What is root cause analysis and incident investigation?

A root cause analysis allows an employer to discover the underlying or systemic,

rather than the generalized or immediate, causes of an incident. Correcting only an
immediate cause may eliminate a symptom of a problem, but not the problem itself.

Root Cause Analysis or RCA

Root Cause Analysis or RCA is a very popular and frequently
used technique to help people find the answer as to why a
problem happened in the first place. Its objective is 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:
What is the basics of 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

1. Determine what happened

2. Determine why it happened
3. Figure out what to do to decrease the possibility that it will
happen again
RCA assumes that systems and events are interlinked. An
action in one area triggers an action in another and another and
so on. By backtracking these actions, you can discover where
the origin of the problem 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 take 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 the three types of causes. It involves
scrutinizing 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.

The Root Cause Analysis Process

RCA has five identifiable steps.

Step One
Define the Problem – It includes seeing what is exactly
happening and finding out the specific symptoms of the
problem.

Step Two
Collect Data – It includes finding proof that the problem exists.
And finding out how long the problem has existed and the
impact of the problem.
Complete analysis of the situation is necessary before you can
move on to look at the 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 – It includes finding the
sequence of events that led to the problem, the conditions that
allowed the problems to occur. And other problems that
surround the occurrence of the central problem. At this step, try
your best to find as many causal factors as possible.

Very frequently, people identify one or two factors and then

stop but thats not enough. With Root Cause Analysis, it is
important to dig deeper into the problem to find out as many
causes as possible instead of just stopping at the surface.
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 “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) – It includes finding out why the
causal factors exist and the real reason behind the problem that
occured.

You can use the same tools as used in Step 3 to identify the
causal factors 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 – It includes finding
solution to prevent the problem from happening again,
implementation of the solution. And the responsibility of the
implementation to be given to someone and the risks involved
in implementing the solution.
 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.

Benefits and goals of root cause

analysis
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

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.

• What are the 7 steps of root cause

analysis?
• Define the Problem. It seems really
simple, but defining the problem
might not be as obvious as it looks. ...
• Gather Data. ...
• Find the Cause(s) ...
• Find Solutions. ...
• Develop Strategies to
Correct/Prevent. ...
• Report Out. ...
• Monitor the Solutions and Close the
Loop. ...
• Revisit Over Time.
What are the 6 P's of root cause analysis?

Causes are often grouped into major categories, which

are classically defined as the 6 Ms (or the 6
Ps): Man/Mind Power (People), Method (Process),
Machines (Program), Materials (Product),
Measurements (Policy), and Milieu/Mother Nature
(Place).

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

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.

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”.
 • The 8D methodology,
developed to represent the
best practices in problem-
solving, provides the
engineering teams with an
effective and efficient team-
oriented problem-solving skill, a
better understanding of Root
Cause Analysis (RCA) and how
to use basic statistical tools
required for problem-solving
• What is the purpose of 8D problem-solving?
•
• The purpose of the 8D methodology is to identify, correct, and eliminate
recurring problems, making it useful in product and process improvement.

•
How to Apply Eight Disciplines of Problem Solving
(8D)
The 8D is a systematic process for the introduction and improvement of quality, and
elimination of problems. Here we will show you the step by step approach of the
problem-solving tools that can make you proficient at identifying causes of problems,
defining problems, and errors. Additionally, it helps identify root causes and take
actions to solve and prevent identified problems in processes. So, let’s take a peep
inside:
 D0: Planning and preparing for the 8D
Proper planning and preparation are always a good start before taking any action.
So, you need to consider the following before forming a team:

 Problem description
 Timeframe for the resolution
 The number of resources to accomplish this

D1: Team establishment

Create a team with people who varied backgrounds and experiences which will lead
to the best quality inputs and a complete solution. For the team to function smoothly,
define clear roles, and responsibilities for your people, and have a team leader.

D2: Problem description

The 8D method’s primary focus is to describe the problem appropriately and
objectively such that it captures all the vital information. During this analysis,
repeated 5W1H (why, what, who, where, when, and how) are required to be asked to
develop a clear description.

D3: Problem containment plan

A temporary problem containment plan is sometimes needed to minimize the impact
of the problem until you develop permanent solutions. On developing the plan based
on the hypothetical cases, the resources for addressing the main problem can be
released. At times, new processes may be required to work around the problem until
you have a permanent fix.

D4: Root Cause Analysis (RCA)

 With the problem temporarily contained, you can now turn to identify all of the root
causes of the nonconformance. There are several tools to identify the actual root
cause of an issue including the 5W1H to understand the problem in-depth, Fishbone
diagrams to visually categorize causes, and Pareto charts to identify the vital causes.

D5: Permanent Corrective Action

Once the root cause of the problem is determined, the team can start brainstorming
permanent corrections to identify what the best long-term solution will be.
Brainstorming sessions combined with tools such as affinity diagrams help organize
ideas based on their relationships and determine the best course of action.

D6: Implement and Validate the Permanent Corrective Action

Once the solution is identified, the management needs to implement and verify the
corrective action using the PDCA (plan-do-check-act) approach for small-scale
testing before large-scale rollout. Thus, the outcomes and corrective actions are
tracked to ensure expected results. To successfully implement a permanent change,
a project plan should incorporate:

 Development of the project plan for implementation

 Communicating the plan to all stakeholders
 Validating improvements using measurement

D7: Prevent Recurrence

A complete solution of problems means preventing them from occurring. Besides,
preventative measures should also be implemented for corrective actions in the 8D
methodology. This requires reviewing management processes, operating
procedures, and training manuals to ensure that best practices are followed.
At this stage, organizations should consider actions including updating process audit
questions and regularly verifying them based on corrective actions to reduce risk in
other processes, presenting poka-yoke or error-proofing devices to big-risk
processes, and conducting red rabbit tests to see how long it takes poka-yoke
devices to detect defective product.
D8: Verification and Team Celebration
Once the problem is solved, the ultimate step is to congratulate the team. It’s
important to recognize their efforts and share their success across the organization
because teams require feedback to allow for satisfactory closure. This facilitates
motivation and employee engagement while helping you improve quality control,
execute process improvements, and aid change management as you grow.
8D and Root Cause Analysis (RCA)
Root Cause Analysis (RCA) is embedded within the 8D process and includes the
following steps and techniques:

Problem Symptom is measured and transformed to “Object and Defect”

Problem Symptom is reformed to Problem Statement using the 5W1H process

Potential Causes are gathered using the tools like Fishbone or Affinity Diagram

Problem Statement should fit using both the “is” and the “isn’t” sections of the
question

Root Cause concepts are developed from remaining possible causes on the tool and
related changes from is/is not

Compare theories with recent data and develop experiments for Root Cause
Verification
 Test and confirm the Root Causes

o
o
o
What are the benefits of the 8D Problem-solving process?
The 8D methodology is often used since it provides a consistent, simple, and
thorough approach to solving raised problems at various stages. If properly applied,
it gives several advantages such as:
 A systematic approach for improving team-oriented problem-solving skills
 A clear understanding of basic statistical tools needed for problem-solving
 A practical understanding of the ‘root cause analysis’ tool
 Creating and expanding relative information about past failures and lessons
learned to avoid future problems in the organization
o

 What is Six Sigma?

 Six Sigma is a term used to define various techniques and
management tools designed to make business processes
more efficient and effective. It provides statistical tools to
eliminate defects, identify the cause of the error, and reduce
the possibilities of error. Thus, Six Sigma creates an
environment of continuous process improvement, enabling
businesses to provide better products and services to
customers. It was developed by Motorola, Inc. in 1986.

 Six Sigma can be applied to any process in any industry to
establish a management system for identifying errors and
eliminating them. It provides methods to improve the
efficiency of business structure and quality of processes,
enhancing the profitability of the business.
 The term “Six Sigma” is derived from the bell curve in
statistics, in which sigma represents the standard deviation
from the center. Hence, a process with six sigmas will
achieve an extremely low defect rate. The failure of a
business process or product is regarded as a defect. When a
process produces less than 3.4 defects for one million
chances, it is considered efficient.


six Sigma Principles
There are five main principles of Six Sigma:
1. Customer focus
The main objective is to maximize the benefits for customers.
Hence, a business must understand the needs of
their customers and the drivers of sales. It requires establishing
quality standards according to the market or customer demands.
2. Assess the value chain and find the problem
Outline the steps of a process to find out unwanted areas and
gather related data. Define goals for data collection, purposes for
data gathering, and expected insights. Verify that the data is
assisting in achieving the objectives, whether more information is
needed to be collected, or if data cleansing is required. Find out
the problem and its root cause.
3. Eliminate defects and outliers
After the identification of the problem, make appropriate
modifications in the process to eliminate defects. Eliminate any
activity in the given process that does not contribute to the
customer value. If the value chain is unable to reveal the problem
area, various tools are used to find out the problem areas and
outliers. Eliminating the outliers and defects removes the
bottlenecks in a given process.
4. Involve stakeholders
A structured process should be adopted where all stakeholders
collaborate and contribute to finding solutions to complex issues.
The team needs to achieve proficiency in the methodologies and
principles applied. Hence, specialized knowledge and training are
required to lower project failure risks and ensure optimal
performance of the processes.
5. Flexible and responsive system
Whenever an inefficient or faulty process is eliminated, the
employee approach and work practices need to be changed. A
flexible and responsive environment to the changes in processes
can lead to the efficient implementation of the projects.
The departments involved should be capable of adapting easily to
the change. Companies that periodically examine the data and
make appropriate changes to their processes may achieve a
competitive advantage.
Six Sigma Methodologies
The following are the two main methodologies of Six Sigma, which
are used in different business environments:
DMAIC
DMAIC is a data-driven approach used for optimizing and
improving the existing business designs and processes. It is an
effective method of controlled change management. The five
phases of DMAIC are listed below, and each phase involves tools
and tasks to help find the final solution.
1. Define the problem and the goals of the
project
 2. Measure the different aspects of the
existing process in detail
3. Analyse data to find the main flaw in a
process
4. Improve the given process
5. Control the way the process is
implemented in the future
DMADV
DMADV focuses on the development of an entirely new process,
product, or service. It is used when existing processes, even after
improvement, do not satisfy the customer’s needs, and new
methods are required to be developed. It comprises five phases:
1. Define the purpose of the project,
product, or service
2. Measure the crucial components of a
process and product capabilities
3. Analyse data and develop design
alternatives, ultimately selecting the best
design
4. Design the selected best alternative and
test the prototype
5. Verify the effectiveness of the design
through several simulations and a pilot
program