There are a ton of Root Cause Analysis methods out there, and new ones are popping up all the time. This post dives into some of the lesser known methods of RCA such as Kepner-Tregoe, Barrier Analysis, and Events and Causal Factor Analysis. Perhaps this will help stock your arsenal so that you have more powerful tools to crack bigger problems.
Root Cause Analysis Method: Kepner-Tregoe Problem Solving and Decision Making
This is a more methodical approach that combines the best of RCA and change management to ensure that not only the problem is clearly identified, but the best solutions are also developed to address them.
There are four basic steps for using the Kepner Tregoe decision matrix:
- Situation appraisal – the process of clarifying the situation, outlining concerns and choosing a direction
- Problem analysis – defining the problem and determining it’s root cause
- Decision analysis – defining alternative solutions and a conducting a risk analysis for each
- Potential problem analysis – further scrutinizing the best alternative solutions against potential problems and negative consequences and proposing actions to mitigate risks
Root Cause Analysis Method: Events and Causal Factor Analysis
This method is used to establish a timeline or “storyline” of events leading up to an incident. It works best for one-off major events that are caused by a series of other significant events.
The steps include:
- Organize the accident data – Collect and categorize all known facts regarding the issue
- Guide the investigation – Create and execute the investigation facilitation plan to discover what is not currently known but needed
- Validate and confirm the true accident sequence – Confirm that known facts are actually truth
- Identify and validate factual findings, probable causes, and contributing factors – Outline potential causes and contributing factors
- Simplify the investigation report – Organize the findings the report in a way in a reader-friendly format
- Illustrate the accident sequence in the investigation report – Incorporate visual aides into the final report that clearly illustrate the accident sequence
Root Cause Analysis Method: Change Analysis
This process ties events or significant shifts in performance back to changes in the process that may have contributed to the result.
The steps include:
- Describe the event or problem
- Describe the situation without the problem
- Compare the two situations
- Document the differences
- Analyze the differences
- Identify the consequences of the differences
Root Cause Analysis Method: Barrier Analysis
This approach assesses the system of controls or “barriers” that are in place to prevent issues from occurring to determine which might have failed or malfunctioned.
The steps include:
- Write the behavior statement – Clearly define what behavior needs to be studied
- Write the behavior screening questions – Develop a set of questions that helps determine if the subject (person) is a doer or non-doer
- Write the research questions – Identify what information needs to be discovered and formulate questions
- Organize the field work – Create a plan to gather the needed data
- Conduct the survey – For any information that cannot be gathered from direct observation, interview subject matter experts
- Coding, tabulating, and analyzing the data – Transform the data and information into a coherent story
- Using the research to make decisions – Decide on the best course of action
Root Cause Analysis Method: Problem Tree Analysis
This method creates a tree diagram of potential causes of an observable problem or result. It includes branches of potential causes instead of a simple linear approach used in the 5 Why’s
Here are the steps involved:
- Define the system or area of interest – Scope the system to be fully inclusive but isolates the problem enough for sufficient controls to be set.
- Identify the initiating events of interest – Scope the specific problem to be addressed
- Identify lines of assurance and physical phenomena – Identify the barriers (both physical and human) put in place to control process outcomes.
- Define contributing factors – Identify potential causes or contributing factors for each known cause.
- Analyze potential root causes for most probable factors – Determine the appropriate frequency and severity of each possible root cause and select which to apply further investigation
- Summarize results – Create a report that lists all accidents stemming from potential root causes
Root cause analysis is a great tool for developing a better understanding of why problems might be occurring in any process-oriented operation. RCA is a cornerstone of Continuous Improvement as it enables more effective solutions to be developed. As with any root cause, there may be several problems resulting from the same root. Therefore, fixing one root cause can produce a multitude of benefits for your operation.
As with any RCA, the root causes are just hypothesis that need to be proven (or dis-proven) through testing and experimentation. This means that a clear plan of action should flow from the RCA activity. The RCA does not improve a process. Making changes and observing what happens is where the real improvement occurs. And if you’re not seeing the result you’re looking for, you need to further your RCA, form new hypothesis, and continue to experiment until you get the right result. RCA coupled with deliberate action accelerates the learning process and produces powerful results in the meantime.