ROUTE CAUSE ANALYSIS &

CORRECTIVE ACTION
19th Jan 2016
 WHAT?
• Root Cause – Deepest underlying cause(s) of positive or
negative symptoms within any process that, if resolved,
would eliminate or substantially reduce the symptom.
• Root Cause Analysis (RCA) – a tool used both reactively,
to investigate an adverse event that already has
occurred, and proactively, to analyze and improve
processes and systems before they break down
• Data Analysis – the process of gathering, reviewing,
and evaluating data.
 Why Use Root Cause Analysis (RCA)?

Root Cause Analysis:

• Helps identify the problem or challenge
• Helps resolve the Problem
• Eliminates Patching
• Conserves Resources
• Facilitates Discussion (leading to solutions)
• Provides Rationale for Strategy Selection

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 Root Cause Analysis - Process
Step 1 Organize Team

Step 2 Define Problem or Issue

Step 3 Conduct Data Analysis

Step 4 Determine Root Cause(s)

Step 5 Improvement Planning

Step 6 Evaluate Progress

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 Step 1 Organize Team

Team Members Duties

Stn Manager / Manager / AMR / MR Identify Problem or Challenge (does it
Supervisor interfere with Service Delivery?)
Technical staf Review Data
Analyze Data (generate questions).
Determine baseline levels
Determine assessment of progress

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 Step 2 Define the Problem

State Problem clearly.

Example:
Equipments did not meet the NE fault target
of 1.00% for month of August 2014.

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 Step 3 Conduct Data Analysis
Examine & Discuss Data
Assessments
Achievement data
Equipment observations, record reviews, and other data

Conduct Data Analysis – View objectively

Patterns
Trends
Variability

Brainstorm - discussion

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 Step 4 Determine Root Cause(s)
Strategies for Determining Root Cause: (select
one)

• Cause and Effect Diagram

(Also Called Fishbone)

• The Five Whys. A process to seek root cause by asking

“why” five times in succession.

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METHOD 1
 Cause and Efect Diagram
(Also Called Fishbone)
• What
– A tool to represent the relationship between an efect (problem)
and its potential causes by category type.
• When
– Carried out when a root cause needs to be determined.
• Why
– To help ensure that a balanced list of ideas have been generated
during brainstorming.
– To determine the real cause of
the problem versus a symptom.
– To refine brainstormed ideas into
more detailed causes.

Root Cause Analysis

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 Example: Fishbone Diagram
Material Machine Methods Discovery of different
discount rates occurs too
late in process
Computer screens

Too many “jumps” Billing process not

Updates accurate
Product
Shortages
Master customer discount
table not up-to-date Effect: Too many price
adjustments at
Incomplete Training on check-out
Power Failures
Management Policies common complaints
Not enough staffing during
peak times
Marketing metrics
counterproductive Unfamiliarity with procedures

For vacation Notification of absence

Mother Nature Measurements Manpower notification
Root Cause Analysis
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METHOD 2
 The Five Whys
Asking the question ‘Why’ 5 times, will lead you to the
root cause of the problem.
Steps:
1.Write down the specific problem. Writing the
problem helps team focus on the same problem.
2.Ask why the problem happens and write down the
answer. Repeat 5 times – 5 ‘Whys’, until team is in
agreement that problem is identified.
See web resource: http://www.isixsigma.com/index.php?option=com_k2&view=item&id=1308:&Itemid=49

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• No new recruitment Why
• The number of reading groups needed Why
requires all teaching staf.
• No other teaching staf available. Why
• No other reading group available at his Why
instructional need level.
• The pace of reading instruction is too fast. Why
reach expected goal.
Problem: Johnny is not making sufficient progress in reading to
5 Whys: Define the Problem–Why is it happening?
 Step 4 Determine Root Cause(s)
Indicators that you have found Root Cause:
Agreement on a root cause.
Cause is logical, makes sense, and provides
clarity to the problem.
Cause is something you can influence and
control
If cause is resolved, there is realistic hope that
the problem can be reduced or prevented in the
future.

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 Step 5 Improvement Planning
Improvement plan reflects correction of noncompliance
issues and sustained practices. The Improvement Plan
should include:
Logical link between root cause and improvement
activities;
Evidence-based practices;
Short- and long-term outcomes, timelines and action
steps for improvement activities.
Personnel (and partners) identified to develop,
implement, monitor, and evaluate the improvement
activity.
Collect Data to evaluate outcomes of improvement
activities.
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 Step 6 Evaluate Progress
Why evaluate progress?
• Gives station/unit/division a process for
gathering, analyzing and using data.
• Allows station/unit/division to determine
whether it is efectively carrying out
planned activities and the extent to which
it is achieving its short-term and long-term
outcomes.

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