What is Root Cause Analysis (RCA)?
Root Cause Analysis is a
systematic investigation for finding the ultimate or basic cause(s) of the failure
– it is by establishing the relation of all the chain of evidence-based logical
factors to the deepest significant underlying cause and identification of
corrective actions that prevent its recurrence and eventually protects the health
and safety of the people, system, and environment.
Since the process of RCA is
iterative and seeks continuous improvement through its investigation and
reporting process, so it is essential for RCA to include five critical phases
in its process.
- Data Collection
- Data Analysis
- Corrective Actions
- Recommendations
- Follow Up
What is not Root Cause Analysis (RCA)?
Effective RCA means that we understand the true cause of the failure. Most of the time all undesirable outcomes are the result of human errors, omission & commission errors, and process flaws. There are number of tools that are being used to examine the root cause of the failure as RCA methodologies, but many are actually not – which doesn’t meet the minimum criteria of the RCA process.
For example: many organizations consider
troubleshooting as RCA Tool, but this is not the case. Troubleshooting is a band-Aid
approach which tries to fix a situation quickly and restore the affected system
as soon as possible. Normally troubleshooting is a process performed by individuals
rather involves a whole team.
Similarly, brainstorming is a process
that is performed by field experts who put out different unsorted and disconnected
ideas as a cause of the failure. Counting this as a root cause analysis doesn’t
do suffice with the acceptable RCA criteria. This process despite being led by
field experts lacks a structured approach to find the cause-and-effect
relationship.
Problem solving is another tool companies
use to take in as root cause analysis since this process is the closest to the criteria
RCA has in the absence of approved standard. Problem solving is a team-based plus
it uses the structured approach towards data gathering – some of its tools might
follow cause-and-effect rule but some might not. Problem solving falls short of
the RCA Criteria because it does not require evidence to back up the teams hypothesize.
Aforementioned processes are not the RCA tools as lacks minimal participation and are concluded in a quick session considering all assumptions as a fact – times without collecting data or evidence to support the assumptions.
Essential Elements of a True Root Cause Analysis:
Owing to differentiate that the process is the root cause analysis or it’s not – some essential points are enlisted hereunder to which root cause analysis process is required to adhere:
- The real cause of the failure is required to be identified in the first place. It requires the problem to be analyzed even deeper till the first and foremost cause of the problem is identified.
- Identification of the cause-and-effect relationship that collectively results in the undesirable outcome.
- Collection of data should be disciplined and so is the preservation of the evidence to support the hypothesis is important.
- Identification of all physical, human, and latent root causes that are linked with the undesirable outcome. Identification of all system deficiencies that leads to poor decision making is also very important for the comprehensive RCA.
- After identification of all root reasons of the problem it is necessary to come up with corrective actions that prevent similar problem to arise in the future. If a good recommendation is not [properly] implemented, then the whole exercise of RCA is of no use.
- Last but not the least is the timely and effective communication to others about the lesson learned from analysis conclusion.
RCA is a thought process – it’s
not tangible but it involves cultural consideration, the complexities, and variabilities
of human mind. RCA delves deeply and seeks to extract out the root of the
problem so that the risk of recurrence of the event goes away one and for all.
There are multiple tools that are
being used as RCA tools such as 5 whys, fishbone diagram, fault tree analysis and
timeline analysis. that are good for problem solving but lacks the depth achieved
in real RCA – these are sometimes called as shallow cause analysis.
Obstacles in Implementing Effective Root Cause Analysis:
Failing to meet the required depth as desired by real root cause analysis have multiple reasons, multiple obstacles are faced by RCA analyst around the world.
- People don’t like change nor are they willing to change their behaviors. People don’t like to admit that they are at mistake and that’s the real obstacle to learning or concluding and effective root cause analysis.
- RCAs are not given priority – sometimes because of organization’s work environment that follows reactive approach and doesn’t accommodate such proactive activity, and sometimes a lack of personal incentives paves the way of not putting too many efforts into real root cause analysis.
- Another obstacle is the lack of time, since RCA is a hectic work which takes time and people are too busy for that.
- As there is no detailed defined standard for RCA process that how far you have to go in your analysis then people likely to settle for less
- “it’s a theoretical approach but is it practically possible?” is one of the main questions that impedes RCA process to conclude effectively.
- The culture of “Urgency” is another main problem that hinders learning from the incident because in organizations the call for urgent conclusion or solution doesn’t allow experts to delve deep into causes and probe more about the problem.
- Culture where short term results are rewarded.
- Lack of training and trained employees who know well about effective RCA tools and practices.
- People don’t understand the importance of root cause analysis that why it’s important to do RCA and learn from things that go wrong.
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