Root cause analysis,

explained with examples and

methods
The easiest way to understand root cause analysis is to think about common problems. If we’re
sick and throwing up at work, we’ll go to a doctor and ask them to find the root cause of our
sickness. If our car stops working, we’ll ask a mechanic to find the root cause of the problem. If
our business is underperforming (or overperforming) in a certain area, we’ll try to find out why.

For each of these examples, we could just find a simple remedy for each symptom. To stop
throwing up at work, we might stay home with a bucket. To get around without a car, we might
take the bus and leave our broken car at home. But these solutions only consider the symptoms
and do not consider the underlying causes of those symptoms—causes like a stomach infection
that requires medicine or a busted car alternator that needs to be repaired. To solve or analyze a
problem, we’ll need to perform a root cause analysis and find out exactly what the cause is and
how to fix it.

In this article, we’ll define root cause analysis, outline common techniques, walk through a
template methodology, and provide a few examples.

Ok. So what is root cause analysis?

Root cause analysis (RCA) is the process of discovering the root causes of problems in order to
identify appropriate solutions. RCA assumes that it is much more effective to systematically
prevent and solve for underlying issues rather than just treating ad hoc symptoms and putting out
fires.

Root cause analysis can be performed with a collection of principles, techniques, and
methodologies that can all be leveraged to identify the root causes of an event or trend. Looking
beyond superficial cause and effect, RCA can show where processes or systems failed or caused
an issue in the first place.

Goals and benefits

The first goal of root cause analysis is to discover the root cause of a problem or event.

The second goal is to fully understand how to fix, compensate, or learn from any underlying
issues within the root cause.
The third goal is to apply what we learn from this analysis to systematically prevent future
issues or to repeat successes.

Analysis is only as good as what we do with that analysis, so the third goal of RCA is important.
We can use RCA to also modify core process and system issues in a way that prevents future
problems. Instead of just treating the symptoms of a football player’s concussion, for example,
root cause analysis might suggest wearing a helmet to reduce the risk of future concussions.

Treating the individual symptoms may feel productive. Solving a large number of problems
looks like something is getting done. But if we don’t actually diagnose the real root cause of a
problem we’ll likely have the same exact problem over and over. Instead of a news editor just
fixing every single omitted Oxford comma, she will prevent further issues by training her writers
to use commas properly in all future assignments.

Core principles
There are a few core principles that guide effective root cause analysis, some of which should
already be apparent. Not only will these help the analysis quality, these will also help the analyst
gain trust and buy-in from stakeholders, clients, or patients.

 Focus on correcting and remedying root causes rather than just symptoms.
 Don’t ignore the importance of treating symptoms for short term relief.
 Realize there can be, and often are, multiple root causes.
 Focus on HOW and WHY something happened, not WHO was responsible.
 Be methodical and find concrete cause-effect evidence to back up root cause claims.
 Provide enough information to inform a corrective course of action.
 Consider how a root cause can be prevented (or replicated) in the future.

As the above principles illustrate: when we analyze deep issues and causes, it’s important to take
a comprehensive and holistic approach. In addition to discovering the root cause, we should
strive to provide context and information that will result in an action or a decision. Remember:
good analysis is actionable analysis.

How to conduct an effective root cause

analysis: techniques and methods
There are a large number of techniques and strategies that we can use for root cause analysis, and
this is by no means an exhaustive list. Below we’ll cover some of the most common and most
widely useful techniques.
5 Whys
One of the more common techniques in performing a root cause analysis is the 5 Whys approach.
We may also think of this as the annoying toddler approach. For every answer to a WHY
question, follow it up with an additional, deeper “Ok, but WHY?” question. Children are
surprisingly effective at root cause analysis. Common wisdom suggests that about five WHY
questions can lead us to most root causes—but we could need as few as two or as many as 50
WHYs.

Example: Let’s think back to our football concussion example. First, our player will present a
problem: Why do I have such a bad headache? This is our first WHY.
First answer: Because I can’t see straight.
Second why: Why can’t you see straight?
Second answer: Because I my head hit the ground.
Third why: Why did your head hit the ground?
Third answer: I got hit tackled to the ground and hit my head hard.
Fourth why: Why did hitting the ground hurt so much?
Fourth answer: Because I wasn’t wearing a helmet.
Fifth why: Why weren’t you wearing a helmet?
Fifth answer: Because we didn’t have enough helmets in our locker room.

Aha. After these five questions, we discover that the root cause of the concussion was most
likely from a lack of available helmets. In the future, we could reduce the risk of this type of
concussion by making sure every football player has a helmet. (Of course, helmets don’t make us
immune to concussions. Be safe!)

The 5 Whys serve as a way to avoid assumptions. By finding detailed responses to incremental
questions, answers become clearer and more concise each time. Ideally, the last WHY will lead
to a process that failed, one which can then be fixed.

Change Analysis/Event Analysis

Another useful method of exploring root cause analysis is to carefully analyze the changes
leading up to an event.
This method is especially handy when there are a large number of potential causes. Instead of
looking at the specific day or hour that something went wrong, we look at a longer period of time
and gain a historical context.

1. First, we’d list out every potential cause leading up to an event. These should be any time a
change occurred for better or worse or benign.

Example: Let’s say the event we’re going to analyze is an uncharacteristically successful day of
sales in New York City, and we wanted to know why it was so great so we can try to replicate it.
First, we’d list out every touch point with each of the major customers, every event, every
possibly relevant change.
2. Second, we’d categorize each change or event by how much influence we had over it. We can
categorize as Internal/External, Owned/Unowned, or something similar.

Example: In our great Sales day example, we’d start to sort out things like “Sales representative
presented new slide deck on social impact” (Internal) and other events like “Last day of the
quarter” (External) or “First day of Spring” (External).

3. Third, we’d go event by event and decide whether or not that event was an unrelated factor, a
correlated factor, a contributing factor, or a likely root cause. This is where the bulk of the
analysis happens and this is where other techniques like the 5 Whys can be used.

Example: Within our analysis we discover that our fancy new Sales slide deck was actually an
unrelated factor but the fact it was the end of the quarter was definitely a contributing factor.
However, one factor was identified as the most likely root cause: the Sales Lead for the area
moved to a new apartment with a shorter commute, meaning that she started showing up to
meetings with clients 10 minutes earlier during the last week of the quarter.

4. Fourth, we look to see how we can replicate or remedy the root cause.

Example: While not everyone can move to a new apartment, our organization decides that if
Sales reps show up an extra 10 minutes earlier to client meetings in the final week of a quarter,
they may be able to replicate this root cause success.

Cause and effect Fishbone diagram

Another common technique is creating a Fishbone diagram, also called an Ishikawa diagram, to
visually map cause and effect. This can help identify possible causes for a problem by
encouraging us to follow categorical branched paths to potential causes until we end up at the
right one. It’s similar to the 5 Whys but much more visual.

Typically we start with the problem in the middle of the diagram (the spine of the fish skeleton),
then brainstorm several categories of causes, which are then placed in off-shooting branches
from the main line (the rib bones of the fish skeleton). Categories are very broad and might
include things like “People” or “Environment.” After grouping the categories, we break those
down into the smaller parts. For example, under “People” we might consider potential root cause
factors like “leadership,” “staffing,” or “training.”

As we dig deeper into potential causes and sub-causes, questioning each branch, we get closer to
the sources of the issue. We can use this method eliminate unrelated categories and identify
correlated factors and likely root causes. For the sake of simplicity, carefully consider the
categories before creating a diagram.

Common categories to consider in a Fishbone diagram:

 Machine (equipment, technology)

  Method (process)
 Material (includes raw material, consumables, and information)
 Man/mind power (physical or knowledge work)
 Measurement (inspection)
 Mission (purpose, expectation)
 Management / money power (leadership)
 Maintenance
 Product (or service)
 Price
 Promotion (marketing)
 Process (systems)
 People (personnel)
 Physical evidence
 Performance
 Surroundings (place, environment)
 Suppliers
 Skills

Tips for performing effective root

cause analysis
Ask questions to clarify information and bring us closer to answers. The more we can drill down
and interrogate every potential cause, the more likely we are to find a root cause. Once we
believe we have identified the root cause of the problem (and not just another symptom), we can
ask even more questions: Why are we certain this is the root cause instead of that? How can we
fix this root cause to prevent the issue from happening again?

Use simple questions like “why?” “how?” and “so what does that mean here?” to carve a path
towards understanding.

Work with a team and get fresh eyes

Whether it’s just a partner or a whole team of colleagues, any extra eyes will help us figure out
solutions faster and also serve as a check against bias. Getting input from others will also offer
additional points of view, helping us to challenge our assumptions.

Plan for future root cause analysis

As we perform a root cause analysis, it’s important to be aware of the process itself. Take notes.
Ask questions about the analysis process itself. Find out if a certain technique or method works
best for your specific business needs and environments.

Remember to perform root cause analysis for

successes too
Root cause analysis is a great tool for figuring out where something went wrong. We typically
use RCA as a way to diagnose problems but it can be equally as effective to find the root cause
of a success. If we find the cause of a success or overachievement or early deadline, it’s rarely a
bad idea to find out the root cause of why things are going well. This kind of analysis can help
prioritize and preemptively protect key factors and we might be able to translate success in one
area of business to success in another area

https://www.tableau.com/learn/articles/root-cause-analysis
The dictionary defines “root cause” as the fundamental cause, basis, or essence of something, or
the source from which something derives.

Root cause analysis defined

Root cause analysis (RCA) is a systematic process for identifying “root causes” of problems or
events and an approach for responding to them. 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.

RCA helps pinpoint contributing factors to a problem or event

RCA helps organizations avoid the tendency to single out one factor to arrive at the most expedient
(but generally incomplete) resolution. It also helps to avoid treating symptoms rather than true,
underlying problems that contribute to a problem or event. While RCA is used in a generic sense,
there is an implication that a methodology is used in the analysis.
Most RCA experts believe that achievement of total prevention by a single intervention is not always
possible and see RCA as an ongoing process that strives for continuous improvement.

Goals
The primary goal of using RCA is to analyze problems or events to identify:
 What happened
 How it happened
 Why it happened…so that
 Actions for preventing reoccurrence are developed

Benefits
Implementing RCA will help the agency:
 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 agency.
 Identify current and future needs for organizational improvement.
 Establish repeatable, step-by-step processes, in which one process can confirm the results
of another.

Principles
 Focusing on corrective measures of root causes is more effective than simply treating the
symptoms of a problem or event.
 RCA is performed most effectively when accomplished through a systematic process with
conclusions backed up by evidence.
 There is usually more than one root cause for a problem or event.
 The focus of investigation and analysis through problem identification is WHY the event
occurred, and not who made the error.

Roots
Root cause analysis is not a one-size-fits-all methodology. There are many different tools,
processes, and philosophies of accomplishing RCA. In fact, it was born out of a need to analyze
various enterprise activities such as:
 Accident analysis and occupational safety and health
 Quality control
 Efficient business process
 Engineering and maintenance failure analysis
 Various systems-based processes, including change management and risk management

Applying RCA
Examples of events where RCA is used to solve problems and provide preventive actions include:
 Major accidents
 Everyday incidents
 Minor near-misses
 Human errors
 Maintenance problems
 Medical mistakes
 Productivity issues
 Manufacturing mistakes
 Environmental releases
 Risk analysis, risk mapping

Basic method to use

 Define the problem.
 Gather information, data and evidence.
 Identify all issues and events that contributed to the problem.
 Determine root causes.
 Identify recommendations for eliminating or mitigating the reoccurrence of problems or
events.
 Implement the identified solutions.

RCA methods
The nature of RCA is to identify all and multiple contributing factors to a problem or event. This is
most effectively accomplished through an analysis method. Some methods used in RCA include:
 The “5-Whys” Analysis” — A simple problem-solving technique that helps users get to the
root of the problem quickly. It was made popular in the 1970’s by the Toyota Production
System. This strategy involves looking at a problem and asking “why” and “what caused this
problem”. Often the answer to the first “why” prompts a second “why” and so on—providing
the basis for the “5-why” analysis.
 Barrier Analysis — Investigation or design method that involves the tracing of pathways by
which a target is adversely affected by a hazard, including the identification of any failed or
missing countermeasures that could or should have prevented the undesired effect(s).
 Change Analysis — Looks systematically for possible risk impacts and appropriate risk
management strategies in situations where change is occurring. This includes situations in
which system configurations are changed, operating practices or policies are revised, new
or different activities will be performed, etc.
  Causal Factor Tree Analysis — An investigation and analysis technique used to record and
display, in a logical, tree-structured hierarchy, all the actions and conditions that were
necessary and sufficient for a given consequence to have occurred.
 Failure Mode and Effects Analysis — A “system engineering” process that examines
failures in products or processes.
 Fish-Bone Diagram or Ishikawa Diagram — Derived from the quality management process,
it’s an analysis tool that provides a systematic way of looking at effects and the causes that
create or contribute to those effects. Because of the function of the fishbone diagram, it may
be referred to as a cause-and-effect diagram. The design of the diagram looks much like
the skeleton of a fish—hence the designation “fishbone” diagram.
 Pareto Analysis — A statistical technique in decision making that is used for analysis of
selected and a limited number of tasks that produce significant overall effect. The premise
is that 80% of problems are produced by a few critical causes (20%).
 Fault Tree Analysis — The event is placed at the root (top event) of a “tree of logic”. Each
situation causing effect is added to the tree as a series of logic expressions.
https://des.wa.gov/services/risk-management/about-risk-management/enterprise-risk-
management/root-cause-analysis
Root Cause Analysis
Tracing a Problem to its Origins

In medicine, it's easy to understand the difference

between treating the symptoms and curing the
condition. A broken wrist, for example, really
hurts! But painkillers will only take away the
symptoms; you'll need a different treatment to
help your bones heal properly.
But what do you do when you have a problem at work? Do you jump
straight in and treat the symptoms, or do you stop to consider whether
there's actually a deeper problem that needs your attention? If you only fix
the symptoms – what you see on the surface – the problem will almost
certainly return, and need fixing over, and over again
However, if you look deeper to figure out what's causing the problem, you can
fix the underlying systems and processes so that it goes away for good.

Root Cause Analysis (RCA) is a popular and often-used technique that helps
people answer the question of why the problem occurred in the first place. It
seeks to identify the origin of a problem using a specific set of steps, with
associated tools, to find the primary cause of the problem, so that you can:

1. Determine what happened.

2. Determine why it happened.
3. Figure out what to do to reduce the likelihood that it will happen again.
RCA assumes that systems and events are interrelated. An action in one area
triggers an action in another, and another, and so on. By tracing back these
actions, you can discover where the problem started and how it grew into the
symptom you're now facing.

You'll usually find three basic types of causes:

1. Physical causes – Tangible, material items failed in some way (for example,
a car's brakes stopped working).
2. Human causes – People did something wrong, or did not do something that
was needed. Human causes typically lead to physical causes (for example,
no one filled the brake fluid, which led to the brakes failing).
3. Organizational causes – A system, process, or policy that people use to
make decisions or do their work is faulty (for example, no one person was
responsible for vehicle maintenance, and everyone assumed someone else
had filled the brake fluid).
RCA looks at all three types of causes. It involves investigating the patterns of
negative effects, finding hidden flaws in the system, and discovering specific
actions that contributed to the problem. This often means that RCA reveals
more than one root cause.

You can apply RCA to almost any situation. Determining how far to go in
your investigation requires good judgment and common sense.
Theoretically, you could continue to trace root causes back to the Stone
Age, but the effort would serve no useful purpose. Be careful to understand
when you've found a significant cause that can, in fact, be changed.

The Root Cause Analysis Process

RCA has five identifiable steps.

Step One: Define the Problem

 What do you see happening?
 What are the specific symptoms?

Step Two: Collect Data

 What proof do you have that the problem exists?
 How long has the problem existed?
 What is the impact of the problem?
You need to analyze a situation fully before you can move on to look at factors
that contributed to the problem. To maximize the effectiveness of your RCA,
get together everyone – experts and front line staff – who understands the
situation. People who are most familiar with the problem can help lead you to
a better understanding of the issues.

Step Three: Identify Possible Causal Factors

 What sequence of events leads to the problem?
 What conditions allow the problem to occur?
 What other problems surround the occurrence of the central problem?
During this stage, identify as many causal factors as possible. Too often,
people identify one or two factors and then stop, but that's not sufficient. With
RCA, you don't want to simply treat the most obvious causes – you want to
dig deeper.

Use these tools to help identify causal factors:

 Appreciation – Use the facts and ask "So what?" to determine all the
possible consequences of a fact.
 5 Whys – Ask "Why?" until you get to the root of the problem.
 Drill Down – Break down a problem into small, detailed parts to better
understand the big picture.
 Cause and Effect Diagrams – Create a chart of all of the possible causal
factors, to see where the trouble may have begun.

Step Four: Identify the Root Cause(s)

 Why does the causal factor exist?
 What is the real reason the problem occurred?
Use the same tools you used to identify the causal factors (in Step Three) to
look at the roots of each factor. These tools are designed to encourage you to
dig deeper at each level of cause and effect.

Step Five: Recommend and Implement Solutions

 What can you do to prevent the problem from happening again?
 How will the solution be implemented?
 Who will be responsible for it?
 What are the risks of implementing the solution?
Analyze your cause-and-effect process, and identify the changes needed for
various systems. It's also important that you plan ahead to predict the effects
of your solution. This way, you can spot potential failures before they happen.

One way of doing this is to use Failure Mode and Effects Analysis (FMEA).
This tool builds on the idea of risk analysis to identify points where a solution
could fail. FMEA is also a great system to implement across your
organization; the more systems and processes that use FMEA at the start, the
less likely you are to have problems that need RCA in the future.
Impact Analysis is another useful tool here. This helps you explore possible
positive and negative consequences of a change on different parts of a
system or organization.
Another great strategy to adopt is Kaizen , or continuous improvement. This is
the idea that continual small changes create better systems overall. Kaizen
also emphasizes that the people closest to a process should identify places
for improvement. Again, with Kaizen alive and well in your company, the root
causes of problems can be identified and resolved quickly and effectively.
Key Points
Root Cause Analysis is a useful process for understanding and solving a
problem.

Figure out what negative events are occurring. Then, look at the complex
systems around those problems, and identify key points of failure. Finally,
determine solutions to address those key points, or root causes.

You can use many tools to support your RCA process. Cause and Effect
Diagrams and 5 Whys are integral to the process itself,
while FMEA and Kaizen help minimize the need for RCA in the future.
As an analytical tool, RCA is an essential way to perform a
comprehensive, system-wide review of significant problems as well as the
events and factors leading to them.
Click on the button below to download a template that will help you log
problems, likely root causes and potential solutions. Thanks to Club
member weeze for providing the basis for this.
https://www.mindtools.com/pages/article/newTMC_80.htm
The highest-level cause of a problem is called the root cause:

The root cause is “the evil at the bottom” that sets in motion the entire cause-and-effect chain
causing the problem(s).

Some root cause analysis approaches are geared more toward identifying true root causes than
others; some are more general problem-solving techniques, while others simply offer support for the
core activity of root cause analysis.

By becoming acquainted with the root cause analysis toolbox, you’ll be able to apply the appropriate
technique or tool to address a specific problem

http://asq.org/learn-about-quality/root-cause-analysis/overview/overview.html
 https://www.thinkreliability.com/cause-mapping/what-is-root-cause-analysis/

https://www.thehealthcompass.org/how-to-guides/how-conduct-root-cause-analysis

https://www.env.nm.gov/aqb/Proposed_Regs/Part_7_Excess_Emissions/NMED_Exhibit_18-
Root_Cause_Analysis_for_Beginners.pdf