Mark Paradies and
Benna Hughes discuss
the fundamentals of
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

This page discusses:

  • 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 data.

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 1980s is:

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

For a history of the definition of a root cause see:

https://www.taproot.com/the-history-of-the-definition-of-a-root-cause/

Our most modern and current 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:

The systematic process of finding the
knowledge or best practice 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. What happens when your root cause analysis tool is “too simple”? CLICK HERE for an explanation of the problems you will experience.

How do we find root causes? What root cause tools or methods should you use? Here is guidance for those deciding what their root cause analysis system should include:

  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 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 these points that will be the start of finding root causes.
  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 the root cause analysis system. Plus, it is important that the root cause analysis tool finds fixable causes of human error without placing blame. Blame is a major cause of failed root cause analysis.
  4. Fourth, this may should strange, but if this is a major issue, you should go beyond the specific root causes of this particular incident. For major investigations, you should look one level 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 repeat 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 to get management approval to make the 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 improving performance.

Root Cause Analysis Training

Having an effective root cause system is just the start. You need to train the potential users (employees, supervisors, engineers, and managers) how to use the system. You should be careful to pick the best root cause 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 training that your facility may need, including:

  • General employee root cause indoctrination.
  • Basic root cause analysis training for investigating low-to-medium risk incidents.
  • Specialized training on 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 skills (continuous improvement)

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’ focussed on finding fixable causes rather than placing blame. This training can usually be accomplished in a four to eight-hour 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 usually be accomplished in a two-day 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 amount of additional information provided.

Fourth, your facilitators (investigation experts) will need 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 human error and equipment failure, and practice 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 a week. 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 the investigations by experience investigation experts to provide feedback and continuing training to sharpen and advance their skills.

For information about root cause analysis training, CLICK HERE.

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 that root cause data

For more on investigation and root cause analysis software, CLICK HERE.

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 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. An example of a root cause analysis grading tool can be found by CLICKING HERE.

Another way to have investigators practice using their root cause analysis skills is to use their skills proactively as part of audits, assessments, or behavior-based safety observations.

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 if you have a significant number of days without a lost time injury.
  • The charts management should use to manage safety, quality, equipment reliability, production, environmental, and financial performance.

For more information about trending training, CLICK HERE.

We hope that this guidance on root cause analysis has helped you develop a road map to design the best incident investigations for safety, quality, equipment reliability, environmental, operational excellence, and human performance problems. Would you like our help analyzing and improving your root cause analysis program? Please contact us by CLICKING HERE. Also, we would be happy to help you learn to use root cause analysis proactively to improve performance before a major accident occurs.

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