Root Cause Analysis

Tracing a Problem to its Origins

Learn how to use Root Cause Analysis
to fix problems more easily.

In medicine, it's easy to understand the difference between treating symptoms and curing a medical condition. Sure, when you're in pain because you've broken your wrist, you WANT to have your symptoms treated – now! However, taking painkillers won't heal your wrist, and true healing is needed before the symptoms can disappear for good.

But when you have a problem at work, how do you approach it? Do you jump in and start treating the symptoms? Or do you stop to consider whether there's actually a deeper problem that needs your attention?

If you only fix the symptoms – what you see on the surface – the problem will almost certainly happen again... which will lead you to fix it, again, and again, and again.

If, instead, you look deeper to figure out why the problem is occurring, you can fix the underlying systems and processes that cause the problem.

Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why the problem occurred in the first place.

RCA seeks to identify the origin of a problem. It uses a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

  1. Determine what happened.
  2. Determine why it happened.
  3. Figure out what to do to reduce the likelihood that it will happen again.

RCA assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, you can discover where the problem started and how it grew into the symptom you're now facing.

You'll usually find three basic types of causes:

  1. Physical causes – Tangible, material items failed in some way (for example, a car's brakes stopped working).
  2. Human causes – People did something wrong, or did not do something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing).
  3. Organizational causes – A system, process, or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid).

RCA looks at all three types of causes. It involves investigating the patterns of negative effects, finding hidden flaws in the system, and discovering specific actions that contributed to the problem. This often means that RCA reveals more than one root cause.

You can apply RCA to almost any situation. Determining how far to go in your investigation requires good judgment and common sense. Theoretically, you could continue to trace root causes back to the Stone Age, but the effort would serve no useful purpose. Be careful to understand when you've found a significant cause that can, in fact, be changed.

The Root Cause Analysis Process

RCA has five identifiable steps.

Step One: Define the Problem

  • What do you see happening?
  • What are the specific symptoms?

Step Two: Collect Data

  • What proof do you have that the problem exists?
  • How long has the problem existed?
  • What is the impact of the problem?

You need to analyze a situation fully before you can move on to look at factors that contributed to the problem. To maximize the effectiveness of your RCA, get together everyone – experts and front line staff – who understands the situation. People who are most familiar with the problem can help lead you to a better understanding of the issues.

A helpful tool at this stage is CATWOE  . With this process, you look at the same situation from different perspectives: the Customers, the people (Actors) who implement the solutions, the Transformation process that's affected, the World view, the process Owner, and Environmental constraints.

Step Three: Identify Possible Causal Factors

  • What sequence of events leads to the problem?
  • What conditions allow the problem to occur?
  • What other problems surround the occurrence of the central problem?

During this stage, identify as many causal factors as possible. Too often, people identify one or two factors and then stop, but that's not sufficient. With RCA, you don't want to simply treat the most obvious causes – you want to dig deeper.

Use these tools to help identify causal factors:

  • Appreciation   – Use the facts and ask "So what?" to determine all the possible consequences of a fact.
  • 5 Whys   – Ask "Why?" until you get to the root of the problem.
  • Drill Down   – Break down a problem into small, detailed parts to better understand the big picture.
  • Cause and Effect Diagrams   – Create a chart of all of the possible causal factors, to see where the trouble may have begun.

Step Four: Identify the Root Cause(s)

  • Why does the causal factor exist?
  • What is the real reason the problem occurred?

Use the same tools you used to identify the causal factors (in Step Three) to look at the roots of each factor. These tools are designed to encourage you to dig deeper at each level of cause and effect.

Step Five: Recommend and Implement Solutions

  • What can you do to prevent the problem from happening again?
  • How will the solution be implemented?
  • Who will be responsible for it?
  • What are the risks of implementing the solution?

Analyze your cause-and-effect process, and identify the changes needed for various systems. It's also important that you plan ahead to predict the effects of your solution. This way, you can spot potential failures before they happen.

One way of doing this is to use Failure Mode and Effects Analysis   (FMEA). This tool builds on the idea of risk analysis to identify points where a solution could fail. FMEA is also a great system to implement across your organization; the more systems and processes that use FMEA at the start, the less likely you are to have problems that need RCA in the future.

Impact Analysis   is another useful tool here. This helps you explore possible positive and negative consequences of a change on different parts of a system or organization.

Another great strategy to adopt is Kaizen  , or continuous improvement. This is the idea that continual small changes create better systems overall. Kaizen also emphasizes that the people closest to a process should identify places for improvement. Again, with Kaizen alive and well in your company, the root causes of problems can be identified and resolved quickly and effectively.

Key Points

Root Cause Analysis is a useful process for understanding and solving a problem.

Figure out what negative events are occurring. Then, look at the complex systems around those problems, and identify key points of failure. Finally, determine solutions to address those key points, or root causes.

You can use many tools to support your RCA  process. Cause and Effect Diagrams   and 5 Whys   are integral to the process itself, while FMEA   and Kaizen   help minimize the need for RCA in the future.

As an analytical tool, RCA is an essential way to perform a comprehensive, system-wide review of significant problems as well as the events and factors leading to them.

Click on the button below to download a template that will help you log problems, likely root causes and potential solutions. Thanks to Club member weeze for providing the basis for this.

Download Worksheet

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Comments (9)
  • Dianna wrote Over a month ago
    Yes, it does take practice... particularly when you are dealing with real issues that are complex with many interrelated variables. And it's tempting to cut corners but often that's when the real 'root' gets missed. After a few tries and some experimentation i think you'll really enjoy using the tool. I'm glad you have a bit more clarity now. Let us know how it goes.

    Dianna
  • theapprenticesct wrote Over a month ago
    Thanks for your instant reply Diana,
    Your example is very straight to the point and effective for me to visualize the steps. I clearly understand the steps now. Just that I have to practice more in order to fully see how these steps can be effectively applied in real and complex problems.

    Sincerely.
  • Dianna wrote Over a month ago
    Hi,
    Root cause analysis can be tricky because it is asking you to go beyond the obvious causes, which are often just symptoms, and try to dig down to the real root. So in step one you are merely describing what is happening. I.e. I am losing customers. People who have been long term customers are coming in less often and I'm seeing fewer new faces as well.

    Step two: data collection. I know I'm losing customers because revenue is down. I am not tuning over inventory like I used to. The decline has happened over the last six months and my quarterly numbers are all down about 20%.

    By breaking these two steps apart it forces you to start separating the problem from the symptoms. It's a subtle shift but it will help you as you start digging deeper into the 'why'. And at this stage you go beyond your own thoughts on the problem and look elsewhere for 'proof' that the problem you have identified is real and valid.

    Steps three and four are different because in step three you are listing all the possible causal factors. But you aren't necessarily looking at the root cause.You are basically brainstorming all the possible causes. This step is important because you start looking at the problem from a variety of angles and potentially uncovering causes that you weren't aware of previously. I.e. there are fewer customers because 1) my marketing is getting old. 2) the store needs a makeover 3) inventory isn't as excitingly because it doesn't move fast and I can't get new product in.

    Then with step four you analyze each of the causal factors you identified in three and look for a common root. What is underlying all of these factors and truly causing the problem?

    In the example a plausible root cause is the way that ordering is done. Quantities of each product are too high therefore products don't turnover quick enough and the store gets 'stale'. It's easier to maker a steady stream of new products. A makeover can be done each time you get new product in. And inventory will be more exciting.

    I realize this is a simplistic example, however I hope it helps to illustrate why each step is different and how they build on each other to help you get to the real root.

    Make a bit more sense?

    Dianna
  • theapprenticesct wrote Over a month ago
    Hi all,
    I have two questions regarding the "Root Cause Analysis Process".
    First one is, in step one, we have to recognize that the problem exists and we have to list all the symptoms of the problem. Doesn't it mean that we are seeking for the proof that the problem exists, which is mentioned in step two?

    What is the difference between them?

    Secondly, why do we have to split the step three and step four since they use the same method. The way I see it is that we list all the causes of the problem and then decide which one is the most significant cause. Am I understanding it in the right way?

    Many thanks.
  • Helena wrote Over a month ago
    Hi everyone

    A generic version of weeze's excellent template can be downloaded here:

    http://www.mindtools.com/pages/article/ ... wnload.htm

    Many thanks for sharing this, weeze!

    Best wishes

    Helena
  • dp7622 wrote Over a month ago
    Hi Weeze,

    I think the article agrees with your observation about FMEA

    This way, you can spot potential failures before they happen.

    One way of doing this is to use Failure Mode and Effects Analysis (FMEA). This tool builds on the idea of risk analysis to identify points where a solution could fail. FMEA is also a great system to implement across your organization; the more systems and processes that use FMEA at the start, the less likely you are to have problems that need Root Cause Analysis in the future.

    Either way, FMEA is a great tool and I'd love to see the template you use.

    Don
  • weeze wrote Over a month ago
    James

    Thanks for your comments. I actually use FMEA's alot , but mainly in development projects, so my comment came from experience rather than an insight out of reading the article

    Will definitely send you my template

    Weeze
  • James wrote Over a month ago
    Hi Weeze

    FMEA isn't used so much during Root Cause Analysis (other than as a way of brainstorming possible points of failure), however it's a great tool to use as part of developing and stress-testing a possible solution, so that it's as robust as possible.

    And we'd love to see the template! Could you please mail it to me at jmanktelow@mindtools.com, and I'll arrange for it to be posted.

    James
  • weeze wrote Over a month ago
    Root cause analysis is a great tool for solving problems. I have my own template I use to help me get to the solution with optimum impact on resolving the issue

    Having read the article I am not sure about the use of FMEA once the problem has already occured. The focus of FMEA is about highlighting the possible problems before they occur, so that you can make sure then don't happen. Would be interested to hear if anyone uses it in the way suggested in the article

    Jag - How do I share an attachment ?

    Weeze

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