Root cause analysis

Description

Root cause analysis (RCA) is a process designed for use in investigating and categorizing the root causes of events .

The term “event” is used to generically identify occurrences that produce or have the potential to produce these types of consequences.

Understanding why an event occurred is the key to developing effective recommendations.

Imagine an occurrence during which an operator is instructed to close valve A;

instead, the operator closes valve B.

The typical investigation would probably conclude operator errorwas the cause.

When to Use

when you want to know the real cause of problem.

i hear you say :""what is the real cause "" Good question.

Real cause also called root cause are :

1- Root causes are underlying causes :

The investigator’sgoal should be to identify specific underlying causes.

The more specific the investigator can be about why an event occurred, the easier it will be to arrive at recommendations that will prevent recurrence.

2-Root causes are those that can reasonably beidentified:

Occurrence investigations must be costbeneficial. It is not practical to keep valuable manpower occupied indefinitely searching for the root causes of occurrences.

Structured RCA helps analysts get the most out of the time they have invested in the investigation.

3- Root causes are those over which managementhas control:

Analysts should avoid using generalcause classifications such as operator error, equipmentfailure or external factor.

4-Root causes are those for which effective recommendationscan be generated: Recommendationsshould directly address the root causes identifiedduring the investigation.

Seven Major Steps Problem Solving:

The RCA is a seven-step process involving the following:

1. Identify the problem : flow chart could be used to imagine the situation and see where the problem is.

2.List possible root casues:

before jumping to conclusion about what to do about the problem its useful to look at wide range of possibilities , Fish bone diagram is often used

3.search out the most likely root cause :

Check points might be used to recored each failure and supporting information.

4- identify potential solutions :

here you list all possible solution arise from Brainstorming

5- select and implement a solution :

to select the most valuable solution use Priorities Matrix

6- follow up to evaluate the effect :

to insure that the problem have been solved , you can use control charts

7- standardize the process:

even after solving the problem you need to train employees , updating procedures , etc... to ensure every one know the new solution and procedure.