recognition of root cause
TRANSCRIPT
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Causal Analysis:
Recognition oRoot Cause
Presented By:
Herrera, Edward Joshua M.
Tombado, Reymond T.
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efinition of Terms:
Recognition
Cau
Causa! "na!ysis# you engage in the $rocess of causal ana
attem$t to determine a cause for an effect. &howing causes, reasons
resu!ts or conse'uences is a natura! way of thin(ing.
E)ery time you try to answer a 'uestion that as(s *why+ you enga
$rocess of causa! ana!ysis
Root Cause# is an initiating cause of either a condition or athat !eads to an outcome or effect of interest
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ROOT CAUSE ANALYSIS
Root cause analysis -RCA# is a method of $rob!em
so!)ing used for identifying the root causes of fau!ts $rob!ems. " factor is considered a root cause if remo
from the $rob!em#fau!t#se'uence $re)ents the fina!
e)ent from recurring/ whereas a causa! factor is
affects an e)ent0s outcome, but is not a root cause. remo)ing a causa! factor can benefit an outcome, it
$re)ent its recurrence within certainty.
Recognition
Cau
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Investigating Incidents
1ncident in)estigation, whether for safety, 'ua!ity, or $roduction, can be
sim$!e or com$!e2 de$ending u$on the se)erity of the e)ent. 1n $rinci$!e,
in)estigators wou!d be trained to
a disco)er the facts,
b co!!ect e)idence,
c ascertain the root cause-s, and
d ma(e recommendations in a written re$ort.
Howe)er, many in)estigators often sei3e on the first set of 4sym$toms5 as
the Root Cause, rather than the Root Cause-s themse!)es. This is why the
same ty$e-s of incidents are often re$eated.
Recognition
Cau
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Root Cause "na!ysis -RC" is a $o$u!ar andoften#used techni'ue that he!$s $eo$!e answer the
'uestion of why the $rob!em occurred in the first $!ace.
1t see(s to identify the origin of a $rob!em using a
s$ecific set of ste$s, with associated too!s, to find the
$rimary cause of the $rob!em, so that you can:
6. etermine what ha$$ened.7. etermine why it ha$$ened.
8. 9igure out what to do to reduce the !i(e!ihood that
it wi!! ha$$en again.
Recognition
Cau
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In Investigating Incidents usually find
three basic tyes of causes!
"hysical causes Tangib!e, materia! items fai!ed in some way -for e2am$sto$$ed wor(ing.
#u$an causes Peo$!e did something wrong, or did not do something thHuman causes ty$ica!!y !ead to $hysica! causes -for e2am$!e, no one fi!!ed
which !ed to the bra(es fai!ing.
Organi%ational causes " system, $rocess, or $o!icy that $eo$!e use tor do their wor( is fau!ty -for e2am$!e, no one $erson was res$onsib!e for )
maintenance, and e)eryone assumed someone e!se had fi!!ed the bra(e f!uid.
Recognition
Cau
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RC" !oo(s at a!! three ty$es of causes. 1
in)o!)es in)estigating the $atterns of
negati)e effects, finding hidden f!aws inthe system, and disco)ering s$ecific
actions that contributed to the $rob!em.
This often means that RC" re)ea!s morethan one root cause.
Recognition
Cau
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The Root Cause Analysis "rocess
RC" has fi)e identifiab!e ste$s.
Ste One! &efine the "roble$;hat do you see ha$$ening+
;hat are the s$ecific sym$toms+
Recognition
Cau
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The Root Cause Analysis "rocess
RC" has fi)e identifiab!e ste$s.
Ste T'o! Collect &ata;hat $roof do you ha)e that the $rob!em e2ists+How !ong has the $rob!em e2isted+
;hat is the im$act of the $rob!em+
%ou need to ana!y3e a situation fu!!y before you can mo)e on to !oo
that contributed to the $rob!em. To ma2imi3e the effecti)eness of ytogether e)eryone e2$erts and front !ine staff who understands t
Peo$!e who are most fami!iar with the $rob!em can he!$ !ead you to
understanding of the issues.
Recognition
Cau
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The Root Cause Analysis "rocess
RC" has fi)e identifiab!e ste$s.
Ste Three! Identify "ossible Causal (actors;hat se'uence of e)ents !eads to the $rob!em+;hat conditions a!!ow the $rob!em to occur+
;hat other $rob!ems surround the occurrence of the centra! $rob!em+
uring this stage, identify as many causa! factors as $ossib!e. Too often, $eo$!e identify one
then sto$, but that0s not sufficient. ;ith RC", you don0t want to sim$!y treat the most ob)iou
to dig dee$er.
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The Root Cause Analysis "rocess
RC" has fi)e identifiab!e ste$s.
Ste (our! Identify the Root Cause+s,;hy does the causa! factor e2ist+
;hat is the rea! reason the $rob!em occurred+
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The Root Cause Analysis "rocess
RC" has fi)e identifiab!e ste$s.
Ste (ive! Reco$$end and I$le$ent S;hat can you do to $re)ent the $rob!em from
ha$$ening again+
How wi!! the so!ution be im$!emented+
;ho wi!! be res$onsib!e for it+;hat are the ris(s of im$!ementing the so!utio
Recognition
Cau
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Thank You