Root Cause Analysis versus Symptom approach

1. RCA – Root Cause Analysis

2. Root Cause Analysis

3. RCA
• Root Cause: The most basic reason for an undesirable
condition or problem which, if eliminated or corrected,
would have prevented it from existing or occurring.

4. Definition
• Root cause analysis (RCA) is a class of problem
solving methods aimed at identifying the root
causes of problems or events.
• RCA is based on the belief that problems are
best solved by attempting to correct or
eliminate root causes, as opposed to merely
addressing the immediately obvious
symptoms.

5. Principles of RCA?
• Aiming corrective actions at root causes is
more effective than just treating the
symptoms of a problem.
• To be effective, RCA must be performed
systematically and conclusions must be
backed up by evidence.
• There is usually more than one root cause for
any given problem and therefore there may be
more than one corrective action.

6. General process for performing root
cause analysis
1. Define the problem.
2. Gather data/evidence.
3. Identify issues that contributed to the problem.
4. Find root causes. Identify which causes to remove
or change to prevent repeated problem.
5. Develop solution recommendations that
effectively prevent repeating the problem.
6. Implement the recommendations / changes.
7. Observe the recommended solutions/changes to
ensure effectiveness of eliminating the problem.

9. Cause Mapping of Root Cause Analysis
• “ROOT” refers to the causes beneath the
surface. It is the system of causes that shows
all the options for solutions.
• Do not focus on a single cause as this can limit
the solutions set resulting in missing a better
solution.
• A Cause Map provides a simple visual look at
all the elements that produced the problem.

10. Root Cause Analysis
Problem or
Unwanted
Event
Occurrence
Symptoms
Apparent Cause
Root Cause
Problem or
Unwanted
Event
Recurrence
Prevent

11. Three Basis Steps of Cause Mapping
1. Define the issue by its impact to overall goals
2. Analyze the cause in a visual map.
3. Prevent or mitigate any negative impact of
the goals by selecting the most effective
solutions.

13.  5 whys
 Pareto Chart
 Fishbone or Ishikawa Diagram
 Chart and/or Graphs
Why?
Why?
Why?
Why?
Why?
Detail
Detail
Detail
Detail
Detail
Detail
Detail
Detail
Detail
Detail
Detail
Detail
Product
Processes
Procedures
People
The Problem
Promotion
Detail
Detail
Detail
Policies
Detail
Detail
Detail
Price
Detail
Detail
Detail
Place/Plant
Detail
Detail
Detail
80%
10%
5%
5%
50% 25
0
0%
Incidences
Tools for RCA

15. Ishikawa or Fishbone Diagram
(Cause and effect)
Problem
Method
Machine
Materials
Environment
Management System
Man

16. Brain storm possible causes
Problem
Method
Machine
Materials
Environment
Management System
Man
Cause A
Cause B
Cause C
Cause D Cause E
Cause F

17. 5 Whys
• Why
• Why
• Why
• Why
• Why
• Basis for even the 20 million questions

18. Five Whys
Event: You are operating a tug that is towing a Vessel in Gulfstream .
Suddenly, the tug becomes uncontrollable, which causes the tow hitch to
break and extensive damage to the aircraft nose gear results.
1. Why did the aircraft become damaged?
- Because the tow bar hit the aircraft.
2. Why did the tow bar hit the aircraft?
- Because the tow hitch broke.
3. Why did the tow hitch break?
- Because the tug was uncontrollable.

19. Five Whys
4. Why did the tug become uncontrollable?
- Because the aircraft was being pulled with a tug rated below 10K draw
bar pull.
5. Why was a tug with a rating that was below minimum being used ?
- Because the tug operator was unaware of the guidance.
6. Why wasn’t the tug operator aware of the guidance?
- Because the tug operator was new and had not been trained on the
guidance.
- Because the operator was unaware of the guidance.
7. Why hadn’t the employee been trained?
- Because there are no procedures for processing new employees.
This process can go on if it is determined, via logical progression, that
additional factors have a direct bearing on the outcome.

20. Pareto Chart

21. Defining the problem
The tackle is the one that has the highest
score. This one will give you the biggest
benefit if you solve it.

22. Charts and Graphs

23. 7 Best Practices to Remember
1. Your root cause analysis is only as good as the info
you collect.
2. Your knowledge (or lack of it) can get in the way of a
good root cause analysis.
3. You have to understand what happened before you
can understand why it happened.
4. Interviews are not about asking questions.
5. You can’t solve all human performance problems with
discipline, training, and procedures.
6. Often people can’t see effective corrective actions
even if they can find the root cause.
7. All investigations do not need to be equal (but some
steps can’t be skipped).