What is THE Root Cause?
Start with a definition of Root Cause
Before you can find the root cause, you have to know what you are looking for. That’s why we developed a definition for a “root cause” and wrote an article about the definition (CLICK HERE for the article).
Our first definition of a root cause was:
ROOT CAUSE DEFINITION
The most basic cause (or causes)
that can reasonably be identified
that management has control to fix.
But we improved our definition over the years. The definition we now use is:
ROOT CAUSE DEFINITION
The absence of a best practice
or the failure to apply knowledge
that would have prevented the problem.
If you want to read about the history of our development of the definition of a root cause, CLICK HERE.
But What is THE Root Cause?
I often have people ask me what is “THE root cause” of an accident. The first thing I have to explain is there isn’t ONE root cause – THE Root Cause. Let me explain why there isn’t a single Root Cause…
But first, before you can understand the root causes, you have to understand what happened that caused the incident. What and how – not WHY. That’s why the TapRooT® Root Cause Analysis System starts out with a SnapCharT® Diagram to get a clear understanding of what happened and how it happened before trying to identify root causes.
What is a SnapCharT® Diagram? Here is a simple example…
Here is a more complex example drawn using the SnapCharT® Diagram module of the TapRooT® Software…
And here is a team developing a SnapCharT® Diagram as part of a TapRooT® Course…
Next, once you understand what/how it happened, you need to identify the Causal Factors before you can find the root causes.
What is a Causal Factor? Our definition is:
A mistake, error, or failure that directly leads to
(or causes) an Incident (the circle on the SnapCharT®) or
fails to mitigate the consequences of the original error.
This diagram might help you get the idea…
The “errors” are Causal Factors.:
- The error that allowed the energy to exist or grow too large,
- The error that allowed a Safeguard to fail.
- The error that allowed a Safeguard to be missing.
- The error that allowed a target to get too close to the energy.
- The error that allowed the incident to become worse (not pictured above).
In the TapRooT® System, we use Causal Factor Worksheets to identify all the Causal Factors. Tim talks about the worksheets in this video from 2020 (shortly after we developed the first Causal Factor Worksheet)…
We designate Causal Factors on a SnapCharT® Diagram with a triangle (see below).
In most incidents, there are multiple Causal Factors. Each Causal Factor can have one or more root causes. In the TapRooT® Root Cause Analysis System, we use the Root Cause Tree® Diagram and Dictionary to find the root causes of Causal Factors.
To read about how the TapRooT® Root Cause Tree® Diagram works, CLICK HERE.
Since each Causal Factor can have multiple root causes and because most incidents have multiple Causal Factors, most incidents have multiple root causes. There is no “THE Root Cause.” There are multiple root causes for a single incident.
Another way to think about it is that most incidents have more than one “best practice or the failures to apply knowledge.” Note that the quote in italics is from the definition of a root cause.
Finding THE Root Causes
If you are ready to learn to find the root causes of:
- Precursor incidents
- Quality issues
- Hospital sentinel events
- Equipment failures
- Cost overruns
- Operational upsets
- Lost time injuries
- Process safety incidents
You should consider attending TapRooT® Root Cause Analysis Training. What course should you attend? CLICK HERE for some courses to consider.
You can attend one of our public TapRooT® Courses being held around the world. See the dates and location HERE.
Or you can schedule a course at your site. Contact one of our TapRooT® Implementation Advisors by CLICKING ON THIS LINK or calling 865-539-2139.
Also, consider attending our annual Global TapRooT® Summit to benchmark your root cause analysis efforts with industry leaders from around the world. CLICK HERE for more Summit information.