Root Cause Analysis - General Principles of Root Cause Analysis

General Principles of Root Cause Analysis

  1. The primary aim of RCA is to identify the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes (consequences) of one or more past events in order to identify what behaviours, actions, inactions, or conditions need to be changed to prevent recurrence of similar harmful outcomes and to identify the lessons to be learned to promote the achievement of better consequences. ("Success" is defined as the near-certain prevention of recurrence.)
  2. To be effective, RCA must be performed systematically, usually as part of an investigation, with conclusions and root causes that are identified backed up by documented evidence. Usually a team effort is required.
  3. There may be more than one root cause for an event or a problem, the difficult part is demonstrating the persistence and sustaining the effort required to determine them.
  4. The purpose of identifying all solutions to a problem is to prevent recurrence at lowest cost in the simplest way. If there are alternatives that are equally effective, then the simplest or lowest cost approach is preferred.
  5. Root causes identified depend on the way in which the problem or event is defined. Effective problem statements and event descriptions (as failures, for example) are helpful, or even required.
  6. To be effective, the analysis should establish a sequence of events or timeline to understand the relationships between contributory (causal) factors, root cause(s) and the defined problem or event to prevent in the future.
  7. Root cause analysis can help to transform a reactive culture (that reacts to problems) into a forward-looking culture that solves problems before they occur or escalate. More importantly, it reduces the frequency of problems occurring over time within the environment where the RCA process is used.
  8. RCA is a threat to many cultures and environments. Threats to cultures often meet with resistance. There may be other forms of management support required to achieve RCA effectiveness and success. For example, a "non-punitive" policy toward problem identifiers may be required.

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