What do you know about 
   RCA?
   • A tool for systematic investigation and analysis
   • Reactive analysis
   • Incident investigation – may apply to losses, failure, inefficiencies
   • What went wrong?  What were the causes? What changes should be 
   made? 
   • Root cause analysis helps identify what, how and why something 
   happened, thus preventing recurrence.
   • Diving deep to find the source of the problem - to avoid addressing just 
   the symptom.
   • Root causes are underlying factors, are reasonably identifiable, can be 
   controlled and allow for generation of recommendations.
   • Various techniques may be used.www.ioas.org
      Root causes 
       • Root causes are specific underlying causes.
       • Root causes are those that can reasonably be identified.
       • Root causes are those management has control to fix.
       • Root causes are those for which effective recommendations for 
         preventing recurrences can be generated.
                                        www.ioas.org
       Inspector uses wrong version of the 
       inspection form…
      • The typical investigation would probably conclude 
        “inspector error” was the cause, inform the inspector 
        and give him the right form.
      • But if the analysis stops here, it has not probed deeply 
        enough to understand the reasons for the mistake.
      • Not enough is known to prevent it from occurring again 
        or to be sure it is not a widespread problem. 
                                         www.ioas.org
      There may be more than 1 root 
      cause of a problem…
                               www.ioas.org
       Many methodologies are employed 
       in RCA
      Complex
      • Failure Modes and Effects            Simple
        Analysis (FMEA)
                                             • Five Whys
      • Causal factor charting
                                             • May incorporate simple 
      • Statistical data analysis
                                               techniques from complex 
      • Fishbone or Ishikawa                   analysis 
        diagram                                 • simple cause and 
                                                  effect maps
                                                • fishbone diagrams
                                         www.ioas.org