HSX MODULE: ROOT CAUSE ANALYSIS - hsdl.org

HSX MODULE: ROOT CAUSE ANALYSIS

March 2017

OVERVIEW

• Definition: Root-cause analysis is an evaluation method utilized for

the identification of root causes of an incident and subsequent

prevention of incident recurrence.

• The goal: comprehensive understanding of causal factors and

effective mitigation

• Components:

• “5-Whys”

• Causal Tree

• Application

Root Cause Analysis

A method primarily used to identify the underlying cause of an

incident or issue, and more effectively mitigate or prevent future

similar incidents

Rather than simply addressing the proximate cause, root cause

analysis seeks the root cause of an incident or issue

Highly effective tool for problem-solving

Proximate cause (direct cause) - occurs immediately prior to

the incident; directly results in its occurrence and, if eliminated

or modified, would have prevented the undesired outcome

Root Cause - One of multiple factors (events, conditions or

organizational factors) that created the proximate cause and

subsequent undesired outcome. Typically multiple root causes

contribute to an undesired outcome.

Source: Office of Safety & Mission Assurance. NASA, July 2003. Web. 16 Feb 2017.

http://www.au.af.mil/au/awc/awcgate/nasa/rootcauseppt.pdf

Causal Tree

• Undesired incident at the top

• Immediate causes below

• Continue to ask what the causes of the causes were until you

reach:

• root cause

• insufficient data

• issue that you cannot personally or organizationally resolve

Source: Office of Safety & Mission Assurance. NASA, July 2003. Web. 16 Feb 2017. http://www.au.af.mil/au/awc/awcgate/nasa/rootcauseppt.pdf

The 5-Whys Method

• Ask “why?” an undesired outcome occurred

• The answer to this question becomes the next “Why?”

question

• The 5-Why method can also be used to aid in the

creation of a causal tree

Source:Lifetime Reliability Solutions, “Understanding How to Use the 5-Whys for Root Cause Analysis.” Web. http://www.lifetime-

reliability.com/tutorials/lean-management-methods/How_to_Use_the_5-Whys_for_Root_Cause_Analysis.pdf

Application of Root Cause Analysis

• Mitigating undesired outcomes

• Preventing recurrence of undesired outcomes

• Fixing/streamlining systems and processes

• Root cause analysis has been applied in business, international risk

management, healthcare, and other diverse sectors

Key Takeaways

• Root cause analysis- Identifying the base causes of an

issue or incident, which may not be immediately

apparent

• Methods:

• Causal tree

• 5 Whys

• Potential for broad application across fields (see

literature resource sheet)

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Literary and Scholastic Resources – Root-Cause Analysis

Date of information: February 2017

Overview: While not exhaustive, the following resources provide a roadmap to understanding the process of root-

cause analysis and how this technique can aid problem-solving and mitigate issue recurrence.

Literary Resources:

Root Cause Analysis for Beginners: Rooney and Heuvel give an overview of methods for using root-cause

analysis to identify what, how, and why an undesired outcome occurs and preventing future recurrence.

o Cite: Rooney, J.J., Heuvel, L.N.V., 2004. Root Cause Analysis for Beginners. Quality Progress.

37, 45–56. Web.

https://www.env.nm.gov/aqb/Proposed_Regs/Part_7_Excess_Emissions/NMED_Exhibit_18-

Root_Cause_Analysis_for_Beginners.pdf

Techniques for Root Cause Analysis: Williams presents multiple techniques and processes of root cause

analysis at varying levels of depth and complexity to identify and mitigate root issues in processes.

o Cite: Williams, Patricia M., “Techniques for Root Cause Analysis.” Proceedings (Baylor

University. Medical Center) 14.2 (2001): 154–157. Web.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292997/

Understanding how to use the 5-Whys for root cause analysis: This document describes the proper

methodology for using the 5-Why technique—a method of root cause analysis—to accurately identify the

root cause of an issue and prevent recurrence.

o Cite: Lifetime Reliability Solutions, “Understanding How to Use the 5-Whys for Root Cause

Analysis.” Web. http://www.lifetime-reliability.com/tutorials/lean-management-

methods/How_to_Use_the_5-Whys_for_Root_Cause_Analysis.pdf

The Application of Formal Methods to Root Cause Analysis of Digital Incidents: Stephenson describes a

formal approach to the utilization of root cause analysis for incident response specifically in the domain of

security.

o Cite: Stephenson, Peter. “The Applications of Formal Methods to Root Cause Analysis of Digital

Incidents.” International Journal of Digital Evidence.3.1 (2004). Web.

https://www.utica.edu/academic/institutes/ecii/publications/articles/A0B62ABA-F4C9-CBCE-

8B9812B7B4055CAC.pdf

Other Scholastic Resources:

Presentations:

Root Cause Analysis Overview: This PowerPoint presentation presents suggested steps for root-cause

analysis and a distinction between proximate and root causes, as well as examples of application of the

method.

o Office of Safety & Mission Assurance. NASA, July 2003. Web. 16 Feb 2017.

http://www.au.af.mil/au/awc/awcgate/nasa/rootcauseppt.pdf

Root Cause Analysis: A Tool for Improvement: This PowerPoint presentation examines root causes

analysis as applied to systems.

o North Dakota Health Care Review, Inc., Center for Rural Health, UND School of Medicine,

October 11, 2006. Web. 16 Feb 2017.

http://www.health.state.mn.us/patientsafety/toolkit/rca_ndpresentation.pdf

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Analytical Tools:

Management Oversight Risk Tree: This webpage describes the Management Oversight Risk Tree (MORT),

a highly effective diagram used to identify underlying management root causes of hazards.

o Federal Aviation Administration, Management Oversight Risk Tree. Web. 16 Feb 2017.

http://www.hf.faa.gov/workbenchtools/default.aspx?rPage=Tooldetails&subCatId=43&toolID=15

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