What is Root Cause Analysis?
Before you can analyze root causes, you need to decide what you are looking for. The first definition of a “root cause” used by TapRooT® was:
“The most basic cause (or causes) that can reasonably be identified
that management has control to fix and, when fixed,
will prevent (or significantly reduce the likelihood of) the problem’s recurrence.”
But in 2008, we published a new definition for a root cause:
“A Root Cause is the absence of a best practice or the failure to apply knowledge
that would have prevented the problem.“
Therefore, root cause analysis is:
“The process of looking for the problems that can be fixed
when best practices and knowledge are applied.”
That may seem like a simple definition, but in finding root causes, the devil is in the details.
In the more than 30 years we have spent developing TapRooT® and improving it until is is an international best practice for root cause analysis, we have found several steps to finding root causes that just can’t be overlooked.
First, you have to understand the sequence of events that lead to an accident or incident BEFORE you can understand why it happened. This understanding comes from careful investigation and collection of facts and organizing those facts into a timeline.
In TapRooT® Courses, we teach investigators to start each investigation by drawing a SnapCharT® – a graphic “picture” of what happened and the facts around each step in the sequence of events.
Second, once the sequence of events and facts surrounding them are understood, investigators are taught to organize the events and facts and identify Causal Factors that, if eliminated, would have prevent the incident or made it less severe. Causal Factors are NOT root causes. Instead, the are the problems that are caused by the root causes. They are usually failed safeguards that were suppose to prevent the accident. These failed safeguards are often related to human errors and equipment failures that need to be prevented in the future to keep the accident from recurring.
Once the Causal Factors have been identified, the investigator is taught to look for each Causal Factor’s root causes.
That’s right. We aren’t looking for the root causes of the accident. Instead, we are looking for the root causes of the Causal Factors that came together on that particular day in that particular sequence to cause the accident. The root causes have often been around for years waiting for just the right sequence of events with the right Causal Factors to cause the accident.
In TapRooT®, we teach a technique called the Root Cause Tree® to help an investigator find the root causes of the Causal Factor. In most other root cause tools, the investigator is limited by their knowledge when analyzing root causes. In other words, that can’t find root causes that they aren’t aware of.
The Root Cause Tree® provides guidance to investigators to get them to consider potential causes beyond their preexisting knowledge by using a set of question and definitions to expand the potential causes that an investigator considers. This set of questions is an eye opener to both new investigators and experienced professionals because of the depth and breadth of the root causes that they are encouraged to consider.
In addition, once investigators get practiced using TapRooT®, they find they do a much better job collecting evidence earlier in an investigation because their eyes have been opened to new lines of inquiry that they previously would not have considered.
Once the specific root causes of the Causal Factors of an accident have been found, TapRooT® Courses teach investigators to look for generic causes.
Generic cause analysis takes the investigator from a root cause to the systemic reasons that the root cause was allowed to exist. For example, if a problem was caused by a valve not being labeled, generic cause analysis would check to see if other valves were also not labeled and, if they weren’t, why labels weren’t being applied (or were being lost) throughout the facility.
Once the root causes and generic causes are identified, the investigators are taught to use two tools – Corrective Action Helper® and SMARTER – to develop effective corrective actions that address the root and generic causes.
Finally in TapRooT® Courses, investigators are taught to present their finding to management so that management can understand what happened and the actions they need to promote to prevent recurrence of the accident.
That’s it! Using TapRooT®, root cause analysis is a systematic, repeatable, auditable process that is focused on finding and fixing the real root causes of problems so that future accidents and incidents can be prevented.
Want more information about TapRooT®? See:
For the various types of TapRooT® Root Cause Analysis Courses, see:
And if you are interested in TapRooT® Training, see our public TapRooT® Root Cause Analysis Courses that we hold around the world at:
Or to arrange a TapRooT® Root Cause Analysis Course at you site, CLICK HERE.