We have all heard the term Root Cause Analysis (RCA) and we all likely interpret its meaning in a different fashion. This is the primary reason we see for the ineffective use of “RCA”, lack of communication or miscommunication amongst the users. If we are all using various forms of RCA, then when we compare our results we are not comparing apples with apples. We will explore the discipline necessary to provide consistency to our RCA application thus quantumly improving the credibility and communication of the results…
Let’s start off agreeing that the term Root Cause Analysis or RCA has become a commodity like many other acronyms/fads we have faced in our careers. RCA’s original intent when used in the aerospace industry has been considerably diluted over time and its various practical applications in the manufacturing, service and healthcare industries. How does this dilution occur?
Usually well-intentioned initiatives such as RCA are destined to face the abuses of human intervention. The theory sounds great, but it is the reality that counts. As we can imagine, when RCA was applied in the aerospace industry, it was very rigid in its application in terms of breadth and depth of analysis. As a result, it was very successful in its application. As is the case when such successes occur, people write white papers, articles and books, and present at trade conferences. Via this media pipeline, the ideas catch on within the same industry as well as in other industries.
Now RCA has become popular and is now introduced into the acronym Hall Of Fame along with the likes of TQM, JIT and SPC/SQC. Being the capitalist nation that we are here in the U.S., this invites competition in the field. Consultants emerge and because they compete against each other, everyone must have their different twist on RCA. This is necessary to make a marketing distinction between competing RCA consultants.
Keep in mind that RCA is now the noun and the competing methods are now the brands of RCA, or the adjectives. The user community is understandably confused at this point because they simply want the RCA that is the rave and every provider in the marketplace says that is what they provide.
As is the case with many acronyms at this point in their maturation process, the clients yearn more and more for quicker, faster RCA tools instead of more efficient and accurate analysis tools. The provider market starts to split and one group moves towards being the purist’s in the marketplace and they tend to focus on strict adherence to methodology and accurate results. The other group tends to move towards providing clients with quick and inexpensive tools that they will call RCA, but in the true RCA community, they are really brainstorming or problem-solving tools. Does this scenario sound familiar with the introduction of Six Sigma into the marketplace?
What is the difference between brainstorming, problem solving and RCA? Based on this author’s 20 years in the RCA business, here is the way that I see it:
is a process by which subject matter experts express their opinions about how a certain undesirable event occurred based on a perceived timeline of events and predetermined cause categories. Predetermined categories may be like manpower, machines, materials and methods for industry and equipment, policies, procedures and people for service type industries. As a result of these brainstorming sessions, recommendations are generated and implemented. Popular brainstorming tools like this include the Ishikawa Fishbone Diagram.
a process by which subject matter experts map out what they feel are the cause-and-effect relationships that lead up to an undesirable outcome. Recommendations are generated and implemented. Popular problem-solving tools include cause-and-effect diagrams and 5-Whys.
Root Cause Analysis
A process by which a trained, unbiased RCA facilitator uses as team of subject matter experts to map out the cause-and-effect relationships that are proven to have led to an undesirable outcome. This proof takes the form of physical evidence related to event and is used to prove or disprove hypotheses developed in the exploration process of determining why things went wrong. RCA will also typically drill down deeper than Problem Solving and identify all of the Physical, Human and Latent root causes. Popular RCA analysis tools include Logic Trees, Causal Trees, Reality Trees, Is/Is Not Analysis, WHY Tress, WHY Staircases, etc.
Brainstorming is often attractive to managements because it is quick and inexpensive. However, of the three approaches listed, it is usually the least accurate. This is due to the fact that cause-and-effect relationships have not been established and evidence is not usually required to back up opinion (hearsay). Therefore ignorance and assumption is oftentimes permitted to fly as fact when brainstorming. This can be costly because it can result in expensive trial-and-error of recommendations based on hearsay.
Problem Solving is more structured in that it does seek to identify cause-and-effect relationships, however it does not require the disciplined collection of evidence to prove and disprove hypotheses. This approach is more accurate than brainstorming, but less accurate than RCA.
RCA is usually unattractive to managements on its face value because to do it properly requires time. The time is not primarily in discerning what logic could have been involved, but what logic WAS involved. Most of the time in conducting an RCA is primarily in collecting evidence or data. However, this approach will yield the most comprehensive and accurate results, so that when money is spent on recommendations, it is usually money well spent.
We all know that all of these approaches have their pros and cons and have their own variations. We also know that the users can abuse them all. This is why it is important to note that no matter what approach a facility uses, if the person facilitating the process does not do so properly, then even the seemingly best approaches will fail.
The skill of the people is what will make or break any approaches mentioned in this article. True RCA is a skill developed by the human being in disciplined thinking. True RCA is applicable anywhere there is an undesirable event. The industry or the event is really irrelevant because the same human thought process is being utilized. It doesn’t matter if we are analyzing why a crude unit in a refinery caught fire, or why we have excessive customer complaints at a service center, the thought process to solve both problems is the same.
So here lies the confusion. Management says they want us to explore RCA for the facility. We do a search on the internet for RCA and find 100,000+ possibilities. Brainstorming and problem solving are commonly referred as RCA as well. Then we find all the different brands of these approaches and are more confused. Usually management wants to provide their people processes and tools that will yield quick results. They also want this for the least expensive initial investment.
We go out and try to do a comparative analysis. We pick a brainstorming, a problem solving tool and an RCA tool. The actual RCA tool might be 5x’s the initial investment of the brainstorming tool. Management reviews and thinks the RCA tool is outrageous and the low cost provider is chosen.
What should a progressive management have been asking in this scenario?
- “What tool provides the greatest value to our organization?”
- “Why is there such a disparity in pricing?”
- “What are the advantages of one method over another?”
- “Which method will provide the most comprehensive and accurate results?”
- “Which approach will start eliminating reactive work while opening time for more productive proactive work?”
Is purchasing intangibles, such as training for the knowledge and skill of our workforce, any different than we find ourselves purchasing tangible things like our office supplies, or process equipment, etc.? I rarely find purchasing people that are paid on the performance of the items that they purchase. That would really change their purchasing practices if they were measured based on that metric. Instead, where do their incentives normally lie? Low initial unit cost.
In conclusion, when seeking to integrate methodologies into our organizations, we should recognize that we are not buying “things”. We are buying concepts that will develop the skills of our people, who will in turn use them to develop bottom line results. Adopting such concepts will also involving supporting them with the infrastructure of the organization. As we have all learned in the past, we can have the greatest technologies in the world, but if our people do not know how to use them, they are worthless.
If we provide our people approaches based solely on initial investment, then we will get what we pay for. If we put more thought into it and provide them with researched and proven methods and tools, the value received will be phenomenal.
Now we will ask again, “What does RCA now mean to you?”
About the Author
Robert (Bob) J. Latino is former CEO of Reliability Center, Inc. a company that helps teams and companies do RCAs with excellence. Bob has been facilitating RCA and FMEA analyses with his clientele around the world for over 35 years and has taught over 10,000 students in the PROACT® methodology.
Bob is co-author of numerous articles and has led seminars and workshops on FMEA, Opportunity Analysis and RCA, as well as co-designer of the award winning PROACT® Investigation Management Software solution. He has authored or co-authored six (6) books related to RCA and Reliability in both manufacturing and in healthcare and is a frequent speaker on the topic at domestic and international trade conferences.
Bob has applied the PROACT® methodology to a diverse set of problems and industries, including a published paper in the field of Counter Terrorism entitled, “The Application of PROACT® RCA to Terrorism/Counter Terrorism Related Events.”
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The Stigma of RCA: What’s in a Name?
Is the 5-Ys a Valid RCA Tool for Significant Events?
RCA in Action: The Space Shuttle Columbia Investigation
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