Root Cause Analysis

(RCA)
& the Business Case
Analysis
 A technique that helps people
answer the question of why the
Root Cause problem occurred in the first place
Analysis seeks to identify the origin of a
(RCA) problem using a specific set of
steps, with associated tools, to
find the primary cause of the
problem
 Goals:
1. Determine what happened.
Root Cause 2. Determine why it happened.
Analysis 3. Figure out what to do to reduce
(RCA) the likelihood that it will happen
again.
Root Cause Analysis (RCA)
Three Types of Causes:
1. Physical causes – Tangible, material items failed in some way (for
example, a car's brakes stopped working).
2. 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).
3. 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).
Root Cause Analysis (RCA) Process
5 Steps
1. Define the problem
2. Collect the data
3. Identify possible causal factors
4. Identify the root cause(s)
5. Recommend and implement solutions
Root Cause Analysis (RCA) Process
Step One: Define the Problem
• What do you see happening?
• What are the specific symptoms?

Step Two: Collect Data

• What proof do you have that the problem exists?
• How long has the problem existed?
• What is the impact of the problem?
Root Cause Analysis (RCA) Process
Step Three: 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?

Tools: Cause and Effect Diagrams, Fishbone Diagrams, Ishikawa

Diagrams, Herringbone Diagrams or Fishikawa Diagrams
Cause and Effect Analysis
Cause and Effect Analysis
• devised by professor Kaoru Ishikawa, a pioneer of quality
management, in the 1960s
• the diagrams are known as Ishikawa Diagrams or Fishbone Diagrams
(because a completed diagram can look like the skeleton of a fish)
How to Use the Tool
Step 1: Identify the Problem
• First, write down the exact problem you face. Where appropriate,
identify who is involved, what the problem is, and when and where it
occurs.
• Then, write the problem in a box on the left-hand side of a large sheet
of paper, and draw a line across the paper horizontally from the box.
This arrangement, looking like the head and spine of a fish, gives you
space to develop ideas.
How to Use the Tool
Step 2: Work Out the Major Factors Involved
Next, identify the factors that may be part of the problem.

Example:
The manager identifies the following factors, and adds these to his diagram:
• Site.
• Task.
• People.
• Equipment.
• Control.
How to Use the Tool
Step 3: Identify Possible Causes
• Now, for each of the factors you considered in step 2, brainstorm
possible causes of the problem that may be related to the factor.
• Show these possible causes as shorter lines coming off the "bones" of
the diagram. Where a cause is large or complex, then it may be best
to break it down into sub-causes. Show these as lines coming off each
cause line.
How to Use the Tool
Step 4: Analyze Your Diagram
• By this stage you should have a diagram showing all of the possible
causes of the problem that you can think of.
• Depending on the complexity and importance of the problem, you
can now investigate the most likely causes further. This may involve
setting up investigations, carrying out surveys, and so on. These will
be designed to test which of these possible causes is actually
contributing to the problem.
Back to RCA
Root Cause Analysis (RCA) Process
Step Four: Identify the Root Cause(s)
• Why does the causal factor exist?
• What is the real reason the problem occurred?
Root Cause Analysis (RCA) Process
Step Five: 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?