1. Root Cause Analysis (RCA) is a technique used to identify the underlying cause of problems by tracing events and causal factors. It involves five steps: defining the problem, collecting data, identifying possible causes, determining the root cause, and recommending solutions.
2. RCA seeks to identify the origin of problems to determine what happened, why it happened, and how to prevent it from happening again. It examines physical, human, and organizational causes using tools like 5 Whys, cause-and-effect diagrams, and failure mode and effects analysis.
3. RCA is useful for understanding complex systems and identifying key points of failure to address the root causes of problems and minimize future issues through continuous improvement.
5. Introduction
• In medicine, it's easy to understand the difference between treating
the symptoms and curing the condition.
• A broken wrist, for example, really hurts!
• But painkillers will only take away the symptoms; you'll need a
different treatment to help your bones heal properly.
6. Introduction
• But what do you do when you have a problem at work?
• Do you jump straight in and treat the symptoms, or do you stop to
consider whether there's actually a deeper problem that needs your
attention?
7. Introduction
• If you only fix the symptoms – what you see on the surface – the
problem will almost certainly return, and need fixing over, and over
again.
• However, if you look deeper to figure out what's causing the
problem, you can fix the underlying systems and processes so that it
goes away for good.
9. Root Cause Analysis (RCA) Definition
• Root Cause Analysis (RCA) is a popular and often-used technique
that helps people answer the question of why the problem occurred
in the first place.
10. Root Cause Analysis (RCA) Definition
• It seeks to identify the origin of a problem using a specific set of
steps, with associated tools, to find the primary cause of the
problem, so that you can:
– Determine what happened.
– Determine why it happened.
– Figure out what to do to reduce the likelihood that it will happen
again.
11. Root Cause Analysis (RCA) Definition
• Root Cause Analysis (RCA) assumes that systems and events are
interrelated.
• An action in one area triggers an action in another, and another,
and so on.
• By tracing back these actions, you can discover where the problem
started and how it grew into the symptom you're now facing.
12. Root Cause Analysis (RCA) Definition
• You'll usually find three basic types of causes:
– Physical causes.
– Human causes.
– Organizational causes.
13. Root Cause Analysis (RCA) Definition
• Physical causes :
– Tangible, material items failed in some way (for example, a car's
brakes stopped working).
14. Root Cause Analysis (RCA) Definition
• Human causes:
– People did something wrong, or did not do something that was
needed.
– Human causes typically lead to physical causes (for example, no
one filled the brake fluid, which led to the brakes failing).
15. Root Cause Analysis (RCA) Definition
• Organizational causes:
– A system, process, or policy that people use to make decisions or
do their work is faulty (for example, no one person was
responsible for vehicle maintenance, and everyone assumed
someone else had filled the brake fluid).
16. Root Cause Analysis (RCA) Definition
• Root Cause Analysis (RCA) looks at all three types of causes.
• It involves investigating the patterns of negative effects, finding
hidden flaws in the system, and discovering specific actions that
contributed to the problem.
17. Root Cause Analysis (RCA) Definition
• This often means that Root Cause Analysis (RCA) reveals more than
one root cause.
• You can apply Root Cause Analysis (RCA) to almost any situation.
18. Root Cause Analysis (RCA) Definition
• Determining how far to go in your investigation requires good
judgment and common sense.
• Theoretically, you could continue to trace the root causes back to
the Stone Age, but the effort would serve no useful purpose.
20. The Root Cause Analysis Process
• Root Cause Analysis (RCA) has five identifiable steps:
1. Define the Problem.
2. Collect Data.
3. Identify Possible Causal Factors.
4. Identify the Root Cause(s).
5. Recommend and Implement Solutions.
21. Step 1: Define the Problem
• What do you see happening?
• What are the specific symptoms?
22. Step 2: Collect Data
• What proof do you have that the problem exists?
• How long has the problem existed?
• What is the Likelihood of the problem?
• What is the impact of the problem?
23. Step 2: Collect Data
• You need to analyze a situation fully before you can move on to look
at factors that contributed to the problem.
• To maximize the effectiveness of your Root Cause Analysis (RCA), get
together everyone – experts and front line staff – who understands
the situation.
• People who are most familiar with the problem can help lead you to
a better understanding of the issues.
24. Step 2: Collect Data
• A helpful tool at this stage is CATWOE.
• With this process, you look at the same situation from different
perspectives:
– The Customers.
– The people (Actors) who implement the solutions.
– The Transformation process that's affected.
– The World view.
– The process Owner.
– Environmental constraints.
26. Step 3: Identify Possible Causal Factors
• What sequence of events leads to the problem?
• What conditions allow the problem to occur?
• What other problems surround the occurrence of the central
problem?
27. Step 3: Identify Possible Causal Factors
• During this stage, identify as many causal factors as possible.
• Too often, people identify one or two factors and then stop, but
that's not sufficient.
• With Root Cause Analysis (RCA), you don't want to simply treat the
most obvious causes – you want to dig deeper.
28. Step 3: Identify Possible Causal Factors
• Use these tools to help identify causal factors:
– Appreciation (Situational).
– 5 Whys.
– Drill Down.
– Cause and Effect Analysis.
30. Appreciation (Situational)
• Starting with a fact, you first ask the question "So what?" – in other
words, what are the implications of that fact? Why is this fact
important? to determine all the possible consequences of a fact.
• You then continue asking that question until you have drawn all
possible conclusions from it.
31. 5 Whys
• Ask "Why?" until you get to the root of the problem.
• You can use 5 Whys for troubleshooting, quality improvement and
problem solving, but it is most effective when used to resolve simple
or moderately difficult problems.
32. 5 Whys
• You need to be more careful when you're tackling complex or
critical problems.
• 5 Whys can lead you to pursue a single track, or a small number of
tracks, of enquiry when there could be multiple causes.
33. Drill Down
• Break down a problem into small, detailed parts to better
understand the big picture.
• Drill Down" helps you to break a large and complex problem down
into its component parts, so that you can develop plans to deal with
these parts.
• It also shows you which points you need to research in more detail
35. Cause and Effect Analysis
• Create a chart of all of the possible causal factors, to see where the
trouble may have begun.
• Also known as Cause and Effect Diagrams, Fishbone Diagrams,
Ishikawa Diagrams, Herringbone Diagrams, and Fishikawa
Diagrams.
36. Cause and Effect Analysis
• When you have a serious problem, it's important to explore all of the
things that could cause it, before you start to think about a solution.
• That way you can solve the problem completely, first time round,
rather than just addressing part of it and having the problem run on
and on.
• Cause and Effect Analysis gives you a useful way of doing this.
37. Step 4: Identify the Root Cause(s)
• Why does the causal factor exist?
• What is the real reason the problem occurred?
38. Step 4: Identify the Root Cause(s)
• Use the same tools you used to identify the causal factors (in Step
Three) to look at the roots of each factor.
• These tools are designed to encourage you to dig deeper at each
level of cause and effect.
39. Step 5: Recommend and Implement Solutions
• What can you do to prevent the problem from happening again?
• How will the solution be implemented?
• Who will be responsible for it?
• What are the risks of implementing the solution?
40. Step 5: Recommend and Implement Solutions
• Analyze your cause-and-effect process, and identify the changes
needed for various systems.
• It's also important that you plan ahead to predict the effects of your
solution.
• This way, you can spot potential failures before they happen.
41. Step 5: Recommend and Implement Solutions
• Use these tools to help Recommend and Implement Solutions:
– Failure Mode and Effects Analysis (FMEA).
– Impact Analysis.
– Kaizen.
42. Failure Mode and Effects Analysis (FMEA)
• This tool builds on the idea of risk analysis to identify points where a
solution could fail.
• FMEA is also a great system to implement across your organization;
the more systems and processes that use FMEA at the start, the less
likely you are to have problems that need Root Cause Analysis
(RCA) in the future.
43. Failure Mode and Effects Analysis (FMEA)
• By looking at all the things that could possibly go wrong at design
stage, you can cheaply solve problems that would otherwise take
vast effort and expense to correct, if left until the solution has been
deployed in the field.
44. Failure Mode and Effects Analysis (FMEA)
• More than this, FMEA provides a useful approach for reviewing
existing processes or systems, so that problems with these can be
identified and eliminated.
45. Impact Analysis
• Also known as Change Impact Analysis, Impact Change Analysis and
Solution Effect Analysis
• This helps you explore possible positive and negative consequences
of a change on different parts of a system or organization.
46. Kaizen (Continuous Improvement)
• This is the idea that continual small changes create better systems
overall.
• Kaizen also emphasizes that the people closest to a process should
identify places for improvement.
• Again, with Kaizen alive and well in your company, the root causes
of problems can be identified and resolved quickly and effectively.
48. Conclusion
• Root Cause Analysis (RCA) is a useful process for understanding and
solving a problem.
• Figure out what negative events are occurring.
• Then, look at the complex systems around those problems, and
identify key points of failure.
• Finally, determine solutions to address those key points, or root
causes.
49. Conclusion
• You can use many tools to support your Root Cause Analysis (RCA)
process.
• 5 Whys and Cause and Effect Analysis are integral to the process
itself, while Failure Mode and Effects Analysis (FMEA) and Kaizen
help minimize the need for Root Cause Analysis (RCA) in the future.
50. Conclusion
• As an analytical tool, Root Cause Analysis (RCA) is an essential way
to perform a comprehensive, system-wide review of significant
problems as well as the events and factors leading to them.