Root cause analysis

Root cause analysis (RCA) is a systematic method used to identify the underlying causes or factors that contribute to incidents, problems, or undesirable outcomes in various settings, including workplaces, healthcare, aviation, and manufacturing. The primary goal of RCA is to determine the root causes, rather than just addressing the symptoms, so that effective corrective and preventive actions can be taken to prevent recurrence. Here’s a step-by-step guide to performing root cause analysis:

1. Define the Problem or Incident:

• Clearly define the problem or incident that requires investigation. Ensure that the problem is well-defined and specific, and state its impact or consequences.

2. Assemble the RCA Team:

• Form a multidisciplinary team with individuals who have expertise in the area being investigated. Include personnel who were directly or indirectly involved in the incident.

3. Collect Data:

• Gather all relevant information about the incident, including incident reports, witness statements, documentation, photographs, and any available data or records.

4. Identify Immediate Causes:

• Identify the immediate or proximate causes of the incident. These are the events or actions that directly led to the problem.

5. Determine Contributing Factors:

• Identify the contributing factors that may have indirectly led to the incident. These factors can include human factors, equipment issues, communication problems, or process deficiencies.

6. Use RCA Tools and Techniques:

• Employ various RCA tools and techniques to systematically analyze the incident. Common tools include:
  • Fishbone Diagram (Ishikawa Diagram): Helps categorize potential causes into branches, such as people, processes, equipment, environment, and management.
  • 5 Whys Technique: Repeatedly ask “why” to drill down to the root cause of each identified factor.
  • Fault Tree Analysis (FTA): Construct a fault tree to diagram the logical relationships between events and contributing factors.
  • Barrier Analysis: Analyze the effectiveness of safety barriers or controls in preventing the incident.

7. Identify Root Causes:

• Continue asking “why” until you reach the fundamental root causes of the incident. Root causes are the underlying systemic issues that, if addressed, would prevent similar incidents in the future.

8. Validate Findings:

• Validate the identified root causes with the team and relevant stakeholders to ensure consensus and accuracy.

9. Develop Corrective and Preventive Actions (CAPAs):

• Based on the identified root causes, develop specific and actionable corrective and preventive actions (CAPAs) to address each root cause. CAPAs should be SMART (Specific, Measurable, Achievable, Relevant, Time-bound).