Root cause analysis

1. Root Cause Analysis
Overview
Performance & Productivity Improvement

2. AgendaAgenda
• Root Cause Analysis Definition
• The Root Cause Analysis Method & Tools
• How Do We Perform Root Cause Analysis?
• Other Quality Improvement Process Tools
• When do we perform RCA?
• References

3. Definition of Root Cause AnalysisDefinition of Root Cause Analysis
• The objective of this process is to determine
the true cause of a problem. It is one of the
most vital functions we can perform to improve
service excellence for our clients because it
helps to prevent problems from occurring
again.
• Everyone in the Organization needs to
understand the purpose of root cause analysis
and should be able to perform the related
procedures.

4. The Root Cause Analysis Method & Tools
The Method is based on determine
what has happened during an
occurrence/ incident, how it did
happen, and why it did happen. The
method includes:
1. Problem/ Incident Detection and Data
Collection.
2. Root Cause Determination.
3. Development of corrective actions
and follow up

5. • Information collected consists of conditions before,
during, and after the occurrence.
• Personnel involvement (including actions taken).
• Environmental factors.
• All information relevant to the condition or problem.
Problem/ Incident
Detection and Data
Collection
Root Cause
Determination
Develop
corrective
actions and
follow up
The Root Cause Analysis Method & Tools
• In the root cause determination phase consider
analyzing data so as to identify the causal factors using
a specific technique and summarizing the findings.
• The major cause areas could be assigned to
Equipment/Material Problem, Procedure Problem,
Personnel Error, Design Problem, Training Deficiency,
Management Problem, External Problem.
• Root cause analysis enables the improvement of
reliability and safety by selecting and implementing
effective corrective actions.

6. How Do We Perform Root Cause Analysis?
After you have asked WHY
five times, you should have reached
the root cause of the problem.
Have you heard of the Rule of Five?

7. How Do We Perform Root Cause Analysis?
Continue asking the WHY
question until you can’t
find any further
underlying problems.
Ask WHY a problem
occurred. A client experienced a Severity 1 outage. Why?
Because the server powered off. Why?
Because the server became unplugged. Why?
Because someone tripped over the power cord.
Why?
Because the power cord was draped over a table.
Why?
Because it was not the appropriate length. Why?
Because the vendor sent the wrong length power
cord. Why?
Because human error occurred
during the vendor manual
ordering process.
This is the
root
cause.

8. Other Quality improvement process tools
• Brainstorming
• Cause & Effect Diagram
• Decision Matrix
• Nine-Block Worksheet &
Grid
• Pareto Analysis
• Planning Worksheet
• Process Model Worksheet
• Quality Audits
• Threads of Similarity
• Check Sheet
• Control Chart
• Flowchart
• Histogram
• Opportunities for Error
• Run Chart
• Team Meeting Review
• Structure Tree

9. When Do We Perform Root Cause Analysis?
• Identify Root Cause Analysis will be
performed based on, but not limited to:
• History of common set of symptoms
(threads of similarity.)
• Problem escalated to Senior Management
and/or Customer Management.
• Root causes compared to existing
requests to determine if association is
possible.
• Identification of preventive actions that
could be useful to implement ongoing
preventive maintenance (i.e. equipment
maintenance) or to propagate corrective
action solution to other environments.

10. When chronic problems occur, the organization will work with all
related parties to identify causes and possible resolutions.
If not resolved in a timely fashion, the project will
escalate the issue until the problem is resolved.
If the chronic problem cannot be resolved, the project
will work with CLIENT to determine appropriate steps.
Root cause analysis is required for severity 1, 2 and 3 problems
and for nonconformance records (CARs), which must be
evaluated every month.
Severity 3 and 4 problems should be considered and evaluated
every 6 months.
When Do We Perform Root Cause Analysis?

11. References
– http://www.dcmc.hq.dla.mil/teaminfo/aqbd/99plan/METRICS/root.htm
– http://www.philipcrosby.com/qualitystore/cdrom.details/cd.
problemsolving.htm
– http://tis.eh.doe.gov/techstds/standard/nst1004/nst1004.pdf