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Root Cause Analysis Guideline
For
Ground Operations
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Get Help Now!What is The Root Cause ?………………………………………………………………………………………3
What is Root Cause Analysis ?………………………………………………………………………………..3
What is the Root Cause Analysis Focus on ?…………………………………………………………….3
Root Cause Analysis (RCA) Objectives and basic purpose ……………………………………….…….3
Root Cause Analysis – “Schools”……………………………………………………………………………………4
Casual Factors ………………………………………………………………………………………………………………5
Root Cause – Look Beyond The Obvious …………………………………………………………….…………5
Why Determine Root Cause ? ……………………………………………………………………………….………6
When to apply Root Cause Analysis ? …………………………………………………………………….…….6
How to Determine a Root Cause ? …………………………………………………………………………….….6
How to Eliminate/Mitigate a root Cause ? …………………………………………………………….……..7
Root Cause Analysis Common Errors …………………………………………………………………….……..7
Root Causes in most cases ……………………………………………………………………………………………8
Root Cause Analysis Tools …………………………………………………………………………………………….8
The Five Whys ………………………………………………………………………………………….…..8
Cause and effect ………………………………………………………………………………………………9
Fault Tree Analysis (FTA) ………………………………………………………………………………….12
Summary of the Root Cause Analysis Tools ………………………………………………………………….15
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What is the Root Cause ?
The original event(s), Action(s), and/or condition(s) generating (directly or in cascade)
and actual or potential undesirable condition, situation, nonconformity or failure.
There are often several root causes for one problem.
What is Root Cause analysis?
It’s in-depth process or technique to identify the most basic factor(s) which cause a
variation in the performance (problem).
What is the Root Cause Analysis Focus on ?
Focus is on systems and processes.
Focus is NOT on individuals.
Root Cause Analysis (RCA) objectives
To innovate.
To improve processes.
To solve problems.
To standardize.
The basic purpose of root cause analysis is to find the actual reason(s) for the occurrence of
problems.
4
Root Cause Analysis Schools
There are many tools, processes& philosophies on RCA, most of them can be classified into
5 distinct “schools”:
Safety-based RCA
Has its origins in accidents, incidents and other occurrence analysis
Production-based RCA
Has its origins in quality control or industrial manufacturing.
Process-based RCA
Has its origins in the production-based RCA, but with a scope that has been expanded to
include business processes.
Failure-based RCA
Has its origins in failure analysis used in engineering and maintenance areas.
System-based RCA
Emerged as a combination of the previous schools, along with concepts used in other
matters, such as change management, risk management, and systems analysis
5
Causal Factors:
Condition or event that results in an effect.
Causal factors can be classified as:
Root causes.
-The original event(s), Action(s), and/or condition(s) generating (directly or in cascade)
and actual or potential undesirable condition, situation, nonconformity or failure.
-There are often several root causes for one problem.
Contribution causes.
-Causes that per se wouldn’t cause a problem, just a potential increase of the risk of an
issue to happen.
-The analysis of these causes should be detailed to ensure a proper identification and
fixing.
Possible causes.
Conditions that appear to have caused the event, but need to be validated.
Root Cause – Look Beyond The Obvious
Note:
The real root cause of a problem may not be the initial reaction or response.
Often the initial stated root cause is incorrect and is just an indication.
Example:
Equipment failure and/or human error.
(These initial responses are usually the symptoms, not the actual root cause of the
problem)
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Why Determine Root Cause ?
To prevent problems from recurring.
To reduce possible injury to personnel.
To reduce rework and scrap.
To increase competitiveness.
To reduce costs.
When to apply Root Cause Analysis ?
To investigate one-time accident/incidents
To identify the underlying or chronic problems within the organization.
To determine current obstacles to improvement.
To find the reason of repetitive human error during a specific process.
To determine the reason of repetitive equipment failures in a specific process.
To determine the reason of repetitive equipment failures in a specific process.
To find the reason of low operational performance compared to a certain standard.
To address non-conformities raised against audit standards.
How to Determine a Root Cause ?
7
How to eliminate/mitigate a root cause ?
If you address only the symptoms the situation can become worse, the problem will still
be there!
Eliminating first- or higher level causes may temporarily alleviate the problem but the
root cause will eventually find another way to show up in the form of another problem!
Root cause analysis common errors
Looking for a single cause.
Often there are 2 or 3 causes which might be interrelated.
Ending the analysis before reaching to the actual root cause.
Determine as the causes of the problem the “why” event that proceeded the actual cause.
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Root Causes in most cases..
A root cause turns out to be:
Process or program failure.
System or organization failure.
Poorly written work instructions.
Lack of training.
Ineffective management.
Lack of adequate staff.
Root Cause Analysis Tools
There are several tools to identify the root cause of a problem. The most common ones
are:
Five Whys
It should be used by an individual or teams when trying to assess and determine the
source of a problem.
It can be used to:
Question whether each identified cause is a symptom, a low level cause, or a root cause.
Validate a root cause.
The Five Whys- Flow Chart:
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Example: Airplane crashed. Why has this happening?
Cause and effect diagram (also known as the fishbone diagram)
It’s a visual tool that helps to identify, sort, and display possible causes of a specific
problem.
It demonstrate the relationship between given outcome and all the factors that influence
the outcomes.
When should we use a cause-and-effect diagram?
Identify the possible root causes, the basic reasons, for a specific effect, problem, or
condition.
Sort out and relate some of the interactions among the factors affecting a particular
process or effect.
Analyze existing problems to apply corrective actions.
To be focused on the problem (not the symptoms).
To create a snapshot of the collective knowledge of the team involved in the analysis.
To create consensus of the problem causes.
To build support for the possible solutions.
To discover the most probable causes for further analysis.
To assess possible connections to other current or future problems.
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Layout of Cause And Effect Diagram
How to Develop Cause And Effect Diagram?
Step1:
Define the problem (effect) to be solved.
Use operational definitions to ensure effect is clearly understood.
Example:
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Step2:
Identify the main causes of the problem or event.
Use brainstorming technique
Often the causes are classified under people, equipment, materials, external factors
4 M’s – Machine, Method, Material and manpower.
4 S’s- Surroundings, Suppliers, Systems and Skills.
5 M’s-Measurement, Maintenance, Money, Management, (environment).
8 P’s-Product, Price, Place, Promotion, People, Process, Physical environment,
and productivity .
3 M’s and P-Method, Materials, Machinery, and People.
4 P’s-Policies, Procedures, People and Plant.
6M’s-Machine, Method, Materials, Measurements, Man and environment.
Other appropriate primary causes include Service, Quality, Technology,
Consumables, Work processes, Environment, Service level, etc.
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Example: Root Cause in Cause and effect Diagram
In below picture we found the root cause under Equipment Branch
Fault tree analysis
It’s a popular and productive hazard identification tool
It provides a standardized discipline to evaluate and control hazards
It’s used to solve a wide variety of problems from safety to management issues
It’s a deductive analysis
It begins with a stated top-level hazardous/undesired even
It uses logic diagrams to identify single events and combinations of events that could
cause the top event .
13
FTA benefits
Clearly shows all the different relationships that produce the top event.
There’s full understanding on the logic and basic causes leading to the top event.
It’s a tangible record of the systematic analysis done .
Provides a framework for a complete qualitative and quantitative evaluation of the top
event .
FTA Disadvantages
Depending on the complexity of the system being analyzed, it can be time consuming,
and therefore very expensive.
It does not identify all hazards, it only recognizes failures associated with the
predetermined top event being analyzed.
Why FTA is carried out?
To identify the causes of a failure thoroughly.
To identify weaknesses in a system .
To assess a proposed design for its reliability or safety.
To identify effects of human errors .
To prioritize contributor factors to failure.
To identify effective upgrades to a system.
To quantify the failure probability and contributor factors.
To optimize maintenance activities .
Construct the fault tree
Fault tree is based on AND and OR gates which define the major characteristics of the
fault tree.
OR gate – the output occurs if any input occurs.
AND gate – the output occurs only if all inputs occur (inputs are independent).
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FTA analysis – steps
– Evaluate the fault tree
– Assess and analyzed for any possible improvement
Control Hazards identified
It differs largely from one system to another
The main objective is after identifying the hazards all possible methods are followed to
decrease the probability of occurrence
Fault tree development – key points
Define the top event as a rectangle
Determine the immediate and sufficient events which result in the top event
Draw the appropriate gate to describe the logic for the intermediate events resulting in the
top event
Treat each intermediate event as top event
Determine the immediate and sufficient causes for each intermediate event and continue
the process
Fault Tree- Basic Structure
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Tools for Root Cause Identification – Summary
Tools Purpose Strength/Advantages Weaknesses/Difficulties
Five Whys -To determine the causes.
-effect relationship in a
problem or failure event.
-Easy to use. – Requires deep knowledge of the
problem.
Cause and
Effect Chart
-To show the relationship
between a given outcome
and all the factors that
influence the outcome.
-Easy to use
-Provides a structured
analysis.
– In complex situations ,
It’s simplicity may make it
difficult to represent the truly
interrelated nature of problems
and causes.
Fault Tree
Analysis
– To produce a clear
overview of the
possible causes
– To identify links
between causes or
identify groups of
related causes .
– Provides insight on how
causes interact .
– Can use results already
produced using five whys .
– In complex situations, the
diagram can be difficult to
build and read.
Prepared By
Rayan H Alotaibi
