ROOT

CAUSE
ANALYSIS

H T T P S : / / Y O U T U . B E / FAV P I S J C
X 9 W ? S I = R Q 0 9 S I 0 7 R Z 4 A KO W
O
What is Root Cause
Analysis?
• Root cause analysis (RCA)
is the process of identifying
the source of a problem
and looking for a solution
so that the problem is
treated at the root level.
RCA (OSHA DEFINITION)

• hen defining root cause

analysis, OSHA calls it a
"fundamental, underlying,
system-related reason why an
incident occurred that
identifies one or more
correctable system errors."
WHAT IS FOR?

• In the world of workplace

safety, a root cause analysis is
for identifying, evaluating, and
correcting root causes
of accidents – but also of near
misses and incidents that fall
short of an accident.
Importance of Doing RCA

Root cause analysis

Hence, identifying the
aims to gauge the
root causes of a
challenges an
problem helps in
organization should
developing more
address to streamline
effective strategies to
its processes and
overcome it.
achieve its goals.
Workplace safety is most
effective when it's proactive.

• While an RCA is a reactive

procedure in that it's triggered
by something going wrong,
employing a root cause analysis
technique automatically
broadens the scope of an
incident investigation.
Why is so important?

• By systematically finding and correcting

root causes, you don't just prevent a
recurrence of the previous incident, but
also any safety hazard that stems from
those flaws.
• That's the importance of root cause
analysis – it helps you avoid the
temptation of blaming an accident on a
single person or an immediate mistake.
TYPES OF RCA
Physical causes

• May arise due to

problems with any
physical component of a
system, such as hardware
failure and equipment
malfunction
M AY O C C U R D U E T O H U M A N
E R R O R , C AU S E D BY L A C K O F
SKILLS AND KNOWLEDGE TO
P E R F O R M A TA S K

Human
causes
Organizational causes

• May happen when

organizations use a system or
process that is faulty or
insufficient, in situations like
giving incomplete instructions,
making wrong decisions, and
mishandling staff and property
 RCA Categories
A C C O R D I N G T O T H E N AT I O N A L A SS O C I AT I O N O F S TAT E
M E N T A L H E A LT H P R O G R A M D I R E C T O R S , M O S T O F T H E
P R I N C I P L E S O F R O O T C A U S E A N A LY S I S A R E C L A S S I F I E D
I N T O 5 M A J O R C AT E G O R I E S
Safety-based RCA

• This process examines and

identifies the root causes of
any failure of safety
observance, accident
analysis, or other issues
related to occupational safety
and health.
Production-based RCA

• This is often conducted in the

field of quality control for
manufacturing to investigate
the root causes of why certain
defects are present either
within the manufacturing
process or end product.
Process-
based
RCA
• Serving as a
follow-on to
production-based
RCA, this
approach has
been expanded
to include
business
processes.
Failure-based • This is rooted in
RCA
the concept of
failure analysis,
which is typically
used in
engineering and
maintenance.
Systems-based RCA

• Combining two or more

methods of RCA, this
approach also takes ideas
from fields such as change
management, risk
management, and systems
analysis
How to Do Root Cause Analysis
Step 1: Realize the
problem.
“What’s the problem?”

When writing a problem statement,

make sure to keep these 3 things in
mind:
• how you would describe the problem;

• what you see happening;

• what the specific symptoms are.

Step 2: Gather data

• Retrieve all relevant and available

data about the incident—including
the documentation files, initial
issues found, preliminary actions
taken, personnel or teams involved,
and other key information that you
think would be beneficial to identify
the root cause.
Step 3: A causal factor is a major unplanned
contributor to a negative event or
Determine undesirable situation. If
eliminated, causal factors would have
possible either prevented the incident from
happening or reduced its risks and
causal frequency.
factors Start this step by reconstructing a
timeline of events in a way that you’ll
be able to pinpoint exactly what led to
the problem and other issues that
coexist with the one you’re dealing
with.
Step 4: Identify
the root cause
• This is where you choose
which of the root cause
analysis tools you should
use to discover the root
causes of each causal
factor you’ll encounter.
Step 5: Recommend and
implement solutions

• Upon identifying the root

cause, you can now
recommend preventive
measures to ensure that
the problem won’t
happen again.
6. Develop a Corrective and
Preventive Action (CAPA) Plan

• Write and implement a corrective

and preventive action (CAPA)
plan based on your findings.
Include corrective actions to
remove immediate hazards and
preventive actions to reduce the
risk of similar incidents in the
future.
7. Review and Monitor
Changes for Safety
Improvements

• Assign and schedule

corrective and preventive
actions at the end of your
RCA. The team should then
report on and review
changes to measure
success.
Root Cause
Analysis
Methods
The 5 Whys

• All you need to do is

start with a problem
statement and then
ask “Why?” 5 times,
with each “Why?”
leading you closer to
the root cause.
Food fot thought

Although the 5 Whys technique works for most situations, the catch
is that you need an initial toehold explanation to get started.

If you're truly starting with no obvious answers to how or why an

incident occurred, you'll need to use the events or change root cause
analysis techniques instead.
Events Analysis

Event analysis is best for one-time incidents, rather than a

pattern of troubling safety behavior.

You build a detailed timeline around the target event and

analyze it to see where things went wrong.
Change Analysis

• In the context of workplace safety, the

change analysis technique works best to
determine the root cause of a general shift
in behavior.
• If your metrics tell you that you're having
more incidents or near-misses lately, that
will call for a change analysis rather than
an event analysis, for example.
How to do it?

• First, you look for all changes in the

organization that proceeded the
change in safety metrics.
• Then you define the relationship
between the possible causes and
effects, categorizing each
organizational change as either
unrelated, correlated, contributing, or
root cause.
Fishbone or Ishikawa
Diagram
• If you need to brainstorm all possible causes
for an incident, a fishbone diagram can help
because it encourages you to think of every
possible cause by examining a wide variety of
aspects of the incident.
• Each category of potential causes forms the
appearance of a rib off the spine (thus, the
name).
Common People, Environment, Management, Process,
Equipment, Materials, and Measurement. The
categories exact categories will vary.

For example, some organizations prefer

Personnel to People (to separate out
management from the workforce).

You'll also see Machine instead of Equipment

and Method instead of Process.

The most important thing is that the

categories are appropriate for the situation,
as well as thorough.
FMEA

• As one of the most in-depth root cause

analysis methods, the Failure Mode and
Effects Analysis or FMEA process uses
hypothetical “What if?” questions to prompt
an understanding of the problem.
• This is best applied to establish cause-and-
effect relationships that aim to describe why
specific issues occur, including the one
you’re dealing with.
• FMEA Template - SafetyCulture
DMAIC
As a cyclical
process, DMAIC includ
Define the project goals and customer deliverables
es the following steps:
Measure the process to assess current performance and quantify the
problem
Analyze and identify the root causes of defects

Improve the process by eliminating and preventing defects

Control future process performance to maintain improved strategies

e, Measure, Analyze, Improve, and Control.

DMAIC Template - SafetyCulture

 D0: Plan

D1: Form a team

8
D2: Describe the problem
Disciplines
D3: Develop a containment plan
Problem
D4: Identify and confirm root causes and
Solving escape points
D5: Verify corrective actions and solutions
before implementation
D6: Define and carry out corrective actions

D7: Map out preventive measures

D8: Recognize and congratulate the team

Change This method applies to cases where
significant changes take place in the
Analysis performance of a system or a process.

It aims to explore changes made in

people, equipment, assets, and data,
among others, that have a relevant
impact on the change in performance.
Ultimately, this also helps in discovering
strategies for risk identification and
overall risk management.
Tips for Root There are often multiple root causes for
any one incident. Address all of them,
Cause rather than trying to narrow it down to
one.
Analysis

Focus on systemic answers, not personal

ones. Maybe a specific person is falling
on the job but firing them won't prevent
future occurrences. It's better to set up
performance metrics and procedures to
hold everyone accountable.
 Although brainstorming is
Tips for Root involved, root cause analysis isn't
Cause just an intellectual exercise. You
need to back up claims with
Analysis evidence of a causal relationship.

While the ultimate goal is to fix

problems at the root, you shouldn't
neglect the proximate problem. Fix
"symptoms" of the root cause as
well.
8 Root
Cause
Analysis
Questions
T H AT Y O U C A N A S K
WHEN PERFORMING
R O O T C A U S E A N A LY S I S
QUESTIONS

Is my problem- Does our problem

solving team trained statement answer
enough and aware of the 5 Ws and 2 Hs for
their respective greater clarity and
functions? accuracy?

Can these actions Does the root cause

temporarily isolate reveal
the problem from our nonconformance or
customers in the hidden flaws in the
future? system?
QUESTIONS

Can these possible Were actions

solutions change the communicated to all
product and/or process stakeholders to mitigate
conditions to permanently the risk and to measure
solve the problem? improvements?

Were similar products

Have I provided relevant
and/or processes
feedback and recognized
reviewed, and work
both team and individual
procedures updated for
efforts?
problem prevention?
Ultimate The root cause(s) of most incidents
can ultimately be categorized as
List of Root either:
Causes for Poor management/supervision
Workplace
Company culture
Injuries and
Illnesses Work environment

Improper training
BY A D D R E SS I N G T H E S E R O O T
C A U S E S , O R G A N I Z AT I O N S C A N
S I G N I F I C A N T LY R E D U C E R E C U R R I N G
INCIDENTS AND IMPROVE
O P E R AT I O N A L R E S I L I E N C E .

Why Conduct
a Root Cause
Analysis?
Preventing Future Incidents
Through Systemic Improvements

• By identifying and mitigating

underlying risks, RCA
systematically lowers the
probability of future accidents,
especially in high-risk industries
like construction, chemical, and
industrial manufacturing.
Enhancing Workplace
Safety and Compliance
RCA ensures a comprehensive risk
management approach by
identifying

[Link] in safety protocols

[Link] maintenance
schedules

[Link] of compliance standards

Ensuring a Culture of
Accountability
• By involving multiple
stakeholders in RCA, including
safety officers, operational
managers, and equipment
operators, the process
encourages a shared
responsibility for identifying and
addressing risks
Increasing Operational Efficiency and Reducing
Costs

A detailed RCA might By correcting these

reveal that inevitable root causes,
equipment failures, organizations reduce
which seemed costly unplanned
random, were due to downtime and
systemic improve
maintenance lapses. productivity.
Supporting
RCA is not a one-time solution; it creates
Continuous a solid data-driven foundation for
continuous improvement.
Improvement
Documenting root causes and corrective
and actions creates a valuable knowledge
base that can be referenced and built
Knowledge upon over time.
Retention This ensures that lessons learned from
past incidents are retained within the
organization and avoided in the future.