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 don’t 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

50

Data shows strong positive

40 correlation.
Minutes

30

20

10

0
0 5 10 15 20 25

Cases/Hour
 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 No reward

students signed up
Schedule not communicated

No time
to learn
Trainer not New trainer assigned late
prepared
Training Turnover
Class
Cancelled
Flexibility
Materials not Late changes Changes up
completed to class date
Current

Floating due date

Training Dept -
other projects This project-
low priority More info needed
 Cautionary Note

“It’s impossible to solve significant

problems using the same level of
knowledge that created them!”
Albert Einstein
 Cautionary Note - Part 2

Cause and effect analysis can’t 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
Potential
Event Event Event Sequence of
happenings
 Events and Causal Factor Chart

Incident
Events
Reason for investigation
Actions that lead
to incident

Person Person
Person Person
steps in hole treated at
walks to car sprains
in parking ER
ankle
lot

CF
No barricades or
Leaves work late
markings for hole
(after dark)

CF
Parking lot
Usual parking lighting
spot in company not working
lot

Conditions or Causal Factors

Amplifying information explaining
the event
 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

1 undesirable
consequence

5
4
Identify Analyze differences for
3 Compare
differences effect on undesired
consequences

Integrate information
relevant to the
Comparable activity
causes of undesired
2 without undesired
result
consequence

6
 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:

Electricians
System Tag Electricians Follow Reactor
Tagout Hung Given Assignment Procedure Trip

Barriers Analysis
Tagout Tagout Communications
Process Process Process
Start Step 1 Step 2 Interface Procedure Occurrence

Barrier Barrier Barrier Barrier Barrier Barrier

Holds Holds Holds Fails Fails 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