The purpose of Root Cause Analysis (RCA) is to identify the facilitators of negatively impacting events and to take action to eliminate or mitigate future recurrence . As discussed in an earlier section, a Root Cause Analysis will contain the root cause(s) and also causal factor(s) (i.e. contributing factors) and Corrective & Preventative Actions (CAPA) associated with the event and analysis.
So how do we go about conducting a Root Causes Analysis? Over the years, many different professional practices and tools have been developed to aid, structure, and facilitate the Root Causes Analysis process. These tools can be used individually or multiple tools used in parallel. Tool usage is dependent on the type of event (including scale & scope), resources available, and knowledge of tool usage.
Root Causes Analysis and tool usage can be complex and viewed as part “Art” & part “Science”. Our recommendation is to first focus on the part “Science” by selecting a couple of common tools to become very knowledgeable in, and after that let the “Art” follow.
Before describing several of the common RCA tools listed below, we want to address why we are referring to these tools as “traditional”. We are doing so because they are known, proven and exert a level of effectiveness for singular event analysis. These tools are very effective at identifying root cause(s) and causal factor(s) on an individual event basis. The important word here is individual, these tools are great at identifying the unique issues of an event, but they are not suited for structuring and classifying data. The lack of structured data clarifications limits the ability to trend and perform predictive and preventative analysis as a holistic approach for event management.
The ThinkGRC Root Cause Analysis System (RCAS) is focused on structuring and classifying data for trend analysis which provides gigantic benefits for operational improvement. We believe that a combined approach of traditional tools for unique identification and a data driven approach as provided by ThinkGRC will give your organization the best possible program/system for Root Causes Analysis. We will discuss more about the ThinkGRC Root Causes Analysis System and the benefits of a data driven approach in future sections, for now let’s focus back on some of the traditional RCA tools available.
As a starter, and because we recommend investing in tools associated with standards, we will review Root Causes Analysis tools as recommended by the U.S. Department of Energy (DOE ) guideline with some additions/changes of our own. We of course recommend that you further research these tools for training, guidance, and application.
- Why Analysis (5 Why) – The Why or 5 Why Analysis maybe the most common Root Causes Analysis tool in use. The tool is based on the fundamental concept of investigation questioning such as: “who”, “what”, “when”, “where”, and “why”. More specifically it uses a drill-down methodology of continuously reexamining or asking “why” the event occurred until a root cause(s) is identified. The questions who, what, when & where are related to to causal factor (i.e. contributing factor) identification and the why questions are related to root causes. This tool is commonly referred to as “5 Whys” because it is said that (in general) you will find the root cause(s) of a problem by asking “why” 5 times. The why is asked in relation to the problem statement, and then in relation to the answer of each preceding question. In theory, you would ask and answer why 5 times finding the root cause(s), but in reality the “why” should be asked as many times as necessary to get to the root cause. This tool is great because it is simple, and can be used on any type of event. The simplicity comes from a very free form method, and it does not require significant training.
- Events and causal factor analysis — Widely used for major, single-event problems such as a refinery explosions, this process uses evidence gathered quickly and methodically to establish a timeline for the activities leading up to the accident. Once the timeline has been established, the causal factor(s) (contributing factors) and root cause(s) can be identified.
- Change analysis — This approach is applicable to situations where a system’s performance has shifted significantly. It explores changes made in people, equipment, information, and more that may have contributed to the change in performance.
- Barrier analysis — This technique focuses on what controls are in place in the process to either prevent or detect a problem, and which might have failed.
- Management oversight and risk tree analysis — One aspect of this approach is the use of a tree diagram to look at what occurred and why it might have occurred.
- Kepner-Tregoe Problem Solving and Decision Making — This model provides four distinct phases for resolving problems:
- Situation analysis
- Problem analysis
- Solution analysis
- Potential problem analysis
New Tools – Preventive/Predictive RCA – “Data” Driven
- ThinkGRC Root Cause Analysis System (RCAS) – The ThinkGRC RCAS is an issue/incident classification and root cause analysis system developed to help Information Technology (IT) professionals better understand how issues/incidents arising within technology are related to the management of operations, organizational structures, systems, and leadership. The goal of the ThinkGRC RCAS is to provide a structured classification system for problem & root cause identification, reporting, and trend analysis which is used to improve operational, technical, management decision making and risk management. Although IT focused, the ThinkGRC RCAS can be applied to any human or operational issue/incident.