Root Cause Analysis

Root Cause Analysis

1. RCA helps identify what, how and why something heppened, thus preventing recurrence.

2. Root causes are underlying, are reasonably identifiable, can be controlled by management and allow for generation of recommendations.

3. The process involves data collection, cause charting, root cause identification and recommendation generation and implementation.

4. Four Major Steps

   • 1.- Data collection
     • The majority of time spent analysing an event is spent in gathering data.
   • 2.- Causal factor charting
     • Provides a structure for investigators to organize and analyze the information gathered during the investigation and identify gaps and deficiencies in knowledge as the investigation progresses.
     • Describes the event leading up to an occurrence, plus the conditions surrounding these events.
     • Casual factors are those contributors (human errors and component failures) that, if eliminated, would have either prevented the ocurrence or reduced its severity.
   • 3.- Root cause indentification
     • Involves the use of a decision diagram called the Root Cause Map to identify the underlying reason or reasons for each casual factor.
       • The map structures the reasoning process of the investigators by helping them answer questions about why particular casual factors exist or ocurred.
   • 4.- Recommendation generation and implementation
     • If the recommendations are not implemented, the efford expended in performing the analysis is wasted.
     • Organizations need to ensure that recommendations are tracked to completion.

5. Presentation of Results

   • Root causes summary tables can orginize the information compiled during data analysis, root cause identification and recommendation generation.
     • Each column represent a major aspect of the RCA process.
       • Firs column
         • A general description of the casual factor is presented along with sufficient background information for the reader to be able to understand the need to address this casual factor.
       • Second column
         • Shows the Path or Paths through the Root Cause Map associated with the causal factor.
           • Use of this three-column format aids the investigator in ensuring root causes and recommendations are developed for each causal factor.
       • Third column
         • Presents recommendations to address each of the root causes identified.
   • The end result of an RCA investigation is generally an investigation report.
     • The format of the report is usually well defined by the administrative documents governing the particular reporting system, but the completed causal factor chart and summary tables proveide most of the information required by most reporting systems.