What is it?
Bad things happen. The extent of the damage now, or whether bad things happen again, is a product of how we respond. Often without any analysis, we charge ahead with hastily-conceived, ill-considered solutions that merely sweep the badness under the edge of the rug, to be inadvertently revealed at some later date… potentially in some much worse incarnation. What we need is a method that helps us find the core issues affecting our performance.
Root cause analysis (RCA) is a methodology for finding and correcting the most important reasons for performance problems. It differs from troubleshooting and problem-solving in that these disciplines typically seek solutions to specific difficulties, whereas RCA is directed at underlying issues.
- As a business process improvement tool, RCA seeks out unnecessary constraints as well as inadequate controls.
- In safety and risk management, it looks for both unrecognized hazards and broken or missing barriers.
- It helps target CAPA (corrective action and preventive action) efforts at the points of most leverage.
- RCA is an essential ingredient in pointing organizational change efforts in the right direction.
- Finally, it is probably the only way to find the core issues contributing to your toughest problems.
While it is often used in environments where there is potential for critical or catastrophic consequences, this is by no means a requirement. It can be employed in almost any situation where there is a gap between actual and desired performance. Furthermore, RCA provides critical info on what to change and how to change it, within systems or business processes.
Significant industries using root cause analysis include manufacturing, construction, healthcare, transportation, chemical, petroleum, and power generation. The possible fields of application include operations, project management, quality control, health and safety, business process improvement, change management, and many others.
Your problems may not be as spectacular as the ones pictured above, but they probably have many similarities under the surface. This is the point of root cause analysis — to dig below the symptoms and find the fundamental, underlying decisions and contradictions that led to the undesired consequences. If you want your problems to go away, your best option is to kill them at the root.
What does this site offer?
This site offers information on the purpose, methods, and process of root cause analysis. It currently does not teach you how to perform RCA, although that is a long-range goal. Instead, it offers articles related to the underlying theory and philosophy… this site is very much concerned with fundamental concepts.
What is all this really about?
We form organizations to get work done. As the work we want to do gets larger and more complex, so do our organizations. At some point, we move beyond the capability to function without extensive, potentially complicated processes and systems. These require management. However, we are human and we make mistakes. All the time. Lots of them. Our processes and systems are imperfect, and so is our ability to manage them. We cannot predict the future with any accuracy, and we are unable to see all the potential ramifications of the actions we take. Stuff happens.
In one way or another, all the various management tools and methods that have been developed over the years are about improving how we manage ourselves, our processes, and our systems. We want productivity, we want quality, we want reliability, and we want safety. We want these things now, and in the future. In fact, we want these things to get better over time. This is called continuous improvement.
Root cause analysis is a process of continuous improvement. It is not a pre-defined set of tools and methods, and it is not a flash in the pan management fad. It recognizes that we are going to experience problems, because that is an unavoidable aspect of being human. It is a guiding philosophy that says “find the real, important reasons for our problems, understand why they exist, and change the conditions that create them!”
There are many different versions of root cause analysis in existence, and the differences between them are not always cosmetic. However, I would put forth the following as a general philosophy that is shared almost universally: root causes exist, and they can be found (and uniquely identified) through careful, evidence-based investigation and thoughtful analysis. Finding and identifying root causes during an investigation adds significant value by pointing out significant, underlying, fundamental conditions that increase the risk of adverse consequences. Targeting corrective measures at the identified root causes is the best way to ensure that similar problems do not occur in the future.
by Bill Wilson
Bill Wilson © 2004-2014