Root Cause Analysis
The phrase root cause analysis has become commonplace when discussing how to investigate an incident. The ultimate goal of a root cause analysis is to implement actions that prevent a failure from reoccurring. Many people are familiar with the analogy comparing a problem to a weed and the concept of eliminating the roots of a problem, rather than only the obvious symptoms.
The idea sounds simple, but how do you actually perform a root cause analysis?
At the most basic level, the process of performing a root cause analysis requires three questions to be answered: What was the problem, What were the Causes of the problem, and What actions should be implemented to prevent the problem from reoccurring?
A thorough root cause analysis involves defining the problem, gathering evidence, identifying the root causes, creating and implementing solutions, and monitoring the solutions to ensure that they successfully prevent the original problem from happening again.
There are many techniques that can be used to perform a root cause analysis, including Cause Mapping, change analysis, the Ishikawa fishbone diagram, 5 Whys, and more. Each technique is designed to help organize an investigation and determine root causes.
At ThinkReliability, the Cause Mapping method of root cause analysis is used. The Cause Mapping method is a simple systems-based approach to root cause analysis that explains complex issues in a clear visual dialogue. Cause Mapping is an intuitive, flexible tool that can be applied to a wide variety of topics.
One element that is common between all root cause analysis techniques is that they require a facilitator to lead the investigation.
The facilitator is responsible for overseeing the collection and organization of all the information associated with the incident. The goal of the facilitator is to help make the investigation go as smoothly as possible. The facilitator should attempt to make the method used transparent during the investigation and keep things as clear and as simple as possible for all parties involved.
The facilitator has many duties during the investigation process. Typically, they coordinate and run any meetings needed during the investigation, contact attendees as necessary and ensure that the documentation of the incident is complete. The job of the facilitator may also include visits to the site or interviews with witnesses and people who have first-hand experience.
A facilitator doesn’t necessarily provide evidence, Causes or solutions during an investigation, but they are responsible for coordinating the information and managing the investigation process. If the facilitator knows any pertinent information, they can certainly provide it, but a facilitator may not have been involved with the problem prior to the start of the investigation.
The facilitator typically owns the investigation of the issue, while a department lead or manager owns the actual issue. In some cases, the facilitator may own both the investigation and the issue.
