Root Cause Analysis for Beginners

Abstract:Root cause analysis (RCA) is a tool to help identify what, how, and why an event occurred so that steps can be taken to prevent future occurrences. Additionally, RCA may be used to target opportunities for systemwide improvement. Root causes are specific underlying causes that can be reasonably identified, are within management's control to remedy, and which generate effective recommendations to prevent recurrences. The RCA process involves data collecting, causal factor charting, root cause identification, and recommendation generation and …

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I have reread this prominent article ~15 years later and found it still very relevant, rather clear and helpful. It is well conceived, rather general, but specific and based on industrial docs on safety and incidents (fires, explosions, intoxications, etc.-see Refer). This article does not address particularly technical failures (malfunctions, nonconformities), however, they are mentioned and concern many practitioners working in technology-driven organizations. Thus, I’d suggest continuing this topic focusing on technical failure analysis (FA), which disappeared after FRACAS downgrading ~20 years ago. FA became unpopular, forgotten and undesirable “orphans”; often skipped by popular safety, quality and reliability literature, conferences, standards, certifications, etc. This strange and dangerous phenomenon has happened in spite of numerous technological live problems with hardware and software, parts and systems, aerospace and consumer products in US and worldwide (refer to news on accidence and incidence, casualties and victims, recalls, lawsuits, famous company’s’ falls-demises-collapses, etc.).
The general FA topic might split to initial and broad FA; thorough advanced root cause FA of important ~10-20% and comprehensive R&D of the most complex failures in promising products and technologies. Also, early failures might be emphasized as the top priority due to the massiveness of “prenatal” and “infant” mortalities; in-warranty obligations; customer sensitivity and the highest risks, losses and costs involved. Systemic approach is essential as it had been lost with FRACAS, which needed considerable improvement (e.g., refer to my presentation at ASQ-2019 conference, which took place at Fort Worth, TX). Thanks

--Dr. David E. Verbitsky, 08-02-2019

Very useful article
--Jamal Al Bassam, 11-02-2018

Well written and useful article.

--Vincent Burris, 05-03-2018

Excellent points of root cause analysis, helps us in improving the process.
--Qaiser iqbal, 03-14-2018

Thanks for this explicit illustration of RCA. Worth reading.
--Bright Obayuwana, 10-06-2017

"Casual Factor Chart" and "Casual Factor Chart part 2".... Casual?
--Gary Ferris, 08-16-2017

Excellent article
--Frederic E Ellis, 01-22-2017

--Chinique , 09-27-2016

What software was used to create the figures?
--Eric St-Amand, 07-13-2016

Very good and to the point
--Frederick Cole, 10-02-2015

I appreciate mostly the figure 2 about "Root Cause Map" that can be used in general. The simple example is also good to understand. Thanks.
--Teddy Lai, 08-10-2012

Thanks, a useful document.
--Shirley Li, 05-24-2011

Great points. Will support our RCA efforts.
--Larry, 01-20-2011

Fantastic briefing with very simple examples, making it much simpler to understand. Thanks.
--Sameer Chauhan, 08-25-2010

An excellent article, very detailed description. It would be great if similar articles on software projects/problems RCA is published, as I have always found only RCA articles either related to manufacturing industry problems or general problem areas.
--Malay Srinivas, 08-09-2010

Excellent article. Reminded me to trend root causes across like processes.
--Gerry Corr, 06-04-2010

Very well defined and explained through flow diagrams and examples.
--Vinai Kumar, 05-21-2010

Excellent article with sufficient detail to implement and execute.
--Barbara Haines, 05-21-2010

--Phillip Sugg, 05-21-2010

This is a very good description of one of the many methods of root cause analysis. It is also one of the better articles in QP in months.
--Tom Fessenden, 05-20-2010

One acid test is "Do the factors identified explain the nature, the magnitude, the location, and the timing of the key consequences?" If the analysis does not pass, you can be sure there is something missing.
--William R. Corcoran, PhD, PE, 07-14-2009

Thanks, excellent article. It is simple and informative. ???
--Marwan Khazindar, 03-11-2008

an abolutely useful article
--raviupadhye, 03-10-2008

--Christi Wallace, 02-26-2008

--Indira Ramjit, 02-20-2008

--Paul Callanan, 02-07-2008

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