Root Cause AnalysisWhat is Root Cause Analysis and why is it important.

What is a Root Cause Analysis?

Root Cause Analysis is a systematic method used in safety management to identify the underlying causes of incidents or near-misses, rather than just addressing the immediate symptoms. By determining the root causes, organizations can implement effective corrective actions to prevent recurrence.

RCA involves collecting data, analyzing the sequence of events, identifying causal factors, and implementing solutions to mitigate risks. This proactive approach not only enhances workplace safety but also improves overall operational efficiency by addressing systemic issues that contribute to unsafe conditions and behaviors.

Why is Root Cause Analysis Important?

Root Cause Analysis is an important process to understand how an event unfolded, why it happened, and what needs to be corrected. Too often, accident/incident investigations are closed based on correcting the symptoms of general or immediate causes. For example, Human error is the most cited reason for machine accidents, using an RCA investigative method, you may be able to gather that the error is due to external factors like poor lighting that may have affected the worker's vision while reading instructions.

RCA focuses on processes, not individuals, it takes into factor the underlying cause(s) that triggers a chain of events that leads to an accident. By correcting underlying problems, you not only eliminate the root of the problem but also the sequence of general and immediate causes that it generates - leading to a reduced risk of injury/accident, reduced costs due to the prevention of Lost Time Injury (LTI), expensive employee litigations or regulatory fines.

Benchmarking your process safety program with proper RCA tools will give you effective control over hazards, improved process reliability, boost employee confidence, decreased production costs, lower maintenance costs, and lower insurance premiums.

Root Cause Analysis problem-solving steps

Benefits of Root Cause Analysis

Root Cause Analysis is a powerful tool in safety management, offering numerous benefits that enhance problem-solving, improve performance, and ensure long-term safety improvements. Here are the key advantages of implementing RCA in your organization.

Unravel the source of a problem

Understand how a problem originated by systematically digging deep into its underlying cause.

Target the core problem not the symptom

Focus on uprooting the underlying or systemic causes, rather than the generalized or immediate.

Find permanent solutions to problems

By eliminating the source of the problem, you make sure that all contributing factors do not resurface.

Logical approach to problem-solving

Analyze data to identify barriers that exist, and ones that may emerge – facilitating constant improvement.

Optimize Cost & Performance

Mitigate the cost of incidents/accidents re-occurrence and drive long-term performance improvement.

Standardize training/work processes

Establish safer standards by implementing RCA findings in work processes and training.

How to Conduct a Root Cause Analysis?

Conducting a Root Cause Analysis involves a structured approach to identifying and addressing the underlying causes of problems, ensuring effective solutions and continuous improvement in safety management. Follow these steps to successfully implement RCA in your organization.

Define the problem

Critically analyze and clearly articulate the source of the problem to diagnose/ isolate the situation as the first step of a containment plan.

Gather Data

Compile, brainstorm, and map data to each process – analyzing the cause of the problem and the factors that lead to its occurrence.

Determine Root Causes

Identify the process that caused the problem, utilizing RCA tools like the Fishbone diagram, 5-Whys, Pareto charts, and more.

Test recorded solutions

Verify that the solution will eliminate the problem. Utilize measurable standards to test the identified cause and effect to take action to permanently fix the problem.

Implement CAPA

Turn data into actionable strategies. Methodically incorporate Corrective and Preventive Action (CAPA) to contain the problem and prevent re-occurrence.

Share the results

Document the results of the RCA findings and share the resource to standardize safety processes and training.

Tools used for Root Cause Analysis

RCA tools are used according to the specific approaches of various businesses and different situations. Here’s a look at 4 of the most used RCA tools:

Fishbone Diagram

Also known as the Ishikawa diagram or cause and effect diagram, learning how to use a fishbone diagram for root cause analysis will help you categorize all of the different factors that led to an issue. A fishbone diagram is shaped to resemble the skeletal structure of a fish, where the problems are placed at the fish’s head and the possible causes are categorized across its branches. A fishbone diagram is an effective RCA tool that helps you break down complex problems by brainstorming – focusing on it from various perspectives to cover all potential root causes.

5-Why Analysis

The” 5-Why Analysis” or “Why-Why” Analysis is a technique devised to identify the root cause by asking "Why" five times. As you keep drilling down a problem by asking "why", the countermeasure becomes more apparent - allowing you can take preventive action to eliminate the problem. While this method may not be useful for solving complex problems, it can serve a quick-fix that peels away from surface-level issues to zone-in to a root cause.

Pareto Analysis

A Pareto Chart is an RCA technique that unearths the underlying cause of a problem by indicating the frequency of defects and cumulative impact. Pareto analysis is based on the Pareto Principle, which states, “For many events, roughly 80% of the effects come from 20% of the causes”. By categorizing each defect, you have a quantitative approach to analyzing data; allowing you to determine the most prominent cause for defects based on the “80/20 Rule”.

FMEA (Failure Mode & Effects Analysis)

FMEA is a part of the robust Six-Sigma toolset for measuring process improvement. FMEA is a highly systematic approach for identifying and analyzing potential failures in processes and systems. Using a chart, FMEA prioritizes on unearthing potential defects based on their severity, expected frequency, and the likelihood of detection.

What Are the Common Workplace Incidents?

Incidents are a common part of any health and safety program. Implementing RCA as a part of an organization's occupational safety and health program enables you to identify how a hazard originates, fortify gaps found beneath the surface and prevent future incidents. Here is a list of common RCA scenarios that is prevalent.

Injuries and illnesses

When a worker severely injures himself from a fall, an RCA investigation takes into account several factors like human error, fall protections unavailability, slippery surface, lack of safety signs, poorly lit surrounding, no PPE, elevated platform malfunction or breakdown, and more. While narrowing down to the root cause, you may find that the inadequate safety training process led to the chain of surface-level issues.

Near misses

Imagine a scenario when a tool slips from a construction worker's hand and falls from a height, narrowly missing a passerby. While this is commonly put down due to human error, an RCA investigation will help you learn that introducing tool lanyards can help prevent tools from falling.

Learn more about the Safetymint Near miss reporting software.

Workplace violence

Violence in the workplace can take many forms including physical altercations, harassment, discrimination, and more. While most of these causes are attributed to stress, disgruntled employees, or uncongenial work environment. A Root Cause Analysis may help you identify that the lack of an Employee Assistance Program is the underlying cause of a hostile work environment.

Quality control problems

When a product does not conform to the quality standards set, it is time to get back to the drawing board. While surface-level problems may expose failure to add additional monitoring resources, a RCA may help you fine-tune quality processes by showing you that it is your management’s resistance to incorporate innovative technologies that are causing the problem.

Root Cause Analysis Templates

A root cause analysis template can be used according to your business domain. An RCA template typically contains the following:

Event description

Provide a comprehensive description of the problem or accident including the date and time, what happened, who witnessed the problem, impact, problem category, and risk analysis.

Timeline

A timeline graph helps you analyze each event that led to the problem before, during, and after CAPA measures are set – enabling you to accurately map problems to events.

Investigative Team/Method

Form teams and divide duties among team members to investigate the problem - providing instructions as to the methods used for collecting, analyzing, and reporting data.

Findings/Root Cause

Determine the root cause that is hindering progress from the reports made available to you by the investigative team.

Corrective Action

Specify Corrective Action and Preventive actions to teams to mitigate the problem— ensuring it doesn’t resurface again.

Commonly used RCA templates:

A Root Cause Analysis Template is generally categorized according to the various RCA tools available, including:

• Cause and Effect Template (Ishikawa “Fishbone” Diagram)
• Change Analysis Template
• 5-Whys Template
• Pareto Chart Template
• Scatter Diagram Template
• FMEA Template (Failure Mode & Effects Analysis)

FAQs

What is Root Cause?

According to OSHA, Root Cause is defined as the underlying, system-related reason why an incident occurred. Root causes generally reflect management, design, and planning, organizational and/or operational failings.

When should we conduct a root cause analysis?

A Root Cause Analysis should be performed when there is a breakdown in your organization's processes or systems that contributed to the non-conforming incident or accident.

What is the goal of conducting a root cause analysis?

The primary goal of conducting a root cause analysis is to analyze safety incidents or accidents to identify:

• What happened
• How did it happen
• Why it happened; and
• What needs to be corrected?

Who should perform a root cause analysis?

Ideally, RCA is performed by a team of accredited and well-trained individuals with the process and product knowledge, and authority to correct the problem.