is critical to root
cause process and effective plant operation
and maintenance.
Root cause analysis cannot be performed
sitting in a conference room, office, or in
front of a computer.
While the RCA process does require working
group meetings, as well as individual and
group interviews, the heart of the process is
gathering factual data that can be used to
isolate, identify, and quantify the real reason
or reasons that resulted in the abnormal
behavior that is being investigated.

The RCA process requires a hands-on process of
interviews, inspections, testing, and evaluations
that can only be done in the plant or field.
Theoretical evaluations have their place, but to
use the RCA process effectively, the
investigators must clearly understand the
operating dynamics of the investigated system,
confirm any and all factors, assumptions, or
hypotheses that may be offered
The number of people required is dependent
on the complexity of the specific event,
deviation, or failure that is being
In rare cases, the personnel required to
properly perform a RCA can be substantial;
but in most cases will require a three to four
person, multi-disciplined team.
Two primary sources of potential problems.

1. KPI key performance indicators and asset history
to detect deviations from normal conditions.

2. The second source for potential analysis is request
from one or more members of the plants workforce.

Therefore, any employee is expected to identify
problems or events that may warrant an analysis.
The investigator is seldom present when an
incident or problem occurs.
Therefore, the first step is the initial notification
that an incident or problem has taken place.
Typically, this report will be verbal, a brief
written note, or a notation in the production
In most cases, the communication will not
contain a complete description of the problem.
Rather, it will be a very brief description of the
perceived symptoms observed by the person
reporting the problem.
The most effective means of problem or
event definition is to determine its real
symptoms and establish limits that bound the
At this stage of the investigation, the task can
be accomplished by an interview with the
person who first observed the problem.
At this point, each person interviewed will have
a definite opinion about the incident, and will
have his or her description of the event and an
absolute reason for the occurrence.
Some perceptions are totally wrong, but they
cannot be discounted. Even though many of the
opinions expressed by the people involved with
or reporting an event may be invalid, do not
disregard them without any investigation.
The use of format that completely bounds
the potential problem or event greatly
reduces the level of effort required to
complete an analysis.

the investigator or team must first clarify the
problem with sufficient definition to:

(1) verify that a problem truly exists and

(2) that the severity of the problem warrants
an analysis.
1. What happened?
2. Where did it happen?
3. When did it happen?
4. What changed?
5. Who was involved?
6. Why did it happen?
7. What is the impact?
8. Will it happen again?
9. How can recurrence be prevented?
RCA should not be based on opinions or
Before starting an analysis, the investigators
must confirm that a problem truly exist and
that it warrants a formal investigation.
If a problem exists there should be a data in
the CMMS or other records keeping system
that supports it.
the first priority when investigating a problem,
deviation from acceptable norm or an event involving
equipment damage or failure is to preserve physical

If possible, the failed machine and its installed system
should be isolated from service until a full
investigation can be conducted.

Upon removal from service, the failed machine and all
of its components should be stored in a secure area
until they can be fully inspected and appropriate tests
If this approach is not practical, the scene of the
failure should be fully documented before the
machine is removed from its installation.

Photographs, sketches, and the instrumentation
and control settings should be fully documented
to ensure that all data are preserved for the
investigating team.

All automatic reports, such as those generated
by computer-monitoring and control system,
should be obtained and preserved.
1. Currently approved Standard Operating
(SOP) and Maintenance (SMP) Procedures for
the machine or area where the event
2. Company policies that govern activities
performed during the event
3. Operating and process data, such as strip
charts, computer output, and data-recorder

4. Appropriate maintenance records for the
machinery or area involved in the event
5. Copies of logbooks, work packages, work
orders, work permits, and maintenance
records; equipment-test results, quality-
control reports; oil and lubrication analysis
results; vibration signatures; and other
6. Diagrams, schematics, drawings, vendor
manuals, and technical specifications,
including pertinent design data for the
system or area involved in the incident
7. Training records, copies of training courses,
and other information that shows skill levels
of personnel involved in the event
8. Photographs, videotape, and/or diagram of
the incident scene
9. Broken hardware, such as ruptured
gaskets, burned leads, blown fuses, failed
bearings, etc.
10. Environmental conditions when the event
occurred. These data should be as complete
and accurate as possible

Copies of incident reports for similar prior
events and history/trend information for the
area involved in the current incident
Not all problems whether real or perceived
justify a formal RCA. Therefore, the clarified and
confirmed problem should be evaluated to
determine if its impact is sufficient to warrant
further investigation.
If the initial steps appear to justify a RCA, the
next step in the process is to perform a top-level
cost-benefit analysis.
The intent of this analysis is to verify that the
potential benefits generated by resolving the
reported problem are greater than the incurred
cost associated with the problem.
The incremental or elevated cost of repairing a
machine with a normal mean time between repair
(MTBR) of 12 months but with an actual MTBR of 3
months; the incremental cost is the difference
between the rebuild cost.
In this case, the pump is being rebuilt three times
more often than the norm and the incremental cost is
three times higher than norm.
If the cost-benefit analysis indicates that the reported
event or problem does not warrant further analysis,
the investigator should notify the person or persons
who initiated the request.
The objective of the design review is to
establish the specific operating
characteristics of the machine or production
system involved in the incident.

The data obtained from a design review
provide a baseline or reference, which is
needed to fully investigate and resolve plant
The evaluation should clearly define the
specific function or functions that each
machine and system was designed to

Simplified Failure Modes and Effects Analysis
(SFMEA), and fault-tree analysis (FTA) in that
it is intended to identify the variables or failure
modes that could contribute to a problem or
The technique is based on readily available,
application specific data to determine the
variables that may cause or contribute to an
In some instances, the process may be
limited to a cursory review of the vendors
Operating And Maintenance (O&M) manual
and performance specifications.

In others, a full evaluation that includes all
procurement, design, and operations data
may be required.
the information required can be obtained
from four sources: equipment nameplates,
procurement specifications, vendor
specifications, and the O&M manuals
provided by the vendors.

Most of the machinery, equipment, and systems used
in process plants have a permanently affixed
nameplate that defines their operating envelope.

For example, a centrifugal pumps nameplate typically
includes flow rate, total discharge pressure, specific
gravity, impeller diameter, and other data that define its
design operating characteristics.

These data can be used to determine if the equipment
is suitable for the application and if it is operating
within its design envelope.
Procurement specifications are normally prepared for all
capital equipment as part of the purchasing process.
These documents define the specific characteristics and
operating envelope requested by the plant-engineering
These specifications provide information that is useful for
evaluating the equipment or system during an
When procurement specifications are not available,
purchasing records should describe the equipment and
provide the system envelope.
Although this data may be limited to a specific type or
model of machine, it is generally useful information.
For most equipment procured as part of
capital projects, a detailed set of vendor
specifications should be available.
Generally, these specifications were included
in the vendors proposal and confirmed as
part of the deliverables for the project.
Normally, these records are on file in two
different departments: purchasing and plant
As part of the design review, the vendor and
procurement specifications should be
carefully compared.

Many of the chronic problems that plague
plants are a direct result of vendor deviations
from procurement specifications.

Carefully comparing these two documents may
uncover the root cause of chronic problems.

O&M manuals are one of the best sources of
In most cases, these documents provide specific
recommendations for proper operation and
maintenance of the machine, equipment, or system.
In addition, most of these manuals provide specific
troubleshooting guides that point out many of the
common problems that may occur.
A thorough review of these documents is essential
before beginning the RCFA.
The information provided in these manuals is
essential to effective resolution of plant problems
The objective of the design review is to
determine design limitations, acceptable
operating envelope, probable failure modes, and
specific indices that quantify the actual
operating condition of the machine, equipment,
or process system being investigated.
At a minimum, the evaluation should determine
design function and specifically what the
machine or system was designed to do.
The review should clearly define the specific
functions of the system and its components.
To fully define machinery, equipment, or
system functions, a description should
include incoming and output product
specifications, work to be performed, and
acceptable operating envelopes.
For example, a centrifugal pump may be
designed to deliver 1000 gal/min of water
having a temperature of 100F and a discharge
pressure of 100 lb/in2.
Machine and system functions depend on the
incoming product to be handled. Therefore, the
design review must establish the incoming
product boundary conditions used in the design
In most cases, these boundaries include:
temperature range, density or specific gravity,
volume, pressure, and other measurable
These boundaries determine the amount of
work the machine or system must provide.
Assuming the incoming product boundary
conditions are met, the investigation should
determine what output the system was
designed to deliver. As with the incoming
product, the output from the machine or system
can be bound by specific, measurable
Flow, pressure, density, and temperature are the
common measures of output product. However,
depending on the process, there may be others.
This part of the design review should determine
the measurable work to be performed by the
machine or system.
Efficiency, power usage, product loss, and
similar parameters are used to define this part of
the review.
The actual parameters will vary depending on
the machine or system.
In most cases, the original design specifications
will provide the proper parameters for the
system under investigation.
The final part of the design review is to define
the acceptable operating envelope of the
machine or system.
Each machine or system is designed to operate
within a specific range, or operating envelope.
This envelope includes the maximum variation
in incoming product, startup ramp rates and
shutdown speeds, ambient environment, and a
variety of other parameters.
Many of the chronic problems that negatively
affect critical production systems are caused
by inherent design deficiencies.
Therefore, the investigator should evaluate
the confirmed data develop before and
during the design review to determine
whether or not the root cause of the problem
can be accurately isolated without continuing
the RCA process.
The obvious next step in the RCA process is to
review the application to ensure that the
machine or system is being used in the proper
application and that the mode of operation and
maintenance are within the operating envelope,
as defined in the design review.
The data gathered during the design review
should be used to verify the application, as well
as operating and maintenance records
associated with the appropriate system or asset.
Factors to evaluate in an application review
include: installation, operating envelope,
operating procedures and practices, such as
standard procedures versus actual practices,
maintenance history, and maintenance
procedures and practices.
Each machine and system has specific installation
criteria that must be met before acceptable levels of
reliability can be achieved and sustained.
These criteria vary with the type of machine or
system, and should be verified as part of the RCA.
Using the information developed as part of the design
review, the investigator or other qualified individuals
should evaluate the actual installation of the machine
or system that is being investigated.
As a minimum, a thorough visual inspection of the
machine and its related system should be conducted
to determine if improper installation is contributing to
the problem.
Photographs, sketches, or drawings of the
actual installation should be prepared as part
of the evaluation.
They should point out any deviations from
acceptable or recommended installation
practices as defined in the reference
documents and good engineering practices.
This data can be used later in the RCA when
potential corrective actions are considered.
Evaluating the actual operating envelope of the
production system associated with the
investigated event is more difficult. The best
approach is to determine all variables and limits
used in normal production.

For example, define the full range of operating
speeds, flow rates, incoming product variations,
and so on, which are normally associated with
the system. In variable-speed applications,
determine the minimum and maximum ramp
rates used by the operators.
This part of the application review consists of
evaluating the standard operating procedures as
well as the actual operating practices.
Most production areas maintain some historical
data that tracks its performance and practices.
These records may consist of logbooks, reports,
or computer data.
These data should be reviewed to determine the
actual production practices that are used to
operate the machine or system being
Evaluate the standard operating procedures
(SOPs) for the affected area or system to
determine if they are consistent and adequate
for the application.
Two reference sources, the design review report
and vendors O&M manuals, are required to
complete this task.
In addition, evaluate SOPs to determine if they
are usable by the operators.
Review organization, content, and syntax to
determine if the procedure is correct and
Special attention should be given to the setup
procedures for each product produced by a machine
or process system. Improper or inconsistent system
setup is a leading cause of poor product quality,
capacity restrictions, and equipment unreliability.

The procedures should provide clear, easy to
understand instructions that ensure accurate,
repeatable setup for each product type.

If they do not, the deviations should be noted for
further evaluation.
Transient procedures, such as start-up, speed change,
and shutdown, also should be carefully evaluated.

These are the predominant transients that cause
deviations in quality and capacity, and that have a
direct impact on equipment reliability. These
procedures should be evaluated to ensure that they
do not violate the operating envelope or vendors

All deviations must be clearly defined for further
This part of the evaluation should determine if the
SOPs were understood and followed before and
during the incident or event. The normal tendency of
operators is to shortcut procedures, which Is a common
reason for many problems.
In addition, unclear procedures lead to
misunderstandings and misuse.
Therefore, the investigation must fully evaluate the
actual practices that the production team uses to
operate the machine or system.
The best way to determine compliance with SOPs is
to have the operator(s) list the steps used to run the
system or machine being investigated.
This task should be performed without referring
to the SOP manual. The investigator should lead
the operator(s) through the process and use
their input to develop a sequence diagram.
After the diagram is complete, compare it to the
SOPs. If the operators actual practices are not
the same as those described in the SOPs, the
procedures may need to be upgraded or the
operators may need to be retrained.

A thorough review of the maintenance history
associated with the machine or system is
essential to the RCA process. One of the
questions that must be answered is will this
happen again?
A review of the maintenance history may help
answer this question. The level of accurate
maintenance data that are available will vary
greatly from plant to plant. This may hamper the
evaluation, but it is necessary to develop as clear
a picture as possible of the system?s
maintenance history.

A complete history of the scheduled and
actual maintenance, including inspections
and lubrication, should be developed for the
affected machine, system, or area. The
primary details that are needed include:
frequency of repair and types of repair,
frequency and types of preventive
maintenance, failure history, and any other
facts that will help in the investigation.

A complete evaluation of the Standard
Maintenance Procedures (SMPs) and actual
practices should be conducted.

The procedures should be compared with
maintenance requirements defined by both
the design review and the vendors O&M
Actual maintenance practices can be
determined in the same manner as described
in earlier or by visual observation of similar
This task should determine if all maintenance
personnel assigned to or involved with the
area that is being investigated consistently
follow the SMPs.

Special attention should be given to the
routine tasks, such as lubrication,
adjustments, and other preventive tasks.
Determine if these procedures are being
performed in a timely manner and if proper
techniques are being used.

More than 27 percent of all reliability
problems are caused by misapplication. While
the initial design and operations of the
system may have been compatible, the
myriad of modifications, upgrades, and other
changes have historically resulted in
operating conditions that are outside the
acceptable operating envelope.
If the preceding steps do not provide a clear
understanding of the more probable reasons for
the problem, the investigator or team must
organize all of the data, assumptions, and
hypotheses into a form that can be used for
further analysis.
The most effective method involves plotting the
accumulated facts, assumptions, and
hypotheses into a graphical format that
facilitates understanding the cause and effect
and interactions of all identified variables.
Common problem classifications are
equipment damage or failure, operating
performance, economic performance, safety,
and regulatory compliance.
Classifying the event as a particular problem
type allows the analyst to determine the best
method to resolve the problem. Each of the
major classifications requires a slightly
different RCA approach.
One of the major classifications of problems that
often warrant RCA is an event associated with
failure of critical production equipment,
machinery, or systems.

Typically, any incident that results in partial or
complete failure of a machine or process system
warrants a RCA. This type of incident can have a
severe, negative impact on plant performance.
Therefore, it often justifies the effort required to
fully evaluate the event and to determine its
root cause.

The most effective methods of resolving an
equipment or system failure problem are
sequence-of events analysis or SFMEA.
Product Quality. Deviations in first-time-
through product quality are prime candidates
for RCA, which can be used to resolve most
quality-related problems.
However, the analysis should not be used for
all quality problems.
Nonrecurring deviations or those that do not
have a significant impact on capacity or costs
are not cost-effective applications.
Many of the problems or events that occur affect a plant?s
ability to consistently meet expected production or
capacity rates. These problems may be suitable for RCA,
but further evaluation is recommended before beginning
an analysis. After the initial investigation, if the event can
be fully qualified and a cost-effective solution found, then
a full analysis should be considered.
Note that an analysis is not normally performed on
random, nonrecurring events or equipment failures.
The preferred analytical tool for these potentially complex
problems is cause and effects analysis.
In some cases where the exact time the problem first
began, sequence-of-events analysis can also be used
Deviations in economic performance, such as
high production or maintenance costs, often
warrant the use of RCA.
The decision tree and specific steps required
to resolve these problems vary depending on
the type of problem and its forcing functions
or causes.
Because of the complexity of economic
deviations, the preferred analytical tool is
again cause and effects analysis.
Any event that has a potential for causing personal injury
should be investigated immediately. While events in this
classification may not warrant a full RCFA, they must be
resolved as quickly as possible.

Isolating the root cause of injury-causing accidents or
events is generally more difficult than for equipment
failures and requires a different problem-solving
approach. The primary reason for this increased difficulty
is that the cause is often subjective.

In most cases, regulator requirements necessitate using all
of the analytical tools, but the primary tool should be
cause and effect.
Any regulatory compliance event can potentially impact
the safety of workers, the environment, as well as the
continued operation of the plant.

Therefore, any event that results in a violation of
environmental permits or other regulatory-compliance
guidelines, such as Occupational Safety and Health
Administration, Environmental Protection Agency, and
state regulations, must be investigated and resolved as
quickly as possible.

Since all releases and violations must be reported and they
have a potential for curtailed production and/or fines this
type of problem must receive a high priority.