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HSX MODULE: ROOT CAUSE ANALYSIS
March 2017
OVERVIEW
• Definition: Root-cause analysis is an evaluation method utilized for
the identification of root causes of an incident and subsequent
prevention of incident recurrence.
• The goal: comprehensive understanding of causal factors and
effective mitigation
• Components:
• “5-Whys”
• Causal Tree
• Application
Root Cause Analysis
A method primarily used to identify the underlying cause of an
incident or issue, and more effectively mitigate or prevent future
similar incidents
Rather than simply addressing the proximate cause, root cause
analysis seeks the root cause of an incident or issue
Highly effective tool for problem-solving
Proximate cause (direct cause) - occurs immediately prior to
the incident; directly results in its occurrence and, if eliminated
or modified, would have prevented the undesired outcome
Root Cause - One of multiple factors (events, conditions or
organizational factors) that created the proximate cause and
subsequent undesired outcome. Typically multiple root causes
contribute to an undesired outcome.
Source: Office of Safety & Mission Assurance. NASA, July 2003. Web. 16 Feb 2017.
http://www.au.af.mil/au/awc/awcgate/nasa/rootcauseppt.pdf
Causal Tree
• Undesired incident at the top
• Immediate causes below
• Continue to ask what the causes of the causes were until you
reach:
• root cause
• insufficient data
• issue that you cannot personally or organizationally resolve
Source: Office of Safety & Mission Assurance. NASA, July 2003. Web. 16 Feb 2017. http://www.au.af.mil/au/awc/awcgate/nasa/rootcauseppt.pdf
The 5-Whys Method
• Ask “why?” an undesired outcome occurred
• The answer to this question becomes the next “Why?”
question
• The 5-Why method can also be used to aid in the
creation of a causal tree
Source:Lifetime Reliability Solutions, “Understanding How to Use the 5-Whys for Root Cause Analysis.” Web. http://www.lifetime-
reliability.com/tutorials/lean-management-methods/How_to_Use_the_5-Whys_for_Root_Cause_Analysis.pdf
Application of Root Cause Analysis
• Mitigating undesired outcomes
• Preventing recurrence of undesired outcomes
• Fixing/streamlining systems and processes
• Root cause analysis has been applied in business, international risk
management, healthcare, and other diverse sectors
Key Takeaways
• Root cause analysis- Identifying the base causes of an
issue or incident, which may not be immediately
apparent
• Methods:
• Causal tree
• 5 Whys
• Potential for broad application across fields (see
literature resource sheet)
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Literary and Scholastic Resources – Root-Cause Analysis
Date of information: February 2017
Overview: While not exhaustive, the following resources provide a roadmap to understanding the process of root-
cause analysis and how this technique can aid problem-solving and mitigate issue recurrence.
Literary Resources:
Root Cause Analysis for Beginners: Rooney and Heuvel give an overview of methods for using root-cause
analysis to identify what, how, and why an undesired outcome occurs and preventing future recurrence.
o Cite: Rooney, J.J., Heuvel, L.N.V., 2004. Root Cause Analysis for Beginners. Quality Progress.
37, 45–56. Web.
https://www.env.nm.gov/aqb/Proposed_Regs/Part_7_Excess_Emissions/NMED_Exhibit_18-
Root_Cause_Analysis_for_Beginners.pdf
Techniques for Root Cause Analysis: Williams presents multiple techniques and processes of root cause
analysis at varying levels of depth and complexity to identify and mitigate root issues in processes.
o Cite: Williams, Patricia M., “Techniques for Root Cause Analysis.” Proceedings (Baylor
University. Medical Center) 14.2 (2001): 154–157. Web.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292997/
Understanding how to use the 5-Whys for root cause analysis: This document describes the proper
methodology for using the 5-Why technique—a method of root cause analysis—to accurately identify the
root cause of an issue and prevent recurrence.
o Cite: Lifetime Reliability Solutions, “Understanding How to Use the 5-Whys for Root Cause
Analysis.” Web. http://www.lifetime-reliability.com/tutorials/lean-management-
methods/How_to_Use_the_5-Whys_for_Root_Cause_Analysis.pdf
The Application of Formal Methods to Root Cause Analysis of Digital Incidents: Stephenson describes a
formal approach to the utilization of root cause analysis for incident response specifically in the domain of
security.
o Cite: Stephenson, Peter. “The Applications of Formal Methods to Root Cause Analysis of Digital
Incidents.” International Journal of Digital Evidence.3.1 (2004). Web.
https://www.utica.edu/academic/institutes/ecii/publications/articles/A0B62ABA-F4C9-CBCE-
8B9812B7B4055CAC.pdf
Other Scholastic Resources:
Presentations:
Root Cause Analysis Overview: This PowerPoint presentation presents suggested steps for root-cause
analysis and a distinction between proximate and root causes, as well as examples of application of the
method.
o Office of Safety & Mission Assurance. NASA, July 2003. Web. 16 Feb 2017.
http://www.au.af.mil/au/awc/awcgate/nasa/rootcauseppt.pdf
Root Cause Analysis: A Tool for Improvement: This PowerPoint presentation examines root causes
analysis as applied to systems.
o North Dakota Health Care Review, Inc., Center for Rural Health, UND School of Medicine,
October 11, 2006. Web. 16 Feb 2017.
http://www.health.state.mn.us/patientsafety/toolkit/rca_ndpresentation.pdf
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Analytical Tools:
Management Oversight Risk Tree: This webpage describes the Management Oversight Risk Tree (MORT),
a highly effective diagram used to identify underlying management root causes of hazards.
o Federal Aviation Administration, Management Oversight Risk Tree. Web. 16 Feb 2017.
http://www.hf.faa.gov/workbenchtools/default.aspx?rPage=Tooldetails&subCatId=43&toolID=15
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