Root Cause Analysis
Root cause analysis is a method of solving complex problems by breaking them down into simple cause-and-effect relationships. Root cause analysis identifies both the obvious and the underlying causes of an issue so that specific solutions can be implemented. A complete root cause analysis consists of a clear definition of the issue, a thorough analysis supported with evidence and a specific action plan for implementing the solutions.
A weed is a useful metaphor for root cause analysis. Solving the obvious problem by just pulling the top of the weed allows it to grow back. To eliminate the weed we have to get to the root. Getting to the root of a problem means digging into the underlying causes. Too often a problem investigation is over simplified and the analysis is stopped too early. What appeared to be a simple case of “human error” may not necessarily reflect the complex nature of the issue and ignore the work processes that contributed to the incident. Many groups also mistakenly believe that root cause analysis is about finding the one thing that caused the problem – the “root cause.”
The Cause Mapping approach to root cause analysis is a simple and effective method that provides a clear process for systematically investigating and solving any type of issue. The Cause Mapping method demonstrates how the cause-and-effect principle applies to all types of issues. Special emphasis is placed on connecting the solutions from the investigation back to the work processes where the incident started. A comprehensive root cause analysis collects and organizes all of the information related to a given problem in a coherent and intuitive format. Half of an investigation is the details and facts and the other half is the clear documentation of the incident with an action plan.
ThinkReliability provides investigations services, both on-site and remotely, and delivers Cause Mapping workshops to different disciplines within a variety of industries. Root cause analysis is done for safety incidents, production problems, customer service issues, equipment failures and operational delays and defects. Industries in which it is applied include manufacturing, refining, power, healthcare, aerospace, military, IT and food processing sectors. The two-day Cause Mapping workshop on root cause analysis is presented regularly at public venues across the United States. The majority of the workshops are client specific, presented at the client’s site by a ThinkReliability consultant.
Cause Mapping is a systems thinking approach to root cause analysis that improves the way individuals and groups analyze, document, communicate and solve problems. An incident, just like a system, consists of different parts that interacted in a particular way to create the undesired event or situation. The Cause Mapping approach is an extremely effective way of visually breaking down complex problems into basic cause-and-effect relationships. Just as a street map shows the layout of the streets a Cause Map shows the relationship of the causes. The Cause Mapping method is an easy to understand, structured process for capturing what is known and what is unknown about an issue. The visual Cause Map provides a simple way to literally see what actually happened.
Root cause analysis is typically considered to be a reactive tool because the investigation is conducted after the incident. In the Cause Mapping method a root cause analysis can be also be done proactively before an incident has occurred. This proactive approach can be used to develop visual troubleshooting guides on specific operations and as a risk management tool to understand the causal relationships of potential failure modes. A proactive root cause analysis shows how other reliability tools such as failure modes effects analysis (FMEA), reliability centered maintenance (RCM), hazard and operability analysis (HAZOP) and risk assessments all align because they are based on cause-and-effect.