Root Cause Analysis - RCA Process and Documenting

General process for performing and documenting an RCA-based corrective action

RCA (in steps 3, 4 and 5) forms the most critical part of successful corrective action, directing the corrective action at the true root cause of the problem. Knowing the root cause is secondary to the goal of prevention, as it is not possible to determine an absolutely effective corrective action for the defined problem without knowing the root cause.

  1. Define the problem or describe the event to prevent in the future. Include the qualitative and quantitative attributes (properties) of the undesirable outcomes. Usually this includes specifying the natures, the magnitudes, the locations, and the timing of events. In some cases, "lowering the risks of reoccurrences" may be a reasonable target. For example, "lowering the risks" of future automobile accidents is certainly a more economically attainable goal than "preventing all" future automobile accidents.
  2. Gather data and evidence, classifying it along a timeline of events to the final failure or crisis. For every behavior, condition, action and inaction, specify in the "timeline" what should have been done when it differs from what was done.
  3. In data mining Hierarchical Clustering models, use the clustering groups instead of classifying: (a) peak the groups that exhibit the specific cause; (b) find their upper-groups; (c) find group characteristics that are consistent; (d) check with experts and validate.
  4. Ask "why" and identify the causes associated with each sequential step towards the defined problem or event. "Why" is taken to mean "What were the factors that directly resulted in the effect?"
  5. Classify causes into two categories: causal factors that relate to an event in the sequence; and root causes that interrupted that step of the sequence chain when eliminated.
  6. Identify all other harmful factors that have equal or better claim to be called "root causes." If there are multiple root causes, which is often the case, reveal those clearly for later optimum selection.
  7. Identify corrective action(s) that will, with certainty, prevent recurrence of each harmful effect and related outcomes or factors. Check that each corrective action would, if pre-implemented before the event, have reduced or prevented specific harmful effects.
  8. Identify solutions that, when effective and with consensus agreement of the group: prevent recurrence with reasonable certainty; are within the institution's control; meet its goals and objectives; and do not cause or introduce other new, unforeseen problems.
  9. Implement the recommended root cause correction(s).
  10. Ensure effectiveness by observing the implemented solutions in operation.
  11. Identify other possibly useful methodologies for problem solving and problem avoidance.
  12. Identify and address the other instances of each harmful outcome and harmful factor.