In the practice of Root Cause Analysis, a problem is a state that occurs when there is an apparently uncorrectable mismatch between what exists and what is required or desired. In other words, we want w but we have h, and we don’t know how to close the gap. This state can arise in several ways. At […]
Equipment degrades, malfunctions, or fails outright… hopefully not too frequently, but every breakdown can be painful. So, of course, you will want to figure out exactly what happened, how it happened, and why (in hardware/software terms). You may want to dig a little deeper, though; every equipment malfunction or failure that you have is a valuable […]
Problems happen all the time. How we choose to respond is a major factor in determining how badly we will be affected by any given problem. I would argue that a systematic response is best, and furthermore, I propose a 9-stage sequence (including root cause analysis) as discussed in this article.
Root cause analysis is one of the best ways to solve difficult or significant problems, but sometimes, root cause analysis efforts fail because the corrective actions weren’t effective. If the original problem happens again, or the needed improvements haven’t materialized, or a new problem arises because of the corrective actions, you need to figure out what happened […]
My previous post about root causes in complex systems, in retrospect, looks a little bit like a rant. That doesn’t bother me too much, really… but I wish I had included the following info: it is one way to go about resolving the mess that complex systems can make of your root cause analysis.
There’s a large number of root cause analysis articles on this site. If you’re already a cause analysis pro, then you can probably just pick through the main RCA Articles list and find things that might interest you. However, if you’re new to root cause analysis, then that probably isn’t going to be a great way to […]
I’m getting so very tired of safety/accident researchers claiming that root cause analysis is an invalid, blame-focused practice that ignores systems and complexity. Most root cause investigators that I know are pretty well oriented towards process, organization, and system issues as the fundamental sources underlying problems and accidents… and even some of our simplest analysis […]
There are several discussion groups on LinkedIn dedicated to Root Cause Analysis in one way or another. I follow a couple of them, but the one I like the most has a serious problem. So, being the dynamic (ha) and proactive (haha) person that I am, I created a new one.
The quality of a Root Cause Analysis (RCA) and its Corrective Action Plan (CAP) should be evaluated many times over its lifecycle (i.e., from initial problem or event, through to final verified and sustainable improved state). Reviews occurring earlier in the lifecycle can really consider only the apparent quality of the investigation/analysis effort itself; these early reviews […]
Here’s a comprehensive list of verified links to freely-available Root Cause Analysis resources all across the web.