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Root Cause Analysis (RCA) & Actions Cheat Sheet (DRAFT) by [deleted]

Steps in Root Cause Analysis & Corrective Actions

This is a draft cheat sheet. It is a work in progress and is not finished yet.

General Principles of Root Cause Analysis (RCA)

1. The primary aim of root cause analysis is: to identify the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes (conse­que­nces) of one or more past events; to determine what behaviors, actions, inactions, or conditions need to be changed; to prevent recurrence of similar harmful outcomes; and to identify lessons that may promote the achiev­ement of better conseq­uences. ("Su­cce­ss" is defined as the near-c­ertain prevention of recurr­ence.)
2. To be effective, root cause analysis must be performed system­ati­cally, usually as part of an invest­iga­tion, with conclu­sions and root causes that are identified backed up by documented evidence. A team effort is typically required.
3. There may be more than one root cause for an event or a problem, wherefore 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 lowest cost in the simplest way. If there are altern­atives that are equally effective, then the simplest or lowest cost approach is preferred.
5. The root causes identified will depend on the way in which the problem or event is defined. Effective problem statements and event descri­ptions (as failures, for example) are helpful and usually required to ensure the execution of approp­riate analyses.
6. One logical way to trace down root causes is by utilizing hierar­chical clustering data-m­ining solutions (such as graph-­the­ory­-based data mining). A root cause is defined in that context as "the conditions that enable one or more causes­". Root causes can be deduct­ively sorted out from upper groups of which the groups include a specific cause.
7. To be effective, the analysis should establish a sequence of events or timeline for unders­tanding the relati­onships between contri­butory (causal) factors, root cause(s) and the defined problem or event to be prevented.
8. Root cause analysis can help transform a reactive culture (one that reacts to problems) into a forwar­d-l­ooking culture (one that solves problems before they occur or escalate). More import­antly, RCA reduces the frequency of problems occurring over time within the enviro­nment where the process is used.
9. Root cause analysis as a force for change is a threat to many cultures and enviro­nments. Threats to cultures are often met with resist­ance. Other forms of management support may be required to achieve effect­iveness and success with root cause analysis. For example, a "­non­-pu­nit­ive­" policy toward problem identi­fiers may be required.
 

General Process for RCA-based Corrective Action

1. Define the problem or describe the event to prevent in the future. Include the qualit­ative and quanti­tative attributes (prope­rties) of the undesi­rable outcomes. Usually this includes specifying the natures, the magnit­udes, the locations, and the timing of events. In some cases, "­low­ering the risks of reoccu­rre­nce­s" may be a reasonable target. For example, "­low­ering the risks" of future automobile accidents is certainly a more econom­ically attainable goal than "­pre­venting all" future automobile accidents.
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. In data mining Hierar­chical Clustering models, use the clustering groups instead of classi­fying: (a) peak the groups that exhibit the specific cause; (b) find their upper-­groups; (c) find group charac­ter­istics that are consis­tent; (d) check with experts and validate.
4. Ask "­why­" and identify the causes associated with each sequential step towards the defined problem or event. "­Why­" is taken to mean "What were the factors that directly resulted in the effect­?"
5. Classify causes into two catego­ries: causal factors that relate to an event in the sequence; and root causes that interr­upted that step of the sequence chain when elimin­ated.
6. 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.
7. Identify corrective action(s) that will, with certainty, prevent recurrence of each harmful effect and related outcomes or factors. Check that each corrective action would, if pre-im­ple­mented before the event, have reduced or prevented specific harmful effects.
8. 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.
9. Implement the recomm­ended root cause correc­tio­n(s).
10. Ensure effect­iveness by observing the implem­ented solutions in operation.
11. Identify other possibly useful method­ologies for problem solving and problem avoidance.
12. Identify and address the other instances of each harmful outcome and harmful factor.