Original Source
DECISIONS systems, inc.
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Root Cause Analysis
What is Root Cause Analysis (RCA)?
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General Definition
Generally speaking, root cause analysis is a procedure for
ascertaining and "analyzing" the causes of problems in an effort to
determine what can be done to solve or prevent them.
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An important element in the definition is the word procedure.
People in all fields within an organization routinely seek to solve their
problems to overcome the day-to-day obstacles to their goals. All members
of an organization are, in a sense, problem solvers. When we experience
problems in our operations, whether they be injuries, interruptions,
obstacles, errors, or counter-quality occurrences, we are all looking for
their "root causes" - those causes which we can remove from the picture,
and by doing so, prevent the problem from occurring again. Root cause
analysis is a "standard operating procedure," a formal process for
discovering these "root causes," and thus, understanding what can be done
to prevent them.
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Nearly all root cause analysis methods would subscribe to this
definition. But not all root cause analysis methods are created equal.
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What Root Cause Analysis Needs to Accomplish
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First let's clarify what it is we are talking about when we say
"preventive solutions." We are not talking about sticking a finger into
the dike. Repairing things, cleaning up, removing, reworking,
redesigning, modifying, and fortifying may temporarily solve the problem
but are not preventative measures that provide reliable control into the
future. In other words, these temporary fixes are at best "corrective"
steps - not preventive measures.
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For example, if solving a problem requires that we "redesign," then
reliable prevention of that problem must consider why the
design was inadequate in the first place. If a piece of equipment breaks
down, then repairing it will correct the problem, but
preventing it from happening again requires that we ask why
the equipment broke down. This is not to say that these corrective
responses are not important when things go wrong, but it is obvious that
the greater benefit will be achieved if we can design our operations so
as to avoid repair, rework, clean up, and expensive redesign. We are
trying to find something that someone can do to keep the problem from
ever happening again. Obviously, the act of cleaning up the mess every
time the problem occurs is not prevention.
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What Root Cause Analysis Needs to Include
There are many root cause analysis processes and methods on the market.
Decision Systems has been researching and developing root cause analysis
methodology for over 30 years. In this time, we have discovered that an
effective and reliable RCA process must provide three essential
qualities:
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- The process must take advantage of people's knowledge while
preventing their biases from controlling the direction of the
investigation.
Most people experienced at their jobs, will be able immediately to spot
something that might prevent recurrence of a problem. However, in most
operations, we will find that if the problem solving is done only through
the eyes of experience, the resulting solutions tend to be
one-dimensional. For example, a maintenance man sees something he can fix
to get the machine up and running again. The Engineer sees changing the
machine design as a way to avoid the same problem. The Production
supervisor sees a way to change the procedure to avoid the problem. The
Operations Manager may see an opportunity to farm the job out to a vendor
as the best solution to that same problem What is needed is a procedure
for problem solving that takes advantage of people’s experience and
expertise, while at the same time ensuring that these potential assets do
not limit the scope of the investigation.
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On the other hand, if the analysis process requires the analyst to
select the cause(s) he judges to be most significant from a prepared list
of causes, then it follows that at least part of the causal
structure producing the problem will not receive attention. The
same is true if the analysis process itself is geared to identify only one
root cause, and the analyst must decide which part of the problem on which
to focus his analysis. If part of the causal system that produced the
problem is overlooked, then avenues to potential solutions will not be
identified. Furthermore, there is no reason to believe that the solutions
that are identified are the most effective. In fact, it is even
possible that the analyst will choose to focus on a part of the causal
structure that leads to no solution whatsoever!
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If our root cause method allows the analyst to use his own judgment
to identify only what he considers to be the most significant root
causes, he is, in effect, being allowed to make management decisions.
Management’s broad knowledge of the organization’s budget, planning, goals
and limitations puts them in a position to make better decisions for the
organization. However, management can only do this well if all the options
are presented to them. If the analyst brings to management only those
solutions that made sense to him, he has effectively filtered away all the
other solutions available, and in so doing, has usurped management's
decision making process.
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So in a nutshell, the problem with subjective, fractured approaches is
this: They allow investigators to focus on the issues that they are
familiar with or those that they simply prefer to look at, and
consequently, overlook the rest. If a method allows an investigator to
focus on certain causes or categories of causes and overlook others, there
is no guarantee that he will arrive at an effective solution, let alone
the best solution.
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For these reasons, a complete root cause analysis requires a process that
leads us to accurately identify all of the corrective
opportunities available to us. We want our decision-makers to have
visibility of all of the available avenues toward
prevention. And we want them to be able to validate, compare and
evaluate the available options before allocating resources of the
organization. It is not possible to discover every potential solution
unless every cause that contributed to the event has been identified and
recorded. For this reason, the root cause analysis methodology
must be such that the analyst's personal experience, knowledge, and even
biases, are not allowed to limit the scope of the investigation.
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A process which ensures that all factors contributing to a problem are
identified so that all possible avenues of prevention can be evaluated is
an exclusive feature of the REASON system.
2. The process must depict the facts of the case so that
the causal relationships are clear and the causal relevance of
those facts can be verified.
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In is not only important that all of the facts contributing to the
problem be included; it is also important that only those facts
contributing to the problem be considered. Including facts which are not
causally relevant takes investigators down paths that will not produce
solutions to the problem, and in fact obscure the paths toward solution.
Root cause analysis needs a process which validates our causal reasoning
so that we can be sure we have included all of the relevant facts,
and at the same time, only the relevant facts.
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The REASON method orders and displays the facts of the event in a
format that makes it easy to check for accuracy and completeness at each
step.
3. The process must also help the analyst and management
understand what actions must be taken to implement potential
solutions and who in the organization needs to take those
actions.
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Once every possible avenue toward prevention is identified, the
analyst must understand what specific actions need to be taken. Is there
a policy already on the books that attempts to address the problem or is
a new policy needed? If a policy already exists, then why wasn't it
effective, and what steps do we need to take to make it effective in the
future? And who in our organization needs to take those steps? If the
appropriate action is not taken at the appropriate level in the
organization, then a sufficient level of control will not be established
to insure prevention into the future. These issues are part of the
process of identifying preventative measures and must be integrated into
the root cause analysis system.
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The REASON method teaches the principles governing corrective
action and integrates them into the root cause analysis process.
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For more information that can help you cost-effectively establish
and deploy a meaningful root cause analysis system, contact DECISION
systems, inc. (903) 236-9973 or email