October 7, 2009 | Dave Janney

Root Cause Analysis Tips – Follow the 7 Steps!

Happy Wednesday, and welcome to this week’s root cause analysis tips column.


I’m writing to you today from Nashville, where the 2009 TapRooT® summit is taking place.  We’ve had a successful set of pre-summit courses on Monday and Tuesday, and are kicking off the main events today.   If you were not able to join us this year, please consider joining us next year; the summit gets better every time it is held, so we would like to see you there.  Keep an eye out on our website for details about the 2010 event.


I wanted to share some information we discussed in the pre-summit course Ken Turnbull and I taught – Advanced TapRooT® Techniques, which is new and was developed for this year’s summit.  In this course, we cover the 7-Step process and share tips about how to best use each step, with a major focus on identification of causal factors.  We also do several exercises with events that have occurred, and that is really fun!


The only way you will identify all the causal factors for your incident is if you have a good SnapCharT®.  This is the foundation for the rest of your work, so you have to get it right.  I use this analogy in the course:


Good SnapCharT®=


Good Causal Factors=


Good Root Cause Analysis=


Good Corrective Actions=




So what are some of the issues I’ve seen with SnapCharT®s?  It is important that after you build your initial chart, you focus on missing events.  These events could be in the middle of the process flow; however, one of the common things I have seen is not starting the chain of events soon enough, so ask yourself “did anything happen before this first event that is important?”  Another thing to consider is whether you have included information about everyone involved.  I’ve seen a tendency to only focus on things within your control; however, if another department or work group was involved, that information needs to be included on your chart.  Finally, wording is critical – if you put effort into good descriptive elements of the chart, your job of defining causal factors will be much easier and you will be much less likely to miss any.


With a good chart in hand, you are ready to move into defining causal factors.  If you’ve done a good job on the chart, some of the causal factors will be obvious.  But what if you are having trouble?  The four step method, including the “so what?” question is essential.  After you’ve defined your causal factors, a best practice is asking yourself “does this meet the definition of a causal factor?”   Safeguards Analysis can also be very helpful in finding causal factors.


Once you have your causal factors identified, you move through steps 4-7 with ease, using the tools available for root cause analysis and corrective action.  Most of your time will be spent in steps 1-3, and it is critical that you take the time to follow the process and get it right so the rest of the process will flow smoothly.


If you have not been to a TapRooT® course before, please join us soon, the course schedule is HERE.  Until then, best of luck with your performance improvement efforts, and see you next year!

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