Quality Illustrated: Root Cause Analysis

G U E S T  A R T I C L E

Blast from the Past
Quality Illustrated : Root Cause Analysis

CapitalQuality News, Issue 9 1998

This month’s article focuses on one of the most important elements of a healthy Quality System, that being Root Cause Analysis. RCA really boils down to digging deep enough to uncover the true source(S) of a problem.


Thé prinary goal of performing root cause analysis is prevention. Root cause is that most basic reason for an undesirable condition or problem. It is usually expressed in terms of the least common denominator ( organizational, personal or activity). Root cause analysis refers to the process of identifying the least common denominator.

The Goal

You must be able to distinguish symptoms clearly from causes. Symptoms are the tangible evidence that something is wrong. Symptoms are not the cause ( the disease), but are the manifestations of the problem. You must also be able to distinguish root cause from apparent cause. Apparent causes represent the immediate or obvious reason for a problem. Of course, the apparent cause may turn out to be the root cause; but until you confirm this with analysis, you should not make the assumption. If you only treat the symptoms or apparent causes, then the problem may reoccur. It boils down to digging deep enough to uncover the root cause.


  • Finds the true cause of unwanted events or conditions
  • Identifies opportunities for improvement
  • Provides better utilization of resources
  • Helps to predict other potential problems
  • Ensures objective problem solving
  • Focuses on prevention


There are a number of root cause analysis techniques that are designed to provide the proper focus. Here are four that you examine for use in your organization.

  • Cause & Effect Diagram
  • The Five Why’s
  • Interrelationship Digraph
  • Tree Diagram

Some Basic Questions You Should Ask

  • What really happened? Quit often, the problem is misstated, obscure, or the real fault is disguised. This ensures that you are working on the right problem.
  • What was the damage or consequence? Once again, as to Question 1, the effects may be camouflaged. It is not unusual for the effect of a problem to be understood.
  • What was different or changed? This may give insight into why the fault occurred, particularly with the first occurrence or problem.
  • What was the effect? Studying the effect of the problem may yield clues to its real nature and source..
  • What might have prevented its occurrence? This may give clues to its real nature and source?
  • What really went wrong? This question is really similar to question 1., but the focus here is not on the what but the why.
  • Did people do what they were supposed to do? The answer here might be difficult to obtain if the organizational climate is wrong, but the answers can point to problems in systems training, etc. It is extremely important for people to realize that your analysis is of the system and not of individuals.
  • Did any event/ action prevent an even worse situation? This information is particularly useful in thinking through solutions to the problem as well as current problems in procedures, training, etc.
  • Did people know what to do? The answer to this question points to holes in present systems if they didn’t.
  • Has this happened before? The answer to this question gives vital information regarding the nature of the problem as well as the effectiveness of any previous corrective and preventative actions taken.
  • What was done before to fix it, if anything! The response to this question could result in an organizational OOPS.
  • Who reported this? Often this is important and may give clues as to problems with the reporting system itself. Look at modifying the procedure to insure earliest possible detection of problems.
  • What might prevent it from happening again? This is not an attempt to jump over the analysis phase to potential solutions, but input along these lines should be held to ensure all possible fixes are eventually considered. Quite often suggested solutions obtained from people close to the problem source will be the best.

Some Root Cause Categories

  • Work Practices : Methods routinely used in performance if a task included are necessary preparation, document use, and practices for error detection.
  • Training / Qualification : Proficiency in the task assigned, including any specified qualification/certification requirements, included the training activity, both formal and informal, and its effectiveness.
  • Work Organization/ Planning : Scoping, planning, organizing, and scheduling the performance of a task or activity. Includes the identification of specific resource requirements.
  • Communications : The presentation of information, spoken or written. Effectiveness is related to both content and method.
  • Supervision : Techniques used to direct personnel in the performance of their assigned task or activity.
  • Management Methods : Techniques used to provide organization, program and administrative policies, overall resource and schedule planning, direction of activities, interface with other groups and oversight of activities.
  • Resource Allocation : The process of allocating manpower, material or other resources, including financial, for the accomplishment of a particular task or objective. Effectiveness is related to schedule and priority considerations.
  • Change Management : The process of modifying/ revising a particular design, operation, technique, or system ( such as procedures, origination, document revision, etc.
  • Physical Conditions : Physical and environmental conditions, equipment layout, accessibility and other factors in the work area impacting personnel or equipment performance.
  • Person/Machine Interface : The design and maintenance of equipment/ items used to communicate information to or from the individual performing the task
  • Design : The design and configuration of equipment/ systems required to support operations or activities.
  • Procurement : The process of acquiring necessary resources, personnel, equipment, material or systems.
  • Equipment Manufacture and Installation : Included on or off site manufacturing/ assembly of equipment, its storage and handling, up to and including its initial installation.
  • Plant/ System Operation : The actual operation of permanently installed, temporary or portable equipment or systems in their intended function.
  • Maintenance/ Testing : Management system and process of maintaining equipment , processes or systems in optimum condition. Includes preventative maintenance, calibration and repairs.
  • Documentation : Preparation, approval, completion, distribution, control and retention of appropriate instructions, procedures, forms, drawings and other documentation or records of activities.
  • External : influence outside the normal control of the organization. Includes requirements imposed by other agencies or organizations, weather, etc.



Ruth Stanley

The post has been contributed by Ruth Stanley, Chair, ASQOttawa Valley Section. You can contact Ruth using our contact form.


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