A basic presentation that the describes the principles of RCA and focuses on the 5-whys method and how it can be utilized to solve our everyday incidents.
2. WHAT IS ROOT CAUSE ANALYSIS(RCA)?
Root Cause Analysis (RCA) is a process used to
identify “root causes” of problems or events and a
method for responding to them. It is based on the
idea that effective management requires more
than merely solving problems that develop, but
finding a way to prevent them.
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3. GOALS OF RCA
What happened?
How it happened?
Why it happened?…so that
Preventative actions are developed
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4. BENEFITS OF RCA
Identifies the causes of problems, so that
permanent solutions can be found.
Identify current and future needs for
organizational improvement.
Establish repeatable, step-by-step processes,
in which one process can confirm the results
of another.
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5. APPLYING RCA
Major accidents (Car collision)
Everyday incidents (Falling object, home
incidents)
Near misses
Human errors
Medical mistakes
Productivity issues
Manufacturing mistakes
Environmental releases
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6. HOW TO DETERMINE ROOT CAUSES
Figure 1: Root cause Analysis[1]
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8. THE 5-WHYS METHOD
A simple problem-solving technique that helps
users get to the root of the problem quickly. This
strategy involves looking at a problem and asking
“why” .Often the answer to the first “why”
prompts a second “why” and so on providing the
basis for the “5-why” analysis.
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9. EXAMPLE: BEAR IN A GYM [3]
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https://youtu.be/wCS1GEYHZh4
10. EXAMPLE: BEAR DESTROYS GYM
Symptoms
Root Causes
Inadequate
training
No supervision
Frustration
Lack of
instructions
Mishandling
Hunger?
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10Hibernation?
11. THE 5-WHYS METHOD EXAMPLE
The bear injured himself and damaged equipment
GYM
Injury/
damage
Handle
broken
Equipment
mishandled
No practice
instructions
Lack of
supervision
Why? Why?
Why?Root
Cause
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Why?
12. CORRECTIVE AND PREVENTATIVE ACTIONS
Corrective action is a method of
communications with employees to improve
attendance, behavior or performance.
Example for wrong check-in PAX, for corrective
action (debriefing sessions, SMT, occurrence
report)
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13. PREVENTATIVE ACTION
Preventative action is a change implemented
to address a weakness that may cause issues in
the future.
Example(Read and sign, safety training and
dangerous goods training, fire extinguishers,
Smoke detectors)
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14. 14
Caught
speeding
Why? Why?
Why? Why?
Why?
Late for
work
Got up
late
Alarm
clock didn’t
work
Batteries
were flat
Forgot to
replace
them
ACTIVITY
MAN CAUGHT SPEEDING
Root Cause Corrective Action
Human
error
Rechargeable
alarm clock
18. REFERENCES
[1] Patrick Yurista. (2017). Root Cause Analysis. Available:
https://digitalmarketing.temple.edu/pyurista/2017/06/09/root-cause-
analysis/. Last accessed 7th May 2018.
[2] Sardar solutions. (2015). Problem Solving & Root Cause
Analysis.Available: http://www.sardarsolutions.com/el-panamericano/.
Last accessed 07th MAY 2018.
[3] https://www.youtube.com/watch?v=SZg4eUBi09Q&t=67s
Last accessed 01st sep18
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19. APPENDIX
Barrier Analysis — Investigation or design method that involves the tracing of pathways
by which a target is adversely affected by a hazard, including the identification of any
failed or missing countermeasures that could or should have prevented the undesired
effect(s).
Change Analysis — Looks systematically for possible risk impacts and appropriate risk
management strategies in situations where change is occurring. This includes situations in
which system configurations are changed, operating practices or policies are revised, new
or different activities will be performed, etc.
Causal Factor Tree Analysis — An investigation and analysis technique used to record and
display, in a logical, tree-structured hierarchy, all the actions and conditions that were
necessary and sufficient for a given consequence to have occurred.
Failure Mode and Effects Analysis — A “system engineering” process that examines
failures in products or processes.
Fish-Bone Diagram or Ishikawa Diagram — Derived from the quality management
process, it’s an analysis tool that provides a systematic way of looking at effects and the
causes that create or contribute to those effects. Because of the function of the fishbone
diagram, it may be referred to as a cause-and-effect diagram. The design of the diagram
looks much like the skeleton of a fish—hence the designation “fishbone” diagram.
Pareto Analysis — A statistical technique in decision making that is used for analysis of
selected and a limited number of tasks that produce significant overall effect. The premise
is that 80% of problems are produced by a few critical causes (20%).
Fault Tree Analysis — The event is placed at the root (top event) of a “tree of logic”. Each
situation causing effect is added to the tree as a series of logic expressions.
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