RCA is typically used as a reactive method of identifying event(s) causes, revealing problems and solving them. Analysis is done after an event has occurred. Insights in RCA may make it useful as a preemptive method. In that event, RCA can be used to forecast or predict probable events even before they occur. While one follows the other, RCA is a completely separate process to Incident Management.
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 outcome
(consequences) of one or more past events in
order to identify what behaviors, 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.
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.
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 preferably
the lowest cost in the simplest way.
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. RCA can help transform a reactive culture 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 root cause
analysis process is used.
General process for performing and documenting an RCA-based Corrective Action;
1. Define the problem or describe the event to
prevent in the future.
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. Ask "why" and identify the causes associated with
each step in the sequence towards the defined
problem or event. "Why" is taken to mean "What
were the factors that directly resulted in the
effect?"
4. Classify causes into causal factors that relate to an
event in the sequence and root causes, that if
eliminated, can be agreed to have interrupted that
step of the sequence chain.
5. 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.
6. Identify corrective action(s) that will with certainty
prevent recurrence of each harmful effect,
including outcomes and factors. Check that each
corrective action would, if pre-implemented before
the event, have reduced or prevented specific
harmful effects.
7. 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.
8. Implement the recommended root cause
correction(s).
9. Ensure effectiveness by observing the implemented
recommendation solutions.
The key to an effective Accident Investigation Program is to dig down to the "Root" of the problem. Otherwise, accidents are simply being reported with very little chance of preventing a recurrence.
For more information, contact the CCAP Loss Control Department at (800) 895-9039; or email us at:
Gary Nicholson, Loss Control Services Manager
Maureen McMahon, Loss Control Specialist
Andrew Smith, Loss Control Specialist
Dennis Cutler, Loss Control Specialist
