Best Practices

Root Cause Analysis

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Tamara Parris's picture
Tamara Parris

EHSQ Community Manager

Root Cause Analysis

Starter resource for Root Cause Analysis (RCA). Please attach resource you might have to enhance this resource offering to other members.

While reading, and conducting your analysis keep these tips top of mind.

1. Any root cause analysis is only as good as the info you are collecting. Keep to facts and keep out bias. Quality information results in quality analysis.

2. Your knowledge or lack of knowledge both can hinder a good root cause analysis.

3. It is key to understand what happened - Listen and observe. Start with understanding the problem and not making the solution.

4. Our interviews with employees are not about asking them a battery of questions.  Keep to understanding the "What"

5. Involve facility leaders in the prioritization and decision to proceed with an RCA.

6. Your problem statement should be objective about what went wrong, not why, or how.

7. Ensure your problem statement will facilitate a more thorough examination of the problem.

Example statement : “Employee X continued to receive managements request to use the faulty powerjack one month after the order was given to discontinue use of the non-compliant equipment.”

As found on Wiki - member offering

Understanding of Methodologies:

A. Safety-based RCA arose from the fields of accident analysis and occupational safety and health.

B. Production-based RCA has roots in the field of quality control for industrial manufacturing.

C. Process-based RCA, a follow-on to production-based RCA, broadens the scope of RCA to include business processes.

D. Failure-based RCA originates in the practice of failure analysis as employed in engineering and maintenance.

E. Systems-based RCA has emerged as an amalgam of the preceding schools, incorporating elements from other fields such as change management, risk management and systems analysis.

General process for performing and documenting an RCA-based corrective action

RCA (in steps 3, 4 and 5) forms the most critical part of successful corrective action, directing the corrective action at the true root cause of the problem. Knowing the root cause is secondary to the goal of prevention, as it is not possible to determine an absolutely effective corrective action for the defined problem without knowing the root cause.

  1. Define the problem or describe the event to prevent in the future. Include the qualitative and quantitative attributes (properties) of the undesirable outcomes. Usually this includes specifying the natures, the magnitudes, the locations, and the timing of events. In some cases, "lowering the risks of reoccurrences" may be a reasonable target. For example, "lowering the risks" of future automobile accidents is certainly a more economically attainable goal than "preventing all" future automobile accidents.
  2. Gather data and evidence, classifying it along a timeline of events to the final failure or crisis. For every behavior, condition, action and inaction, specify in the "timeline" what should have been done when it differs from what was done.
  3. In data mining Hierarchical Clustering models, use the clustering groups instead of classifying: (a) peak the groups that exhibit the specific cause; (b) find their upper-groups; (c) find group characteristics that are consistent; (d) check with experts and validate.
  4. Ask "what" (edited) and identify the causes associated with each sequential step towards the defined problem or event. "What were the factors that directly resulted in the effect?"
  5. Classify causes into two categories: causal factors that relate to an event in the sequence; and root causes that interrupted that step of the sequence chain when eliminated.
  6. Identify all other harmful factors that have equal or better claim to be called "root causes". If there are multiple root causes, which is often the case, reveal those clearly for later optimum selection.
  7. Identify corrective action(s) that will, with certainty, prevent recurrence of each harmful effect and related outcomes or factors. Check that each corrective action would, if pre-implemented before the event, have reduced or prevented specific harmful effects.
  8. Identify solutions that, when effective and with consensus agreement of the group: prevent recurrence with reasonable certainty; are within the institution's control; meet its goals and objectives; and do not cause or introduce other new, unforeseen problems.
  9. Implement the recommended root cause correction(s).
  10. Ensure effectiveness by observing the implemented solutions in operation.
  11. Identify other possibly useful methodologies for problem solving and problem avoidance.
  12. Identify and address the other instances of each harmful outcome and harmful factor.
Health & Safety, Quality, Risk Management Best Practices

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Tamara Parris's picture
Tamara Parris
November 15, 2017 @ 11:41 AM EST