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Understanding Root Cause Analysis in the Business Environment


Checklist Description

This checklist presents a brief guide to root cause analysis, outlining how the method works and examining some potential uses.

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Definition

Root cause analysis (RCA) is a process of investigating and determining the root cause of specific problems with the intention of building and implementing a solution that will prevent a reoccurrence of the problem. RCA focuses on underlying issues rather than the specific symptoms of problems, with the consequence that its use to analyze a relatively minor undesirable event that has already occurred can expose previously unrecognized vulnerabilities from which a much more serious problem could arise in the future. RCA aims to help managers to answer questions such as what went wrong, how it went wrong, and, most importantly, why it went wrong. In addition to identifying unseen operational hazards, RCA can also have applications in improving business processes by flagging inadequate or over-zealous control mechanisms.

In its most basic form, RCA initially requires some formalization of undesirable results, such as the basic problem of a failure or weakness that has been exposed. Then facts with any possible relevance to the issue are collected, such as where the problem appeared and the circumstances surrounding the incident. A list of all possible sources of the problem should be compiled at this stage. Next, a chart is created to demonstrate graphically how the event on the chart’s heading can be linked to the circumstances present at the time of the failure. Brainstorming can frequently be utilized at this stage to help ensure that all possible causes are included in the analysis. At all stages, questions should be posed to challenge assumptions, particularly “why” questions in relation to the fundamental causes of the problem. Then the reasoning behind the list of all possible causes should be rechecked, with all those which don’t stack up being rejected and eliminated from the chart. Finally, results that fit with both root and proximate causes should be created, and a series of recommendations produced that offer solutions and/or corrective actions.

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Advantages

  • Root cause analysis can help executives to understand how and why a wide range of undesirable events—from minor operational difficulties to potentially catastrophic failures—occur, helping them to take action to avoid the problem in the first place.

  • RCA aims to tackle the fundamental causes of the problem, rather than just papering over inadequacies by performing a patch to fix that specific problem.

  • The process can highlight underlying operational shortcomings which, if left unaddressed, could result in more serious future problems.

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Disadvantages

  • RCA charts can become highly complex because of the level of detail that can be analyzed in an attempt to find a solution.

  • In practice, some problems may have their origins spread across a range of process inadequacies. Some of the simpler RCA investigations work on the assumption that a problem has a single underlying cause.

  • Some managers may interpret the conclusions of RCA as a criticism of the way they perform their jobs—for example, if a persistent power system failure is deemed to result from poor maintenance, this could reflect badly on those responsible for allocating the maintenance budget.

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Action Checklist

  • Involve a wide range of employees in the RCA process. A production worker, for example, may be able to offer insights into potential process weaknesses which an office-based manager may fail to identify.

  • Repeatedly ask “why?” in relation to the way things are done. A basic approach to RCA suggests that the question should be posed at least five times to drill deep in the search for flawed assumptions or logic.

  • Be prepared to “tread on toes” to question assumptions, as this may be the most rigorous means of ultimately finding the root of the problem.

  • However, acknowledge that people are at the heart of processes and that modifying behavior may therefore be the key to success.

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Dos and Don’ts

Do

  • During the analysis process, probe common assumptions by asking questions such as who, what, and why.

  • Ensure that all analysis conducted during the process is truly rigorous; be aware of the possibility that subjective analysis will be presented to support the outcomes favored by one or more parties within the organization.

Don’t

  • Don’t expect the “silver bullet” of a single conclusion to fully address the problem. In many cases, the root cause of a problem can be multiple in nature;

  • Don't expect the conclusions of a RCA process to be welcomed by all; in practice, one or more company departments—including specific individuals within those units—may be directly linked to the failings.

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Further reading

Books:

  • Latino, Robert J., and Kenneth C. Latino. Root Cause Analysis: Improving Performance for Bottom-Line Results. 3rd ed. Boca Raton, FL: CRC Press/Taylor & Francis, 2006.
  • Vanden Heuvel, Lee N., et al. Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigation. 3rd ed. Brookfield, CT: Rothstein, 2008.

Articles:

  • Doggett, Mark A. “Root cause analysis: A framework for tool selection.” Quality Management Journal 12:4 (October 2005): 34–45. Online at: tinyurl.com/3eh82cf [PDF].
  • Okes, Duke. “The human side of root cause analysis.” Journal for Quality and Participation 31:3 (October 2008): 20–29. Online at: tinyurl.com/3bepsuo [PDF].

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