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Root Cause Analysis general principles and best practice guidelines, tools and process
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ROOT CAUSE ANALYSIS – TOOLS
AND PROCESS
CHARLES COTTER
15-16 MAY 2014
TRAINING PROGRAMME
OVERVIEW• Defining the fundamental concepts
• Building a Business Case for RCA
• 10 General Principles of RCA
• 3 Basic types of causes
• Foremost RCA tools and techniques
• The 5-step RCA process
INTRODUCTION
DEFINING THE
FUNDAMENTAL CONCEPTS
• Root cause
• Root Cause Analysis (RCA)
• Problem-solving
• 8-D Problem-solving process
TYPES OF SOLUTIONS• Mop-It (Temporary)
• Stop-It (Permanent/Sustainable)
DEFINING ROOT CAUSE
ANALYSIS (RCA)• RCA is a useful process for understanding and solving a problem. RCA is a
systematic process for identifying “root causes” of problems or events and an approach for responding to them.
• Wilson et al. (1993) have defined the Root Cause Analysis (RCA) as an analytic tool that can be used to perform a comprehensive, system-based review of critical incidents.
• It includes the identification of the root and contributory factors, determination of risk reduction strategies and development of action plans along with measurement strategies to evaluate the effectiveness of the plans.
• RCA is based on the basic idea that effective management requires more than merely “putting out fires” for problems that develop, but finding a way to prevent them.
• Essentially, RCA means finding the specific source(s) that created the problem so that effective action can be taken to prevent recurrence of the situation.
8-D PROBLEM-SOLVING
PROCESS
BUILDING A BUSINESS CASE
FOR
RCA• Purpose of RCA
• Goals of RCA
• Benefits of RCA
• Utility value and functionality of RCA
BENEFITS OF RCA• Identify barriers and the causes of problems,
so that permanent solutions can be found
• Develop a logical approach to problem-solving, using data that already exists in the organization
• Identify current and future needs for organizational improvement
• Establish repeatable, step-by-step processes, in which one process can confirm the results of another
10 GENERAL PRINCIPLES OF
RCA• RCA is a diagnostic and analytical tool
• Effective RCA is a systematic process
• Effective implementation of RCA requires a fundamental shift in attitudes and mindset
• RCA requires supportive organizational and management cultures
• Persistence and sustainability in the RCA effort
10 GENERAL PRINCIPLES OF
RCA• RCA is an efficient and economical process
• Effective problem statements and event descriptions are helpful, or even required
• RCA can help transform a reactive culture into a forward-looking culture and it also reduces the frequency of problems occurring over time within the environment
• RCA requires a collaborative, multidisciplinary team effort
• The focal points of RCA are corrective measures of root causes and not simply treating the symptoms of a problem or event
The focus of investigation and analysis through problem identification is WHY the
event occurred, and not who made the error i.e.
“Hard on the problem, soft on the person.”
BEST PRACTICE RCA
(COMPETENCE)
CONTENT
CONTEXT
PROCESS
THREE BASIC TYPES OF
CAUSES
• Physical
• Human
• Latent/Organizational
FOREMOST RCA TOOLS AND
TECHNIQUES
FOREMOST RCA TOOLS AND
TECHNIQUES• Brainstorming
• Cause Effect Analysis/Fishbone Diagram
• Fault Tree Analysis/Diagram
• 5-Why Analysis
• Force-field Analysis
• Failure Modes and Effects Analysis (FMEA)
CAUSE EFFECT/FISHBONE
DIAGRAM
FAULT TREE
ANALYSIS/DIAGRAM
FTA PROCESS
• Step 1: Define the fault condition, and write down the top level failure.
• Step 2: Using technical information and professional
judgments, determine the possible reasons for the failure to occur.
• Step 3: Continue to break down each element with additional gates to lower levels. Consider the relationships between the elements to help you decide whether to use an "and" or an "or" logic gate.
• Step 4: Finalize and review the complete diagram. The chain can only be terminated in a basic fault: human, hardware or software.
• Step 5: If possible, evaluate the probability of occurrence for each of the lowest level elements and calculate the statistical probabilities from the bottom up.
SUMMARY OF FTA SYMBOLS
5-WHY ANALYSIS
5-STEP DMAIC RCA PROCESS• Step 1: Define (What problem needs to be solved?)
• Step 2: Measure (collect data and evidence to determine the scope and magnitude of the problem)
• Step 3: Analyze (Identify and classify the root cause/s of the problem)
• Step 4: Improve (What are the countermeasures/solution to solve the problem?)
• Step 5: Control (Evaluate the effectiveness, impact and sustainability of the implemented solution)
DMAIC RCA PROCESS
(ILLUSTRATION)
STEP 1: DEFINE• Objective: Identify and define the problem
• Specify the nature, the magnitude, the location/s and the timing of events
• Use integrated methodology (quantitative and qualitative techniques)
Brainstorming
Fishbone Diagram or FTA Diagram
• Outcome: Definition of a well-formulated Problem Statement
STEP 2: MEASURE• Objective: Through the collection of data and
evidence, the determination of the scope and significance of the problem
• Preferred tools:
CATWOE or Situational Analysis
Application of Quantitative and Qualitative data collection methods
• Outcome: Development of a Scope-Significance Matrix and an in-depth understanding of the problem
CATWOE ANALYSIS
SCOPE-SIGNIFICANCE
MATRIX
High Scope- Low Significance (MODERATE PRIORITY)
High Scope-High Significance(HIG
H PRIORITY)
Low Scope-Low Significance
(LOW PRIORITY)
Low Scope-High Significance (MODERATE PRIORITY)
DATA COLLECTION METHODS
AND SOURCES OF DATA• The two (2) categories of data collection
methods:
Quantitative – numeric e.g. statistics Qualitative – subjective e.g. surveys and focus
groups
• The predominant sources of data:
Electronic Documentary Experimental Human
DATA COLLECTION PROCESS• Step 1: Develop a Data Collection plan/strategy
• Step 2: Data Collection
• Step 3: Data Collation
• Step 4: Data Analysis
• Step 5: Data Interpretation
• Step 6: Data Verification
• Step 7: Publication
STEP 3: ANALYZE• Objective: To identify the root cause/s of the
problem
• Preferred tool:
• 5-Why Analysis
• Outcome: Identification and classification of the underlying cause that must be addressed to alleviate/remedy the problem
5-WHY ANALYSIS TEMPLATE
STEP 4: IMPLEMENT• Identify countermeasures/solutions for the problem (by
means of creative and analytical thinking)
• Evaluate the proposed solutions (by means of a Decision Matrix) focused on the following criteria:
Viability Feasibility Sustainability
• Apply Risk Mitigation techniques:
FMEA Impact Analysis Force-field Analysis
• Implement the solution (by means of an Action Plan)
FORCE-FIELD ANALYSIS
IMPLEMENTATION ACTION
PLAN TEMPLATE
STEP 5: CONTROL• Objective: Evaluate the effectiveness, impact
and sustainability of the implemented solution
• Management tools:
Observe Monitor Evaluate Review Amend
CONCLUSION
• Key points
• Summary
• Questions
CONTACT DETAILS
• Charles Cotter
• (+27) 84 562 9446
• Twitter: Charles_Cotter