Root cause began as a introductory tool to Incident Investigation and was meant to determine the initial cause of Incidents beyond the prevailing "human error" reason. However, Root Cause remains a topic of great debate for a few different reasons:

  • Some believe it was created to place blame on workers
  • Incidents may have more than 1 cause
  • The recommendations fell on deaf ears, or worse, approvals not followed through on.
How to conduct a Root Cause Analysis
  1. Gather relevant data and define the problem scenario.
  2. Classify and organise data into keywords.
  3. Determine frequency of keywords.
  4. Consider which high frequency keyword can the other keywords can get classified into.
  5. Use the classifying keyword to consider cause and effect with other problems.
  6. Select the keyword that shows cause and effect with other problems.
  7. Design questionnaire, and gather further evidence to test hypothesis.
  8. If hypothesis does not stand repeat selection and testing with another key word.
  9. Define the root cause of the problem and devise a solution.

When it comes to Root Cause analysis, Identifying the cause is only half the battle. Getting something done to eliminate the causes is a whole different story.

Picture this scenario:


You identified a failure worthy of Root Cause Analysis and implemented a solution to prevent the problem from happening again in the future.

However, had the process not been effectively IMPLEMENTED or audited to check for existing EVIDENCE of compliance, the company may experience:

  • Manpower dollars expended
  • Maintenance dollars expended
  • Lost profit opportunities (During time out of office) and much more.

Sure you've developed recommendations to eliminate the causes identified, implementing them should solve all issues surrounding the incident, correct?

But what happens when you've done the leg work using logic, diligence and dedication. You cared enough about the issue to do something to resolve it. You had included various team members in the solution to see all sides of the resolution. Think of how you might feel when nothing happens as a result of all your hard work - what if the Mouse was simply removed and none of your corrective actions were put into place. Would you stick your neck out again? How willing would you be to help again if your ideas were shot down, disrespected and not seriously considered?

Root cause is fine, but when push comes to shove, do you think others' will be as willing to adhere to proposed solutions when it comes time to put in the work?

Robert J Latino at the Reliability Centre Inc. states:

It is ironic that we see average returns for RCA in the neighborhood of 800% to 1000%, yet no one believes these figures because they are considered too “pie-in-the-sky”. If management honestly believed that such returns were obtainable then they should not have a problem in making sure the recommendations were executed immediately. The problem we see is that they do not believe it. Some of their thinking in this regard may be well founded. For instance, maybe such efforts in the past have not produced what they promised, therefore, why take the risk again.'

One of the things you can do is to display the costs: What is the lost cost of housekeeping, the lost cost of personnel out of the office due to clean-up/stench removal, and the cost of repair maintenance VERSUS the cost of a 6 month inspection and minimal preventative maintenance repairs.

Sometimes management needs to see the dollars and cents, it just makes sense.

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