Root Cause Analysis Fundamentals
(Definitions, Methods, Training,
Software, Evaluation, and Trending)

The root cause analysis fundamentals are necessary to help you effectively solve problems.

What is root cause analysis? Root cause analysis is a systematic process to find the root causes of problems.

“Get the fundamentals down, and
the level of everything you do will rise.”
– Michael Jordan

Getting the fundamentals right can be the difference between root cause analysis success and failure.

What are the root cause analysis fundamentals? This page explains:

• The definition of a root cause and root cause analysis,
• The best way to find root causes,
• Root cause analysis training,
• Root cause analysis software,
• Grading a root cause analysis, and
• Trending root cause analysis data.

Read on to learn more about all of these topics…

Definition of a Root Cause and Root Cause Analysis

To understand root cause analysis, you must define a root cause. A  definition we developed in the mid-1980s is:

Root Cause
The most basic cause(s)
that can reasonably be identified and
that management has control to fix.

HISTORY OF THE DEFINITION OF A ROOT CAUSE

Our current, modern definition of a root cause is:

Root Cause
The absence of a best practice
or the failure to apply knowledge
that would have prevented the problem.

By this definition, root cause analysis is:

root cause analysis
The systematic process of
finding the knowledge or best practices
needed to prevent a problem.

The Best Way to Find Root Causes

There are many methods to find root causes. Some say it can be as simple as asking, “Why?” However, this is not a very systematic process and a committee developing an industry standard for root cause analysis decided that asking why did not meet the minimum requirement for being a recommended root cause analysis tool. Also, ASQ published an article critical of 5-Whys (Under Scrutiny). Even Wikipedia lists criticisms of the 5-Why technique. Kevin McManus wrote a comparison of different root cause analysis tools at THIS LINK.

What happens when a root cause analysis tool is “too simple”? CLICK HERE for an explanation of the problems you will experience.

What root cause analysis tools or methods should you use? Here is guidance to help you pick the root cause analysis system you should implement:

1. First, you need to understand what happened. You can’t understand WHY an incident occurred if you don’t understand HOW it happened (what happened). So, your root cause analysis system should include a tool or tools to help the investigator collect and organize information and understand what happened.
2. Second, you need to identify the multiple Causal Factors (there are usually more than one) that caused the problem (the incident). Your root cause analysis system should have tools to help you identify Causal Factors. Identifying Causal Factors starts the root cause analysis.
3. Third, you will need to dig deeper and find each of the Causal Factor’s root causes. These are the causes of human performance and equipment reliability issues. We have found that investigators (even experienced investigators) need guidance – an expert system – to help them consistently identify the root causes of human performance and equipment reliability issues. This guidance should be part of a good root cause analysis system. Plus, the root cause analysis tool must find fixable causes of human error without placing blame. Blame is a major cause of failed root cause analysis.
4. Fourth, if this is a major issue, you should go beyond the specific root causes of this particular incident. For major investigations, you should look deeper for the Generic (systemic) Cause of each root cause. Not every root cause will have a Generic Cause. But, if you can identify the Generic Cause of a root cause, you may be able to develop corrective action that will eliminate a whole class of problems. Thus, your systematic process should guide you to find Generic Causes for major investigations.
5. Fifth, root cause analysis is useless if you don’t develop effective corrective actions (fixes) that will prevent the recurrence of incidents. We have seen that investigators may not be able to develop effective fixes for problems they haven’t seen fixed before. Therefore, your root cause analysis system should have guidance for developing effective fixes.
6. Finally, you will need management’s approval to make changes (the fixes) to prevent repeat problems. Thus, your root cause analysis system should include tools to effectively present what you have found and the corrective actions to management so they can approve the resources needed to make the changes happen.

If you have a system that guides you through the process outlined above and produces effective fixes, you will be well on your way to great root cause analysis and improved performance.

Root Cause Analysis Training

Having an effective root cause analysis system is just the start. You need to train the potential users (employees, supervisors, engineers, managers, and even senior executives) to use and understand the root cause analysis system. You should be careful to pick the best root cause analysis training. Training that helps incident investigators find the root causes of problems that they previously would have overlooked. Look for training that includes practical examples and allows the trainees to test the system using incidents from their facility/industry.

There are different types of root cause analysis training that your facility may need, including:

• General employee root cause analysis overviews.
• Basic root cause analysis training for investigating low-to-medium risk incidents.
• Specialized training for interviewing, evidence collection and preservation, and equipment troubleshooting.
• Advanced root cause analysis training for team leaders/facilitators.
• Continuing training and feedback to sharpen their root cause analysis skills (continuous improvement)
• Training for senior executives and managers to understand the root cause analysis system and their important roles in the root cause analysis process.

First, all employees that will be involved in investigations (either as part of an investigation team, as a facilitator, or as an interviewee) will need a basic understanding of the investigation process and tools. This helps them understand their role, and the process focused on finding fixable causes rather than placing blame. This training can usually be accomplished in a four to eight-hour root cause analysis introduction course.

Second, employees who will be performing basic investigations will need to know how to use the essential (minimum) root cause analysis tools to investigate simple incidents. This training can be accomplished in a two-day course or a 3-day virtual course.

Third, your investigators may need specialized training to conduct effective interviews, gather and preserve evidence, or troubleshoot equipment problems. This training can be combined with their basic training or be given as additional training to develop the investigator’s skills as they gain proficiency in the basic root cause analysis tools. This training can be designed to fit the employee’s needs and may take from four hours to several days, depending on the additional information provided.

Fourth, your facilitators (investigation experts) will need root cause analysis training to investigate major accidents. This will include in-depth knowledge of the root cause analysis tools, extensive practice, understanding of evidence collection techniques (including interviewing), understanding of human errors and equipment failures, and practice in developing effective corrective actions. This training covers the basics plus the additional skills needed to handle the investigation of major accidents. This training will probably take about five days. Additional experience investigating precursor incidents is suggested before the investigator is assigned to facilitate a major accident investigation.

Finally, all investigators need to hone their skills after their initial training. This should include reviews of their root cause analyses by experience investigators to provide feedback. Also, consider continuing training to sharpen and advance their root cause analysis skills.

INFORMATION ABOUT ROOT CAUSE TRAINING

Root Cause Analysis Software

Modern root cause analysis systems have software to facilitate their use and make them more effective. The best root cause analysis software should:

• Allow collaboration between team members
• Track investigation progress
• Provide advanced root cause analysis tools in an easy-to-use format
• Provide expert systems to help find root causes and develop effective fixes
• Provide presentation tools to help the investigator present the results of the investigation to management
• Track corrective actions
• Collect root cause data for trending
• Provide management with information about root cause data
• Connect with your QHSE software via an API

MORE ABOUT INVESTIGATION AND ROOT CAUSE ANALYSIS SOFTWARE

Grading a Root Cause Analysis

As we mentioned in the section on root cause analysis training, investigators need feedback on the effectiveness of their investigations and corrective actions to continually improve their skills. This feedback will help investigators continuously improve their root cause analysis skills (instead of having their skills decay over time).

One way to provide this feedback is to grade their investigation using a systematic grading tool. The tool should follow the suggestions provided in the section on performing a root cause analysis. A grading tool is built into the TapRooT® VI Software.

EXAMPLE OF ROOT CAUSE ANALYSIS GRADING TOOL

Trending Root Cause Analysis Data

Root cause analysis data can help:

• Find Generic Causes
• Measure improvement
• Spot areas needing improvement
• Spot developing problems

Many think that basic, linear graphing techniques are sufficient to provide effective root cause analysis trending. We have discovered that this isn’t true. Advanced trending techniques are needed to find trends in infrequently occurring safety data (and sometimes in quality, equipment reliability, human performance, and environmental incident data in high-reliability organizations).

What knowledge is required for advanced trending?

• How trends and graphs are misused.
• What are the best performance measures?
• How to use Pareto Charts to find areas begging for improvement.
• How the Pareto Principle works and when it IS NOT present.
• What is a Process Behavior Chart?
• The best way to use Process Behavior (XmR) Charts to spot real trends.
• How to use Rate Process Behavior Charts to spot problems in infrequently occurring (safety) data.
• How to use Interval Process Behavior Charts to prove that improvement has occurred in infrequently occurring (safety) data.
• The best way to prove your safety performance has improved.
• The charts management should use to manage safety, quality, equipment reliability, production, environmental, and financial performance.

LEARN MORE ABOUT TRENDING

Get More Information About Advanced Root Cause Analysis on our Executive Portal

Use the guidance on root cause analysis provided above to develop your road map to implement the best incident investigations for safety, quality, equipment reliability, environmental, operational excellence, and human performance problems. We would be glad to help analyze and improve your root cause analysis program. We can help you learn advanced root cause analysis both reactively and proactively to improve performance before a major accident occurs. Please visit our Executive Portal to request a free executive briefing.

Visit Executive Portal

To receive a FREE weekly newsletter about root cause analysis, incident investigation, and performance improvement, register using the form below.