Root cause analysis

An Overview
Root Cause analysis (RCA) – Definitions
• is the generic name of problem-solving techniques
• is a systematic approach to identifying the causes of a problem and taking action
to prevent it from happening again in the future.
• is a process to (a) identify factors that underlie variation in performance

Why is it needed ?
If a problem occurred then RCA allows to
• find out exactly what the cause is and how to fix it.
• to improve the overall performance of an organization
Little bit of History

• its origins in the quality control aspect of engineering and manufacturing.

• Root cause analysis (RCA) was developed by manufacturers in the 1950s to better
understand industrial events.
• It was created by founder of Toyota Industries Co., Ltd., Sakichi Toyoda
• The first use of the term root cause analysis was in 1986 when it first consisted of
data collected from multiple sources to generate a report. This system helped in
understanding what went wrong with a product and provided ways of preventing
more problems from occurring in the future.
The 5 Whys Method
• The 5 Whys method is one of the earliest models used in the history
of the root cause analysis, and it simply seeks to ask “why” five times
until the main cause of the problem is revealed. This technique
systematically rules out other causes each time a “why” is asked
Problem: The computer monitor is not working.

why? The monitor’s light signal is not on.

Why? The monitor’s power cord is not functioning.

Why? The cord is damaged.

Why? It was placed under a heavy load.

Why? I didn’t place the cords properly when the monitor was plugged in, which
caused damage
5 Whys

The Five Whys technique has been criticized as too basic a tool to analyze root causes
to the depth required to ensure that the causes are fixed because

•The tendency of investigators to stop at symptoms, and not proceed to lower level
root causes.
•The inability of investigators to cast their minds beyond current information and
knowledge.
•Lack of facilitation and support to help investigators ask the right questions.
•The low repeat rate of results: different teams using the Five Whys technique have
been known to come up with different causes for the same problem.
Clearly, the Five Whys technique will suffer if it is applied through deduction only. The
process articulated earlier encourages on-the-spot verification of answers to the
current “why” question before proceeding to the next, and should help avoid such
issues.
 Quality
• In 1986, Motorola developed a new strategy for risk management called Six
Sigma.
• Six Sigma uses specific methods, including statistical information, to outline a RCA.
It also puts its workers in a specific infrastructure based on their qualification.

• The high standard of risk management achieved with Six Sigma is measured by
the low number of defective products produced, which is about 99.99966% or a
mere 3.4 errors or defective products per million. Due to its high success rate, the
Six Sigma quality standards were soon adopted by other manufacturing industry
giants, such as General Electric. Although first used in manufacturing industries,
Six Sigma is now applied in service industries as well.
The Federal Aviation Administration (FAA)

• In 1975, FAA established the Aviation Safety Reporting System (ASRS)

to conduct its safety management. Following its establishment, the
FAA has reduced death rates from airline accidents by 80 percent. It
has been said the success of the FAA’s risk management system
comes from its separation of power; ASRS being funded by FAA, but
administered by the National Aeronautics and Space Administration
(NASA)
Initiation in the Health Care System
Beginning in 1999, the health care system took a special interest in root cause
analysis techniques to address the high number of adverse results reported in
patient safety and hospitalization standards. The statistics gathered were
staggering. According the Institute of Medicine, death rates due to medical errors
were estimated to be between 44,000 and 98,000 - more than the death rates of
breast cancer, motor vehicle accidents, and AIDS.
A systematic system was desperately needed as the medical field became
increasingly complex, resulting in greater chances for preventable errors to occur.
Modern Day Techniques

• Bayesian Inference - Used to determine the probability of a hypothesis through

statistical inference.

• Failure Mode and Effects Analysis - A method of studying failure and its effects to
successfully weed out problem areas with minimum effort.

• Fault Tree Analysis - Used in safety and reliability engineering fields.

• Ishikawa Diagram - Used in project management.
• Pareto Analysis (80/20 Rule) - Most problems or 80 percent of the problems occur due
to a few or 20 percent of the causes and by identifying these key 20 percent of the
causes, you can solve the problem.

• Change Analysis - Analyzing differences that occurred during an event to monitor change
and locate root causes.

• Current Reality Tree - A process used to study many organizational problems at once.

• Barrier Analysis - Process industries use this model to trace energy flows and identify the
barrier in those flows.

• Rapid problem resolution (RPR) Problem Diagnosis - A method used in the IT field and
deals with failures, incorrect output and performance issues, and its particular strengths
are in the diagnosis of ongoing & recurring grey problems.
 General RCA Corrective Action Process
1. Factually describe and document the whole event.
2. Gather the evidence to support your description of the event.
3. Classify your evidence along a proper timeline in which the events occurred ending with the final
failure.
4. Identify the causes by asking “why” along each step. Remember the 5 Whys method.
5. Separate root causes along each step that impacted the event in any way from the casual causes
without direct impact on the final failure.
6. Identify all possible preventive measures and place them in order with the most simplest and cost-
effective measure at the top.
7. Classify these measures further by identifying the ones that have a group consensus and are likely to
have the highest possible rate of preventing the problem in the future without creating other
disturbances.
8. Seek any other methods necessary to reach the root cause depending on the complexity of your
problem and field.
9. Apply these corrective measures to ensure future prevention and safety.
Why do businesses use root cause analysis?
• Risk management can be more effective after root cause analysis because it helps
to identify preventive steps and corrective actions in a particular situation. The
identification of root causes leads to the reduction of operational risks. This helps
the team to learn from mistakes. For example, a company may lack the staff to
handle its workload, so it hires more people. With a root cause analysis, it's then
found that the team members don't have enough training to handle their tasks
efficiently. It costs much less to train employees than to hire more, so the RCA
provides an effective solution.
• A root cause analysis can evaluate whether an event has its cause in human error
or equipment failure. The goal of the analysis is to identify what's causing
something to malfunction and how to prevent the situation from happening
again. A root cause analysis usually helps a team to focus on what's necessary for
them to fix a problem.
What measures can make root cause analysis successful?

A successful root cause analysis means that a problem doesn't reoccur or that a more
desired outcome reoccurs consistently. A successful root cause analysis is about learning
from failure or success, analyzing what happened and taking action to reduce or increase
the risk of it happening again

The success of a root cause analysis depends on the following factors:

• the degree of accuracy in the analysis

• a willingness to accept uncertainty until testing begins
• the extent to which the analysis can uncover a reason for an issue
• the extent to which the report can offer actionable recommendations
• how well you can communicate the report and accept feedback
Challenges of root cause analysis

• Gathering the data you use, cleaning it and performing analysis on it can take
significant amounts of time, even when you automate parts of the process.

• Sometimes there are multiple root causes of a problem or issue, making it vital to
have as much information as possible and not to discount any possible causes
until completing the testing phase.

• When you have multiple sources of data in different databases, it's easy to
overlook important aspects of it. The problem with big data is that companies
store it in multiple places and sometimes the information needs collating.