Root cause analysis - tools and process

ROOT CAUSE ANALYSIS – TOOLS

AND PROCESS

CHARLES COTTER

15-16 MAY 2014

TRAINING PROGRAMME

OVERVIEW• Defining the fundamental concepts

• Building a Business Case for RCA

• 10 General Principles of RCA

• 3 Basic types of causes

• Foremost RCA tools and techniques

• The 5-step RCA process

INTRODUCTION

DEFINING THE

FUNDAMENTAL CONCEPTS

• Root cause

• Root Cause Analysis (RCA)

• Problem-solving

• 8-D Problem-solving process

TYPES OF SOLUTIONS• Mop-It (Temporary)

• Stop-It (Permanent/Sustainable)

DEFINING ROOT CAUSE

ANALYSIS (RCA)• RCA is a useful process for understanding and solving a problem. RCA is a

systematic process for identifying “root causes” of problems or events and an approach for responding to them.

• Wilson et al. (1993) have defined the Root Cause Analysis (RCA) as an analytic tool that can be used to perform a comprehensive, system-based review of critical incidents.

• It includes the identification of the root and contributory factors, determination of risk reduction strategies and development of action plans along with measurement strategies to evaluate the effectiveness of the plans.

• RCA is based on the basic idea that effective management requires more than merely “putting out fires” for problems that develop, but finding a way to prevent them.

• Essentially, RCA means finding the specific source(s) that created the problem so that effective action can be taken to prevent recurrence of the situation.

8-D PROBLEM-SOLVING

PROCESS

BUILDING A BUSINESS CASE

FOR

RCA• Purpose of RCA

• Goals of RCA

• Benefits of RCA

• Utility value and functionality of RCA

BENEFITS OF RCA• Identify barriers and the causes of problems,

so that permanent solutions can be found

• Develop a logical approach to problem-solving, using data that already exists in the organization

• Identify current and future needs for organizational improvement

• Establish repeatable, step-by-step processes, in which one process can confirm the results of another

10 GENERAL PRINCIPLES OF

RCA• RCA is a diagnostic and analytical tool

• Effective RCA is a systematic process

• Effective implementation of RCA requires a fundamental shift in attitudes and mindset

• RCA requires supportive organizational and management cultures

• Persistence and sustainability in the RCA effort

10 GENERAL PRINCIPLES OF

RCA• RCA is an efficient and economical process

• Effective problem statements and event descriptions are helpful, or even required

• RCA can help transform a reactive culture into a forward-looking culture and it also reduces the frequency of problems occurring over time within the environment

• RCA requires a collaborative, multidisciplinary team effort

• The focal points of RCA are corrective measures of root causes and not simply treating the symptoms of a problem or event

The focus of investigation and analysis through problem identification is WHY the

event occurred, and not who made the error i.e.

“Hard on the problem, soft on the person.”

BEST PRACTICE RCA

(COMPETENCE)

CONTENT

CONTEXT

PROCESS

THREE BASIC TYPES OF

CAUSES

• Physical

• Human

• Latent/Organizational

FOREMOST RCA TOOLS AND

TECHNIQUES

FOREMOST RCA TOOLS AND

TECHNIQUES• Brainstorming

• Cause Effect Analysis/Fishbone Diagram

• Fault Tree Analysis/Diagram

• 5-Why Analysis

• Force-field Analysis

• Failure Modes and Effects Analysis (FMEA)

CAUSE EFFECT/FISHBONE

DIAGRAM

FAULT TREE

ANALYSIS/DIAGRAM

FTA PROCESS

• Step 1: Define the fault condition, and write down the top level failure.

 • Step 2: Using technical information and professional

judgments, determine the possible reasons for the failure to occur.

• Step 3: Continue to break down each element with additional gates to lower levels. Consider the relationships between the elements to help you decide whether to use an "and" or an "or" logic gate.

• Step 4: Finalize and review the complete diagram. The chain can only be terminated in a basic fault: human, hardware or software.

• Step 5: If possible, evaluate the probability of occurrence for each of the lowest level elements and calculate the statistical probabilities from the bottom up.

SUMMARY OF FTA SYMBOLS

5-WHY ANALYSIS

5-STEP DMAIC RCA PROCESS• Step 1: Define (What problem needs to be solved?)

• Step 2: Measure (collect data and evidence to determine the scope and magnitude of the problem)

• Step 3: Analyze (Identify and classify the root cause/s of the problem)

• Step 4: Improve (What are the countermeasures/solution to solve the problem?)

• Step 5: Control (Evaluate the effectiveness, impact and sustainability of the implemented solution)

DMAIC RCA PROCESS

(ILLUSTRATION)

STEP 1: DEFINE• Objective: Identify and define the problem

• Specify the nature, the magnitude, the location/s and the timing of events

• Use integrated methodology (quantitative and qualitative techniques)

Brainstorming

Fishbone Diagram or FTA Diagram

• Outcome: Definition of a well-formulated Problem Statement

STEP 2: MEASURE• Objective: Through the collection of data and

evidence, the determination of the scope and significance of the problem

• Preferred tools:

CATWOE or Situational Analysis

Application of Quantitative and Qualitative data collection methods

• Outcome: Development of a Scope-Significance Matrix and an in-depth understanding of the problem

CATWOE ANALYSIS

SCOPE-SIGNIFICANCE

MATRIX

High Scope- Low Significance (MODERATE PRIORITY)

High Scope-High Significance(HIG

H PRIORITY)

Low Scope-Low Significance

(LOW PRIORITY)

Low Scope-High Significance (MODERATE PRIORITY)

DATA COLLECTION METHODS

AND SOURCES OF DATA• The two (2) categories of data collection

methods:

Quantitative – numeric e.g. statistics Qualitative – subjective e.g. surveys and focus

groups

• The predominant sources of data:

Electronic Documentary Experimental Human

DATA COLLECTION PROCESS• Step 1: Develop a Data Collection plan/strategy

• Step 2: Data Collection

• Step 3: Data Collation

• Step 4: Data Analysis

• Step 5: Data Interpretation

• Step 6: Data Verification

• Step 7: Publication

STEP 3: ANALYZE• Objective: To identify the root cause/s of the

problem

• Preferred tool:

• 5-Why Analysis

• Outcome: Identification and classification of the underlying cause that must be addressed to alleviate/remedy the problem

5-WHY ANALYSIS TEMPLATE

STEP 4: IMPLEMENT• Identify countermeasures/solutions for the problem (by

means of creative and analytical thinking)

• Evaluate the proposed solutions (by means of a Decision Matrix) focused on the following criteria:

Viability Feasibility Sustainability

• Apply Risk Mitigation techniques:

FMEA Impact Analysis Force-field Analysis

• Implement the solution (by means of an Action Plan)

FORCE-FIELD ANALYSIS

IMPLEMENTATION ACTION

PLAN TEMPLATE

STEP 5: CONTROL• Objective: Evaluate the effectiveness, impact

and sustainability of the implemented solution

• Management tools:

Observe Monitor Evaluate Review Amend

CONCLUSION

• Key points

• Summary

• Questions

CONTACT DETAILS

• Charles Cotter

• (+27) 84 562 9446

• [email protected]

• LinkedIn

• Twitter: Charles_Cotter