THE ESSENTIAL ELEMENTS OF RCA

Getting Back to Basics

The Essential Elements of RCA

• Identification of the Real Problem to be Analyzed in the

First Place
• Identification of the Cause-And-Effect Relationships that
Combined to cause the Undesirable Outcome
• Disciplined Data Collection and Preservation of Evidence to
Support Cause-And-Effect Relationships
• Identification of All Physical, Human and Latent Root
Causes Associated with Undesirable Outcome
• Development of Corrective Actions/Countermeasures to
Prevent Same and Similar Problems in the Future
• Effective Communication to Others in the Organization of
Lessons Learned from Conclusions.
RCA vs. Shallow Cause Analysis

• Brainstorming: A technique teams use to generate ideas

on a particular subject. Each person in the team is asked
to think creatively and write down as many ideas as
possible. The ideas ire not discussed or reviewed until
after the brainstorming session.

• Problem Solving: The act of defining a problem;

determining the cause of the problem ; identifying,
prioritizing and selecting alternatives for a solution; and
implementing a solution.

• Trouble Shooting: To identify the source of a problem and

apply a solution to fix it.

• Root Cause Analysis: The establishing of logically

complete, evidence based, tightly coupled chains of factor
from the least acceptable consequence to the deepest
significant underlying causes.
RCA: Effectiveness vs. Efficiency vs.
Strength of Evidence
(Paper-Based Approach)

Hi
Accuracy (Effectiveness) Hi

Disciplined

Strength of Evidence
RCA

Problem Solving

Brainstorming

Trouble shooting
Lo Lo

Hours Months
Time (Efficiency)
 Contrasting PI Processes

Identifying
Used on
Rigid Data Typ. Formal of Physical
Chronic Evidence-
Collection Team Cause-And- (P), Human
vs. Based
PI Technique Typically vs. Ind. Effect (H) and/or
Sporadic Validation
Required Based Process Latent (L)
Events Used (Y/N)
(Y/N) (T/I) Utilized (Y/N) Root
(C/S)
Causes
Brainstorming
C or S N T N N P or H
(i.e. Fishbone)
Problem
Solving C or S N T N N P or H
(i.e. 5 Whys)
Trouble
Shooting
C or S N I N N P
(i.e. Trial and
Error)
Root Cause
Analysis C or S Y T Y Y P, H and L
(i.e. PROACT)
The Basic Logic Tree Concept
1. Event Consequences

2. Modes

3. Hypotheses

4. Validation Using Evidence

5. ID Physical Roots

6. ID Human Roots

7. ID Latent Roots
Breadth and Depth

Trial and Error/

Troubleshooting

Shallow Cause
PR Brainstorming and
Problem Solving

HR
Witch Hunting

RCA
LR
Root Cause Analysis
Thank You