ROOT CAUSE ANALYSIS

(R.C.A.)
Ok. So what is root cause analysis?

• Root cause analysis (RCA) is the process of

discovering the root causes of problems in order
to identify appropriate solutions.
• In science and engineering, root cause
analysis (RCA) is a method of problem
solving used for identifying the root causes of
faults or problems.
Ok. So what is root cause analysis?

• RCA can show where processes or systems failed

or caused an issue in the first place.
• It is widely used in IT
operations, telecommunications, industrial
process control, accident analysis (e.g.,
in aviation,[2] rail transport, or nuclear
plants), medicine (for medical diagnosis), &
healthcare industry
Ok. So what is root cause analysis?

• A standard process of:

 identifying a problem
 containing and analyzing the problem
 defining the root cause
 defining and implementing the actions required to eliminate
the root cause
 validating that the corrective action prevented recurrence of
problem
What is a root cause?
ROOT CAUSE =
• The causal or contributing factors that, if corrected, would
prevent recurrence of the identified problem
• The “factor” that caused a a problem or defect and should
be permanently eliminated through process improvement
• The factor that sets in motion the cause and effect chain
that creates a problem
• The “true” reason that contributed to the creation of a
problem, defect or nonconformance
A Brief History of Root Cause Analysis

First Appearance of RCA in Engineering

• Before its current form as a widely used process
throughout all industries, RCA’s first appearance
was in the field of engineering. The method is
credited to none other than the founder of
Toyota Industries Co., Ltd., Sakichi Toyoda.
A Brief History of Root Cause Analysis
• Sakichi Toyoda
A Brief History of Root Cause Analysis
Sakichi Toyoda

• One of his contributions was identifying root causes to

problems to solve or prevent detrimental situations.
The technique Toyoda developed was called the
“5 Whys.”
Goals and benefits

• The first goal of root cause analysis is to discover

the root cause of a problem or event.
Goals and benefits

• The second goal is to fully understand how to

fix, compensate, or learn from any underlying
issues within the root cause.
Goals and benefits

• The third goal is to apply what we learn from

this analysis to systematically prevent future
issues or to repeat successes.
How to conduct an effective root cause
analysis?: techniques and methods

5 Whys
How to conduct an effective root cause
analysis?: techniques and methods
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.
The 5 Whys Method:
For example:
• 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.
• The answer to the last why is the root cause of the initial problem of the
computer monitor not working.
How to conduct an effective root cause
analysis?: techniques and methods

Cause and effect

Fishbone diagram
How to conduct an effective root cause
analysis?: techniques and methods
Cause and effect Fishbone diagram
• Another common technique is creating a Fishbone
diagram, also called an Ishikawa diagram, to visually
map cause and effect. This can help identify possible
causes for a problem by encouraging us to follow
categorical branched paths to potential causes until we
end up at the right one. It’s similar to the 5 Whys but
much more visual.
Cause and effect Fishbone diagram

Common categories to consider • Product (or service)

in a Fishbone diagram: • Price

• Promotion (marketing)
• Machine (equipment, technology)
• Process (systems)
• Method (process)
• People (personnel)
• Material (includes raw material, consumables,
and information) • Physical evidence
• Man/mind power (physical or knowledge work) • Performance
• Measurement (inspection) • Surroundings (place, environment)
• Mission (purpose, expectation) • Suppliers
• Management / money power (leadership) • Skills
• Maintenance
Cause and effect
Fishbone diagram
In science and engineering, there are essentially
two ways of repairing faults and solving problems:

Reactive management
-consists in reacting quickly after the problem
occurs, by treating the symptoms. This type of
management is implemented by reactive systems.
-The goal here is to react quickly and alleviate the
effects of the problem as soon as possible
In science and engineering, there are essentially
two ways of repairing faults and solving problems:

Proactive management
-conversely, consists in preventing problems from occurring. Many
techniques can be used for this purpose, ranging from good
practices in design to analyzing in detail problems that have
already occurred, and taking actions to make sure they never
reoccur.
-Speed is not as important here as the accuracy and precision of
the diagnosis. The focus is on addressing the real cause of the
problem rather than its effects.
Work with a team and get fresh eyes

• Whether it’s just a partner or a whole team of

colleagues, any extra eyes will help us figure out
solutions faster and also serve as a check against
bias. Getting input from others will also offer
additional points of view, helping us to challenge
our assumptions.
Transition to corrective actions

• The goal of RCA is to identify the root cause of the problem. The
next step is to trigger long-term corrective actions to address the
root cause identified during RCA, and make sure that the
problem does not resurface. Correcting a problem is not formally
part of RCA, however; these are different steps in a problem-
solving process known as fault management in IT and
telecommunications, repair in engineering, remediation in
aviation, environmental
remediation in ecology, therapy in medicine, etc.
Application domains

• Manufacturing and industrial process control

• IT and telecommunications
• Health and safety
• Systems analysis
General RCA Corrective Action Process
Tips for performing effective root cause
analysis
• Ask questions to clarify information and bring us closer to
answers. The more we can drill down and interrogate every
potential cause, the more likely we are to find a root cause. Once
we believe we have identified the root cause of the problem (and
not just another symptom), we can ask even more questions:
Why are we certain this is the root cause instead of that? How
can we fix this root cause to prevent the issue from happening
again?
• Use simple questions like “why?” “how?” and “so what does that
mean here?” to carve a path towards understanding.