root cause analysis hypothesis

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• Guide: Root Cause Analysis

Daniel Croft

Daniel Croft is an experienced continuous improvement manager with a Lean Six Sigma Black Belt and a Bachelor's degree in Business Management. With more than ten years of experience applying his skills across various industries, Daniel specializes in optimizing processes and improving efficiency. His approach combines practical experience with a deep understanding of business fundamentals to drive meaningful change.

• Last Updated: September 5, 2023
• Learn Lean Sigma

Root Cause Analysis (RCA) is a key tool in continuous improvement, acting as a systematic approach to identify and tackle the underlying issues behind problems. RCA aims not only to provide a temporary fix but to offer long-lasting solutions by addressing the root causes.

RCA, such as the Fishbone Diagram , the 5 Whys , and FMEA . Whether you’re looking to solve complex challenges or improve cost-efficiency, this guide will offer understanding of how to identify the root cause of problems with useful Lean Six Sigma tools.

Table of Contents

What is root cause analysis.

Root Cause Analysis, often referred to as RCA, is like being a detective for problems in your business or project. Imagine you have a leaking pipe in your house. You could keep mopping up the water every time it leaks, but that’s not really solving the issue. The right thing to do is find out why it’s leaking in the first place and fix that. RCA works the same way; it helps you find out the “why” behind a problem so you can fix it for good.

Structured Approach

When we say RCA is a “structured approach,” we mean it’s not just random guesswork. It’s a planned way to dig deep into a problem. You will follow certain steps and use specific tools to figure out what’s really going on. This makes sure you’re not just treating the “symptoms” of the problem, like mopping up water from a leak, but you’re finding out why the problem is happening in the first place.

Identify Underlying Reasons

The “underlying reasons” are the real culprits behind a problem. For example, if a machine in a factory keeps breaking down, simply repairing it each time isn’t enough. You need to find out why it’s breaking down. Is it old? Are people using it wrong? RCA helps you answer these kinds of questions.

Long-term Solutions

The coolest part about RCA is that it’s focused on long-term solutions. Once you know the root cause of a problem, you can create a fix that will (hopefully) make sure it never happens again. This is way better than just putting out fires all the time.

By understanding and using RCA, you’re not just stopping at “What is the problem?” You’re going the extra mile to ask, “Why did this problem happen?” and “How can we make sure it doesn’t happen again?” That’s a game-changer in making things better for the long run.

Importance of Root Cause Analysis

Understanding the “why” behind a problem isn’t just something that’s nice to do; it’s crucial for several reasons.

Problem Solving

Imagine you have a puzzle, but all the pieces are jumbled up. Trying to see the whole picture from this mess would be overwhelming, right? RCA is like sorting these puzzle pieces into groups; maybe by color or edge pieces versus middle pieces. When you break down a big, complex problem into smaller parts, it becomes much easier to solve. RCA helps you dissect a problem into its basic elements so you can tackle each one individually. This makes it easier to find out what’s really going wrong and fix it.

Cost-Efficiency

You know the saying, “Time is money”? Well, constantly fixing the same problem over and over again is like throwing both time and money down the drain. If you use RCA to get to the bottom of an issue and solve it at its root, that issue is less likely to come back. This means you spend less time, effort, and money on it in the future. For a business, this is a big deal because it means you can focus on growing and improving, rather than fixing the same old problems. This is where most businesses fail to progress as they spend the day to day activities fire fighting repreated problems.

Quality Improvement

Let’s say you run a bakery, and you notice that your chocolate chip cookies are coming out burnt too often. You could just toss the burnt cookies and make a new batch, but that doesn’t stop the next batch from burning too. If you use RCA to find out why they’re burning—maybe the oven temperature is wrong or the baking time is too long—you can fix that issue and make perfect cookies every time. This makes your customers happy and keeps them coming back. In the same way, RCA helps you improve the quality of your products or services by fixing the real issues, not just the symptoms. This leads to happier customers and better reviews, which are good for any business.

Types of Root Cause Analysis Methods

When it comes to finding the real reason behind a problem, one size doesn’t fit all. Different situations may require different approaches. That’s why there are several methods for conducting RCA. Let’s explore three of the most commonly used methods.

Fishbone Diagram (Ishikawa)

Imagine a fish. The head represents the problem you’re facing, and the bones branching off from the fish’s spine are the possible causes of the problem. This is what a Fishbone Diagram looks like. Also known as an Ishikawa Diagram or Cause and Effect Diagram, this method helps you visually break down a problem into different categories or “themes.”

For example, if you’re running a restaurant and customers are complaining about long wait times, you could use a Fishbone Diagram to categorize potential causes into themes like ‘Staffing,’ ‘Kitchen Efficiency,’ ‘Order Process,’ etc. Within each theme, you list out possible root causes. This helps you see the whole picture and makes it easier to identify where the real issue might be coming from.

You can learn more about the fishbone diagram process with our guide

Remember being a curious kid and asking “Why?” about everything? The 5 Whys method is pretty much the same. Start with the problem at hand and ask “Why did this happen?” Once you have an answer, ask “Why?” again, digging deeper. Keep asking “Why?” until you’ve asked it five times or until you reach a point where the root cause becomes clear.

For example, if a machine in a factory stops working, you could ask:

• Why did the machine stop? (Answer: The motor burned out.)
• Why did the motor burn out? (Answer: The motor was overloaded.)
• Why was the motor overloaded? (Answer: The machine was running at high capacity for too long.)
• Why was the machine running at high capacity for so long? (Answer: There was a backlog of orders.)
• Why was there a backlog of orders? (Root Cause: Poor planning and scheduling.)
• This helps you trace back the chain of events to find the root cause of the problem.

You can learn more about the 5 Whys process with our guide.

FMEA (Failure Modes and Effects Analysis)

FMEA is like looking into a crystal ball to see what could go wrong in the future. It’s a way to evaluate different ways a process or product could fail and to understand the impact of those failures. You list out all possible failure modes, how likely they are to happen, how bad the impact would be, and how well you could detect them before they cause problems. This helps you prioritize which potential issues need immediate attention.

Below is an example from a manufacturing business. The higher the RPN (risk priority number) the more important it is to address the issue.

You can learn more about the FMEA with our guide

Selecting an RCA method

If you are new to root cause analysis it can be difficult knowing which approach to use to solve your problem. This can be made simpler by considering the below

Is the problem simple and straightforward?

Use The 5 Whys Method

Is the problem complex with multiple factors?

Use Fishbone Diagram (Ishikawa)

Is a quantitative risk assessment needed?

Use FMEA (Failure Modes and Effects Analysis)

Use other specialized RCA techniques or hybrid methods

The Five-Step RCA Process

RCA isn’t something you can do haphazardly; it requires a structured approach to be effective. That’s where the Five-Step RCA Process comes in handy. It provides a roadmap to tackle your problem methodically. Let’s start by discussing the first step in detail.

Step 1: Define the Problem

Before you can find a solution to any problem, you need to know exactly what that problem is. You’d be surprised how often people jump to fixing things without clearly understanding what’s wrong in the first place. Defining the problem is like setting the GPS before going on a trip; it sets the direction for everything that follows. Here’s how to go about it:

Be Specific

Let’s say you’re running a coffee shop, and you notice that customers aren’t coming back. Simply saying, “Business is slow,” is too vague. A more specific problem statement would be, “Customer return rate has dropped by 20% in the last two months.”

Numbers don’t lie. Whenever possible, use data to define your problem. In the coffee shop example, you could look at sales records, customer surveys, or loyalty program participation to pinpoint the decline.

Consider the 5 Ws

• Who:  Who is affected by this problem? Is it just one department, the whole company, or maybe your customers?
• What:  What exactly is the issue? Try to describe it in one sentence.
• Where:  Where is this problem occurring? Is it in a specific location or across various places?
• When:  When did you first notice this problem? Is it a constant issue or does it happen only at certain times?
• Why:  At this stage, you may not know the root cause, but you might have some initial thoughts on why the problem might be occurring.

Write it Down

Once you’ve gathered all this information, write down your problem statement. This serves as a reference point for everyone involved in the RCA process, making sure everyone is on the same page.

After gathering all the relevant information, the problem statement for RCA could be:

“The rejection rate for Widget A produced on Line 3 has increased by 15% in Q2 2023 compared to Q1 2023, predominantly due to ‘Cracked Surface’ defects. This issue first became apparent at the beginning of Q2 and has been consistent since. Initial observations suggest it may be due to material quality or machine calibration issues.”

Step 2: Gather Data

Once you’ve clearly defined the problem, the next step is like being a detective gathering clues. You’ll need to collect all the relevant information that will help you get to the bottom of the issue. This stage is crucial because the quality of your Root Cause Analysis depends on the quality of your data. Here’s how to go about it:

Identify Data Sources

First, figure out where you can get the information you need. This could be anything from company records and employee interviews to customer surveys and machine logs. For example, if your problem is a decrease in product quality, you might look at manufacturing data, quality control reports, and customer feedback.

Types of Data to Collect

• Quantitative Data : These are numerical data that can be measured. Examples include sales figures, production rates, and customer satisfaction scores.
• Qualitative Data : These are descriptive data that can be observed but not measured. Examples include employee morale, customer comments, and the observable state of machinery or processes.

Timing Matters

When did the problem start? Was it gradual or sudden? Understanding the timeline can offer important insights into potential causes. Collect historical data if possible, as this will help you see trends and patterns.

Use Tools to Collect Data

Depending on your needs, various tools can help in data collection. Spreadsheets can be useful for tracking numbers and metrics. Surveys and questionnaires can capture customer or employee feedback. Advanced organizations may use specialized software for data collection and analysis.

Document Everything

Make sure to keep a record of all the data you collect. Organize the data in a way that’s easy to understand and analyze. Charts, graphs, or tables can be helpful here.

Verify Your Data

Before you move on to analyzing the data, make sure it’s accurate and reliable. Double-check your numbers, verify survey results, and confirm any observations. The last thing you want is to make important decisions based on faulty information.

Gathering data might seem like a time-consuming step, but it’s essential for a successful Root Cause Analysis. The more thorough you are at this stage, the easier it will be to identify the actual root cause of the problem later on.

Example Collected Data

Here’s a snapshot of what some of the collected data could look like:

Machine Logs (June 2023)

Quality control reports (june 2023), employee interviews.

• Operators have noticed the machine making unusual noises.
• Quality control staff report an increase in defects that look like cracks on the surface.

Step 3: Identify Possible Causes

After you’ve defined your problem and collected all the relevant data, it’s time to roll up your sleeves and dig into the “why” behind the issue. This step is like brainstorming, but more structured. You’re trying to come up with a list of all the things that could possibly be causing the problem you’ve identified. Here’s how to do it:

Choose a Method

As mentioned earlier, there are various methods you can use to identify possible causes. Two of the most common are the Fishbone Diagram and the 5 Whys. The choice depends on the nature of your problem.

• Fishbone Diagram: This is good for complex problems where multiple factors could be at play. The diagram allows you to visually organize potential causes into different categories, making it easier to focus your investigation.
• The 5 Whys: This method is more straightforward and works well for simpler problems. By repeatedly asking “Why?” you dig deeper into the issue until you identify possible root causes.

Involve the Right People

Don’t try to do this all on your own. Involve team members who are familiar with the problem area. They can offer valuable insights you might not have considered. If you’re dealing with a technical issue, for instance, having an engineer in the room can be incredibly helpful.

Generate a List of Possible Causes

Using your chosen method, start listing down all the potential causes. Be as comprehensive as possible. If you’re using a Fishbone Diagram, for instance, you’d list potential causes under each category or “bone” of the fish. For the 5 Whys, you’d document the chain of reasoning that leads you to potential root causes.

Use Your Data

Remember the data you collected in Step 2? Now’s the time to use it. Align your list of possible causes with the data to see which ones are most likely. For example, if one of your potential causes is “Poor Training,” but your data shows that all employees have completed mandatory training, then you might want to reconsider that cause.

Prioritize Causes

Not all causes are created equal. Some are more likely than others to be the root cause of your problem. Use your team’s expertise and the data you’ve collected to prioritize which causes to investigate further.

By the end of this step, you should have a well-organized list of possible causes for your problem, backed by data and expert input. This sets the stage for the next steps, where you’ll zero in on the actual root cause and figure out how to fix it.

Example of Identifying Possible causes

Following on with the same example, as this is a more complex issue with multiple factors, it makes sense to conduct the root cause analysis using the Fishbone method. Therefore, we need to ensure to include the right people—a cross-functional team. In this case, that would comprise production engineers who understand the machinery, quality control experts who have the data on defects, and machine operators who can provide firsthand experience and observations.

The next step is to collectively brainstorm and categorize potential causes for the increased rejection rate in Widget A. Utilizing the Fishbone Diagram, the team breaks down the problem into six major categories: Machine, Method, Material, Manpower, Environment, and Measurement.

Identifying the possible causes in our example

Following on with the same example, as this is a more complex issue with multiple factors, it makes sense to conduct the root cause analysis using the Fishbone method. Therefore, we need to ensure to include the right people—a cross-functional team. In this case, that would comprise production engineers who understand the machinery, quality control experts who have the data on defects, and machine operators who can provide firsthand experience and observations. The next step is to collectively brainstorm and categorize potential causes for the increased rejection rate in Widget A.  Utilizing the Fishbone Diagram, the team breaks down the problem into six major categories: Machine, Method, Material, Manpower, Environment, and Measurement.

Step 4: Determine the Root Cause

After identifying a list of possible causes, it’s time to put on your detective hat again and figure out which one is the real culprit—the root cause of your problem. 

This is a critical step, as identifying the wrong cause can lead you down a path of ineffective solutions. Here’s how to go about it:

Review Your List of Possible Causes

Start by revisiting the list you made in the previous step. This will serve as your “suspect list” in identifying the root cause. At this point, you’ve already done some initial prioritization, so you have an idea of which causes are most likely.

Analyze the Data

Remember the data you collected in Step 2? Now is the time to dive deep into it. Compare each possible cause against the data to see if it holds up. Look for patterns, correlations, or anomalies that might point to one cause over the others.

For example, if you’re dealing with a decrease in product quality and one of your possible causes is “Faulty Raw Materials,” you could look at inspection reports, batch numbers, and supplier records to see if there’s a correlation.

Conduct Tests or Experiments

Sometimes, analyzing existing data isn’t enough. You might need to conduct additional tests or experiments to validate or rule out possible causes. For instance, if you suspect a machine is malfunctioning and causing a problem, you might run it under controlled conditions to see if the issue repeats.

Use Logical Reasoning

Sometimes the root cause isn’t obvious, even with data and testing. In such cases, logical reasoning can help. You might use deductive reasoning to rule out unlikely causes or inductive reasoning to generalize from specific observations.

Involve Experts

If you’re stuck or the root cause isn’t clear, don’t hesitate to consult experts. These could be internal team members with specific expertise or external consultants who specialize in the problem area you’re investigating.

Confirm the Root Cause

Before you move on to finding a solution, make sure you’ve found the real root cause and not just a symptom of a deeper issue. Validate your findings by asking:

• Does this cause explain most or all of the problem?
• If we fix this, is it likely that the problem will be solved?
• Do most team members agree that this is the root cause?

Once you’ve determined the root cause, document it clearly. You’ll use this information in the next step to develop and implement a solution that addresses the issue at its core, ensuring it’s less likely to recur in the future.

Determining the Root Cause of our Example

Continuing with our example, the cross-functional team now shifts its focus to determining the root cause of the increased rejection rate for Widget A. Armed with their prioritized list of possible causes and the data gathered, they delve into the next step of the RCA process.

The team begins by revisiting the “suspect list” generated using the Fishbone Diagram. Machine-related factors, particularly temperature fluctuations, pressure inconsistencies, and cycle time variability, are at the top of this list, followed by material quality concerns. Analyze the Data Digging deeper into the data collected, the team finds that the temperature, pressure, and cycle time increases directly correlate with the spike in the ‘Cracked Surface’ defect type. They also note that the unusual noises observed by machine operators started to occur around the same time the defects increased. Conduct Tests or Experiments To validate these observations, the team decides to run the molding machine under controlled conditions, varying one parameter at a time while keeping the others constant. After a series of tests, they discover that an increase in temperature directly leads to the ‘Cracked Surface’ defects in the widgets. Use Logical Reasoning Using deductive reasoning, the team rules out other possible causes. For instance, since all operators have completed mandatory training and the material batches show no signs of contamination, these are less likely to be the root causes. Confirm the Root Cause After careful consideration and validation, the team reaches a consensus that the root cause of the problem is “Temperature Fluctuations in the Molding Machine.” This conclusion satisfies the criteria for root cause identification: It explains most, if not all, of the ‘Cracked Surface’ defects. Fixing this issue is likely to resolve the problem. Most team members agree that this is the root cause. The team documents this root cause clearly and prepares for the next step in the RCA process: developing and implementing a solution that will fix this issue at its core, thereby preventing its recurrence in the future.

Step 5: Implement and Monitor Solutions

Congratulations, you’ve identified the root cause! But your journey doesn’t end here. The whole point of Root Cause Analysis (RCA) is to not just find the root cause but to fix it so the problem doesn’t happen again. This is where Step 5 comes in, where you implement solutions and make sure they actually work. Here’s how to go about it:

Develop a Solution Plan

The first thing you need to do is come up with a plan for how you’re going to fix the root cause you’ve identified. This should include:

• What  needs to be done: The specific actions that will address the root cause.
• Who  will do it: The people responsible for each action.
• When  it will be done: A timeline for implementation.
• How  it will be done: The resources and methods needed to implement the solution.

Gain Approval and Support

Before you start making changes, make sure you have the necessary approvals. This might mean getting a budget approved or getting buy-in from key stakeholders. The more support you have, the smoother the implementation process will be.

Implement the Solution

Now it’s time to roll up your sleeves and get to work. Follow the plan you’ve developed, and start implementing the solution. This could involve anything from retraining staff and revising procedures to repairing equipment or introducing new technology.

Monitor Effectiveness

You can’t just implement a solution and walk away. You need to monitor how well it’s working. This means going back to the data you collected in Step 2 and continuing to track those metrics. Are they showing improvement? If not, you may need to revisit your solution or even go back to earlier steps in the RCA process.

Make Adjustments as Needed

Sometimes a solution that looks great on paper doesn’t work out as well in the real world. If you find that your solution isn’t as effective as you’d hoped, be prepared to make adjustments. This could mean tweaking your current solution or going back to the drawing board to identify a different root cause.

Document the Process

Don’t forget to document everything you’ve done, from the solutions you implemented to the results you achieved. This documentation can be invaluable for future problem-solving efforts and for creating a knowledge base that can help prevent similar problems in the future.

Implementing and monitoring solutions of our example

After identifying “Temperature Fluctuations in the Molding Machine” as the root cause, the team crafts a detailed solution plan: What Needs to Be Done : Overhaul the machine’s cooling system and recalibrate temperature settings. Who Will Do It : A dedicated team of production engineers and machine operators. When It Will Be Done : To be completed within a two-week timeframe. How It Will Be Done : Allocate necessary resources like new cooling components and software for recalibration.

Gain Approval and Support Before proceeding, the team prepares a budget proposal and secures approval from management. They also consult with the quality control team and machine operators to gain their buy-in, ensuring a smoother implementation process. Implement the Solution The team then sets out to execute the plan. The cooling system is overhauled, and the machine is recalibrated. A pilot run is conducted to ensure that the new settings are effective in maintaining consistent temperature levels. Monitor Effectiveness After implementing the changes, the team goes back to the data. They continue to monitor the same metrics—temperature, pressure, cycle time, and defect count. Initial results show a significant reduction in the ‘Cracked Surface’ defect type. The temperature fluctuations have notably decreased. Make Adjustments as Needed While the initial results are promising, the team remains vigilant. They agree to meet bi-weekly to review the data and make any necessary adjustments to the solution. So far, no further modifications are required. Document the Process The entire RCA process, from problem identification to solution implementation and monitoring, is meticulously documented. This documentation will serve as a valuable resource for future troubleshooting and continuous improvement initiatives. By diligently following this five-step RCA process, the team has not only identified the root cause of the problem but has also successfully implemented a solution to prevent its recurrence.

RCA is more than just a problem-solving method; it’s a strategic approach that dives deep into issues to eliminate them at their source. By following the Five-Step RCA Process, organizations can not only identify the real culprits behind their problems but also develop and implement long-lasting solutions. This guide walked you through each step in detail, from defining the problem to monitoring the effectiveness of your solutions. Remember, the quality of your RCA is as good as the effort and attention to detail you put into it. Whether you’re looking to improve product quality, enhance customer satisfaction, or increase cost-efficiency, a well-executed RCA can be a game-changing tool in your continuous improvement arsenal. It’s not just about fixing what’s broken; it’s about building something better for the long term.

• Williams, P.M., 2001, April. Techniques for root cause analysis . In  Baylor University Medical Center Proceedings  (Vol. 14, No. 2, pp. 154-157). Taylor & Francis.
• Gangidi, P., 2018. A systematic approach to root cause analysis using 3× 5 why’s technique.   International Journal of Lean Six Sigma ,  10 (1), pp.295-310.
• Wong, K.C., Woo, K.Z. and Woo, K.H., 2016. Ishikawa diagram.   Quality Improvement in Behavioral Health , pp.119-132.

Q: Why is Root Cause Analysis important?

A: Identifying and resolving the root cause of an issue is crucial for achieving sustainable improvements. Focusing only on symptoms can lead to temporary fixes that may mask the underlying problem. RCA helps you understand the systemic issues contributing to a problem, allowing you to put in place measures that result in lasting change.

Q: What are the common methods used for Root Cause Analysis?

A: Several methods are commonly used for Root Cause Analysis, including:

• 5 Whys : A simple technique that involves asking “why” multiple times until the root cause is identified.
• Fishbone Diagram (Ishikawa Diagram) : A visual tool used to categorize potential causes of a problem.
• Fault Tree Analysis : A graphical representation of various probable causes of an issue, arranged in a hierarchical manner.
• Pareto Analysis : Identifying the most significant factors contributing to a problem based on the Pareto principle.
• FMEA (Failure Modes and Effects Analysis) : A structured approach to identifying potential failure modes and their consequences.

Q: How do I start a Root Cause Analysis?

A: Initiating a Root Cause Analysis typically involves the following steps:

• Define the Problem : Clearly articulate what the issue is.
• Collect Data : Gather relevant information and evidence.
• Identify Possible Causes : List potential causes that could be contributing to the problem.
• Analyze : Use RCA methods like the 5 Whys or Fishbone Diagram to dig deeper.
• Identify Root Cause(s) : Through analysis, pinpoint the underlying cause(s).
• Develop and Implement Solutions : Create action plans to address the root cause(s).
• Review : Evaluate the effectiveness of the solutions and make adjustments as needed.

Q: Can Root Cause Analysis be applied to non-manufacturing sectors?

A: Absolutely, Root Cause Analysis is a versatile tool that can be applied in various sectors, including healthcare, IT, logistics, and even the public sector. The principles remain the same: identify the root cause to implement effective, long-term solutions.

Q: What are some common pitfalls to avoid in Root Cause Analysis?

A: Some common pitfalls to be aware of include:

• Rushing the Process : Skipping steps or rushing through them can lead to incorrect conclusions.
• Blaming Individuals : RCA should focus on systemic issues rather than blaming individual employees.
• Ignoring Data : Failing to consult data can result in assumptions that may not be accurate.
• Lack of Follow-Up : Without proper evaluation and adjustment, even good solutions may fail over time.

Daniel Croft is a seasoned continuous improvement manager with a Black Belt in Lean Six Sigma. With over 10 years of real-world application experience across diverse sectors, Daniel has a passion for optimizing processes and fostering a culture of efficiency. He's not just a practitioner but also an avid learner, constantly seeking to expand his knowledge. Outside of his professional life, Daniel has a keen Investing, statistics and knowledge-sharing, which led him to create the website learnleansigma.com, a platform dedicated to Lean Six Sigma and process improvement insights.

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• What Is Root Cause Analysis? | Definition & Examples

What Is Root Cause Analysis? | Definition & Examples

Published on January 6, 2023 by Tegan George . Revised on November 17, 2023.

Root cause analysis is a problem-solving approach that uses the analogy of roots and blooms to model cause-and-effect relationships. Rather than focusing on what’s above the surface, root cause analysis troubleshoots solutions to problems by analyzing what is causing them. Note Similarly to exploratory research , it’s important to remember that root cause analysis does not provide solutions to problems. Rather, it’s one method within a larger problem-solving landscape.

Root cause analysis is a form of quality management, often used in organizational management, quality control, and in healthcare fields like nursing. Root cause analysis can be a helpful study tool for students, too, when used for brainstorming or memorization exercises.

Table of contents

Root cause analysis template, the “5 whys” of root cause analysis, advantages and disadvantages of root cause analysis, other interesting articles, frequently asked questions.

It’s easy to draw root cause analysis charts by hand, on a whiteboard or a big piece of paper. Many people use fishbone diagrams as well, or you can download our template below.

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One of the most common ways to conduct root cause analysis is using the “5 Whys” method, popular in lean management. The 5 Whys are an interconnected method of analysis: after defining your problem, you ask “why?”  and answer as concisely as possible. The first “why” often leads to the second, which leads to the third, etc.

In short, you continue to ask “why” until the answer provided is no longer a contributor to the broader issue, but a possible solution to that issue. In other words, as you strategize, you’ll sense it’s time to stop when a provided answer has the potential to stop the whole problem from occurring, rather than only one aspect of that problem. This often takes 3-5 “whys” but can definitely stretch out for longer.

You can use this template to map out your whys.

Root cause analysis is a great way to organize your thoughts, but its simplicity leads to a few downsides.

• Great brainstorming tool for individual or group projects.
• Can help identify causal relationships and clarify relationships between variables .
• “5 whys” system can help simplify complex issues and drive possible solutions.

Disadvantages

• Can be overly simplistic, not leaving much room for nuance or variations.
• Path dependence can occur if the wrong question is asked, leading to incorrect conclusions.
• Cannot provide answers, only suggestions, so best used in the exploratory research phase .

If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

Methodology

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

There are several common tools used for root cause analysis , the most popular of which include fishbone diagrams , scatterplots, and the “5 whys.”

A fishbone diagram is a method that can be used to conduct root cause analysis.

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Root Cause Analysis

Posted by Ted Hessing

A Root Cause Analysis (RCA) is a problem-solving method to identify the root causes of faults or problems. A factor is considered a root cause if removal from the problem-fault sequence prevents the final undesirable event from recurring. Short-term actions are not profitable for the organization; thus, RCA helps permanently eliminate the issues.

Root cause analysis is a collection of tools and processes we can use to determine the most critical causes for an issue we are trying to resolve. This is an essential function as one of the top 5 reasons for project failures is poor root causation / no root cause identified. If we can determine the root cause of an issue, we have a good chance of solving it.

“Take away the cause, and the effect ceases.” – Miguel De Cervantes in Don Quixote .

Why Root Cause Analysis ?

In a process, unpredicted problems may occur at any time, which leads to machine downtime, rework, rejections, or customer dissatisfaction. Fixing a process quickly becomes a convenient solution. However, it does not prevent the problem’s re-emergence. Hence, teams should focus on finding the root cause using appropriate tools to develop a more effective strategy to overcome it.

When should we conduct Root Cause Analysis?

The RCA process involves data collection, analysis, root cause identification, initiating corrective actions, and implementation. You should perform a root cause analysis to determine what happened, why the issue occurred, and what action to implement to reduce or eliminate it. RCA is used to identify issues in the process and analyze customer complaints, reasons for high rework, machine downtime, etc. Moreover, it helps identify target opportunities for systemwide improvement.

Basics of Root Cause Analysis

Before using the aforementioned tools, it is good to start with Causal Theory. In other words, why does a specific problem exist?

To do this, we start with a basic equation: Y = f(x) ;

• Y is the output of a process.
• Xs are the process elements that influence Y.

Another way to state this is Y is the crime; Xs are the suspects that explain the crime of Y.

Data door & Process door

Some of my instructors refer to the data door and the process door. Both are good for root causation, but specific tools are better in certain circumstances.

• Effectiveness project – use data door.
• Efficiency project – use process door.

Root Cause Analysis: Open-Narrow-Close

To validate the root causes identified in the Open-Narrow-Close efforts, the team should employ three tools/techniques:

• Basic data collection : In the  DMAIC  methodology, a data collection plan is created during the Measure phase. It is a useful tool to focus your data collection efforts on.
• Scatter Analysis / Regression : Linear regression is a statistical technique to estimate the mathematical relationship between dependent and independent variables. In other words, predict the change in the dependent variable according to the change in the independent variable.
• Design of Experiments : The objective of Design of Experiments (DOE) is to Establish optimal process performance by finding the correct settings for key process input variables. Furthermore, the Design of Experiments is a way to intelligently form frameworks to decide which course of action you might take. This is helpful when trying to sort out what factors impact a process.

You want to gather as many ideas as possible in the open phase. To do that, first, you use the Brainstorming method. This method generates a large number of creative ideas in a short period of time. Later in the project, you can boil or funnel these ideas to a smaller list of priority items.

The team then pairs the ideas with a Fishbone or cause-and-effect diagram . It is one of the seven basic quality tools identifying many possible causes for an effect or problem. Effective brainstorming can use a Fishbone diagram to achieve stellar results. It sorts ideas into useful categories.

Narrow Phase

After  brainstorming , you can use the Fishbone or Cause and Effect Diagram or another expansion tool to generate many possibilities. Then, the group must decide how to narrow down the list.

Multivoting allows a group to narrow a list of choices down to a manageable few. While multi-voting is NOT a decision-making tool, it is a great way to achieve consensus on the option the group favors most.

Close Phase

Once the agreed actions are implemented, the team closes the process by validating using a hypothesis and convicting them or setting them free. During the  IMPROVE phase, the team will work on the validated Xs.

Types of Root Cause Analysis Tools

You perform a Root Cause Analysis (RCA) using various statistical tools. However, no fixed rule exists for applying certain tools. Hence, subject matter experts like the Quality team or the Six Sigma champion determine the appropriate tool based on the scenario.

• Brainstorming : Brainstorming is a method for generating a large number of creative ideas in a short period of time. It is energetic, moves rapidly, and is synergistic. Brainstorming creates a large list of ideas that may eventually be converted into a smaller list of priority items later in the project.
• Fishbone Diagram : A Cause and Effect Diagram (aka Ishikawa, Fishbone) is a pictorial diagram showing possible causes (process inputs) for a given effect (process outputs). In other words, it is a visual representation to determine the cause(s) of a specific problem.
• 5 Whys : The 5 Whys is a basic  root cause analysis  technique; to solve a problem, we need to identify the root cause and then eliminate it. The 5 Whys method asks the question “Why” enough times–until all the problem symptoms have been narrowed down to the root cause (not just till 5 whys).
• Pareto and data analysis : The  Pareto Chart  is a graphical tool to map and grade business process problems from the most recurrent to the least frequent. In other words, this helps to identify the most frequently occurring problems or separate the vital few from the trivial many.
• FMEA : Failure Mode Effects Analysis (FMEA) is a tool for anticipating problems with a product or process and identifying possible causes and probabilities of failure.

Steps to Perform a Root Cause Analysis

• Form a small team (consisting of members from the process area, subject matter experts, and the Quality team) to perform a root cause analysis.
• Define the problem and describe it in clear and comprehensive language.
• Collect the data and create a timeline to visualize the events’ sequence.
• Differentiate causal factors or symptoms and the root cause of the problem.
• Use tools such as 5Why or Fishbone to systematically identify the root cause of the problem.
• Prioritize the root cause that needs to be addressed first, which greatly impacts the process.
• Implement appropriate corrective action(s) to prevent the recurrence of the same issue in the future.
• Monitor the progress and communicate with relevant stakeholders

Root Cause Example in DMAIC Project

Example 1: A female operator from XYZ organization fell in the assembly area and was injured during the second shift. Perform the root cause analysis to prevent the issue from recurring.

Example 2: XYZ organization reported most of the service complaints are due to inaccurate seal diameter (out of specification).

• Root cause analysis helps to define the problem and identify the root cause(s) of the problem.
• Help to identify improvement opportunities in the organization.
• Provides confidence to the customers that organizations are valuing the feedback and analyzing systematically to identify root causes
• Root cause analysis helps to implement mistake-proofing solutions 
• It helps to implement preventive actions across the organization.

Root Cause Analysis Videos

It’s a good video with awful sound. I muted it and just clicked through at a good pace. It gets the point across.

Other Helpful Notes

Also, see Linear Regression for Y = f(x)

Causal Theory=f(x)

Hypothesis Testing

When you’re ready, there are a few ways I can help:

First, join 30,000+ other Six Sigma professionals by subscribing to my email newsletter . A short read every Monday to start your work week off correctly. Always free.

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Comments (8)

Root cause can also be calculated from 4M aka Fishbone diagram

Absolutely right, Srijit. Thank you.

For a failure there may be so many causes -but the cause or causes identified for the current failure is called the root cause . Corrective action to be taken in such a way that will not occurring again ie avoiding recurrence. Preventive action is the one what we take before the occurrence of that event ie avoiding occurrence.

Great points, T. Thank you for contributing.

My Question is when to initiate a root cause analysis and when to find causes through application of six sigma ?

In Six Sigma you generally follow the DMAIC paradigm – Define, Measure, Analyze, Improve, and Control.

You would do root cause analysis in the Analyze phase.

Does that help?

Great post! I completely agree with your points on the importance of identifying and addressing the root cause of problems in order to effectively resolve them. It’s so easy to jump to solutions without properly understanding the underlying issues, but doing so can often lead to inefficiencies and wasted resources. I’ve seen firsthand how a thorough root cause analysis can prevent similar problems from occurring in the future, saving time and money in the long run. Thank you for sharing your insights!

Thank you for the warm comments.

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Root Cause Analysis: What It Is & How to Perform One

• 07 Mar 2023

The problems that affect a company’s success don’t always result from not understanding how to solve them. In many cases, their root causes aren’t easily identified. That’s why root cause analysis is vital to organizational leadership .

According to research described in the Harvard Business Review , 85 percent of executives believe their organizations are bad at diagnosing problems, and 87 percent think that flaw carries significant costs. As a result, more businesses seek organizational leaders who avoid costly mistakes.

If you’re a leader who wants to problem-solve effectively, here’s an overview of root cause analysis and why it’s important in organizational leadership.

Access your free e-book today.

What Is Root Cause Analysis?

According to the online course Organizational Leadership —taught by Harvard Business School professors Joshua Margolis and Anthony Mayo— root cause analysis is the process of articulating problems’ causes to suggest specific solutions.

“Leaders must perform as beacons,” Margolis says in the course. “Namely, scanning and analyzing the landscape around the organization and identifying current and emerging trends, pressures, threats, and opportunities.”

By working with others to understand a problem’s root cause, you can generate a solution. If you’re interested in performing a root cause analysis for your organization, here are eight steps you must take.

8 Essential Steps of an Organizational Root Cause Analysis

1. identify performance or opportunity gaps.

The first step in a root cause analysis is identifying the most important performance or opportunity gaps facing your team, department, or organization. Performance gaps are the ways in which your organization falls short or fails to deliver on its capabilities; opportunity gaps reflect something new or innovative it can do to create value.

Finding those gaps requires leveraging the “leader as beacon” form of leadership.

“Leaders are called upon to illuminate what's going on outside and around the organization,” Margolis says in Organizational Leadership , “identifying both challenges and opportunities and how they inform the organization's future direction.”

Without those insights, you can’t reap the benefits an effective root cause analysis can produce because external forces—including industry trends, competitors, and the economy—can affect your company’s long-term success.

2. Create an Organizational Challenge Statement

The next step is writing an organizational challenge statement explaining what the gap is and why it’s important. The statement should be three to four sentences and encapsulate the challenge’s essence.

It’s crucial to explain where your organization falls short, what problems that poses, and why it matters. Describe the gap and why you must urgently address it.

A critical responsibility is deciding which gap requires the most attention, then focusing your analysis on it. Concentrating on too many problems at once can dilute positive results.

To prioritize issues, consider which are the most time-sensitive and mission-critical, followed by which can make stakeholders happy.

3. Analyze Findings with Colleagues

It's essential to work with colleagues to gain different perspectives on a problem and its root causes. This involves understanding the problem, gathering information, and developing a comprehensive analysis.

While this can be challenging when you’re a new organizational leader, using the double helix of leadership —the coevolutionary process of executing organizational leadership's responsibilities while developing the capabilities to perform them—can help foster collaboration.

Research shows diverse ideas improve high-level decision-making, which is why you should connect with colleagues with different opinions and expertise to enhance your root cause analysis’s outcome.

4. Formulate Value-Creating Activities

Next, determine what your company must do to address your organizational challenge statement. Establish three to five value-creating activities for your team, department, or organization to close the performance or opportunity gap you’ve identified.

This requires communicating organizational direction —a clear and compelling path forward that ensures stakeholders know and work toward the same goal.

“Setting direction is typically a reciprocal process,” Margolis says in Organizational Leadership . “You don't sit down and decide your direction, nor do you input your analysis of the external context into a formula and solve for a direction. Rather, setting direction is a back-and-forth process; you move between the value you'd like to create for customers, employees, investors, and your grasp of the context.”

5. Identify Necessary Behavior Changes

Once you’ve outlined activities that can provide value to your company, identify the behavior changes needed to address your organizational challenge statement.

“Your detective work throughout your root cause analysis exposes uncomfortable realities about employee competencies, organizational inefficiencies, departmental infighting, and unclear direction from leadership at multiple levels of the company,” Mayo says in Organizational Leadership .

Factors that can affect your company’s long-term success include:

• Ineffective communication skills
• Resistance to change
• Problematic workplace stereotypes

Not all root cause analyses reveal behaviors that must be eliminated. Sometimes you can identify behaviors to enhance or foster internally, such as:

• Collaboration
• Innovative thinking
• Creative problem-solving

6. Implement Behavior Changes

Although behaviors might be easy to pinpoint, putting them into practice can be challenging.

To ensure you implement the right changes, gauge whether they’ll have a positive or negative impact. According to Organizational Leadership , you should consider the following factors:

• Motivation: Do the people at your organization have a personal desire for and commitment to change?
• Competence: Do they have the skills and know-how to implement change effectively?
• Coordination: Are they willing to work collaboratively to enact change?

Based on your answers, decide what behavior changes are plausible for your root cause analysis.

7. Map Root Causes

The next step in your analysis is mapping the root causes you’ve identified to the components of organizational alignment. Doing so helps you determine which components to adjust or change to implement employee behavior changes successfully.

Three root cause categories unrelated to behavior changes are:

• Systems and structures: The formal organization component, including talent management, product development, and budget and accountability systems
• People: Individuals’ profiles and the workforce’s overall composition, including employees’ skills, experience, values, and attitudes
• Culture: The informal, intangible part of your organization, including the norms, values, attitudes, beliefs, preferences, common practices, and habits of its employees

8. Create an Action Plan

Using your findings from the previous steps, create an action plan for addressing your organizational problem’s root cause and consider your role in it.

To make the action plan achievable, ensure you:

• Identify the problem’s root cause
• Create measurable results
• Ensure clear communication among your team

“One useful way to assess your potential impact on the challenge is to understand your locus of control,” Mayo says in Organizational Leadership , “or the extent to which you can personally drive the needed change or improvement.”

The best way to illustrate your control is by using three concentric circles: the innermost circle being full control of resources, the middle circle representing your ability to influence but not control, and the outermost circle alluding to shifts outside both your influence and control.

Consider these circles when implementing your action plan to ensure your goals don’t overreach.

The Importance of Root Cause Analysis in Organizational Leadership

Root cause analysis is a critical organizational leadership skill for effectively addressing problems and driving change. It helps you understand shifting conditions around your company and confirm that your efforts are relevant and sustainable.

As a leader, you must not only effect change but understand why it’s needed. Taking an online course, such as Organizational Leadership , can enable you to gain that knowledge.

Using root cause analysis, you can identify the issues behind your organization’s problems, develop a plan to address them, and make impactful changes.

Are you preparing to transition to a new leadership role? Enroll in our online certificate course Organizational Leadership —one of our leadership and management courses —and learn how to perform an effective root cause analysis to ensure your company’s long-term success. To learn more about what it takes to be an effective leader, download our free leadership e-book .

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Better problem solving with root cause analysis (with template)

If you walk into your kitchen to find your favorite vase smashed on the floor, it might be safe to assume that the grinning cat nearby was the root cause of this problem. If only it was this simple in business and we could just say “the cat did it.” Product problems are often much more complex and connected to a variety of root causes.

If you think of a weed, the surface is only the problem you can immediately see. However, if you cut the weed from the ground level, it’s likely to grow back from the root. This is just like fixing product problems with a band-aid with little to no investigation of a root cause — it’s likely to return.

These types of problems need a more thorough root cause analysis (RCA) to determine how, and why the problem happened, and how to prevent it in the future.

What is root cause analysis?

Root cause analysis is a tool you can utilize when determining the true cause of a problem. You might have assumptions about what the cause of a problem might be or experience biases towards one as the main cause.

Performing a root cause analysis can help you determine what the underlying causes of a problem are to help address a more impactful and valuable solution:

What are the 4 steps in a root cause analysis?

When you’re trying to uncover the roots of a problem, it can be daunting to figure out where to start. The process to conduct a root cause analysis can be broken down into a few easy steps:

• Define the problem
• Identify and map the problem causes
• Identify the evidence that supports your causes
• Create a root cause analysis report and set up your action plan

1. Define the problem

A clear definition of the problem is the first step. Sometimes problems are easy to identify, like a broken link. More often, problems can be abstract and need clarification, like a decrease in overall purchases through a site or an increase in bugs reported.

Here are some more examples of problems:

• A 20 percent drop in customer purchases placed from the shopping cart page from the previous week
• 60 percent of customers on hold end up dropping their call and, as a result, the company has experienced a decrease in NPS scores
• A 40 percent increase of customer reported issues with using the folders feature in a CRM
• A 15 percent decrease in user engagement with a core feature on a social media site

It’s also critical to understand how to define a problem:

2. Identify and map the problem causes

Using tools like a fishbone analysis and the Five Whys framework can help you put together causes and start to categorize themes of the problem. When going through a Five Whys diagram, try to come up with a few alternate pathways and you might notice overlapping areas.

Each example of a Five Whys diagram is accurate, but only looking at one cause can prevent you from understanding the fuller picture. For example, there was more than one reason why the Fyre Festival failed and it’s important to identify overlapping themes to avoid leaning on only one cause:

In a product example, there might be numerous reasons why session times have decreased, or user reported bugs are up.

After evaluating the size, impact, general cause themes, and urgency of the problem, you’ll have a better understanding of how much effort will be needed for the analysis. The larger the problem on the surface, the more underlying causes you might find. Even simple problems can sometimes have numerous causes to consider and you need to determine how in-depth you need to dig to “unroot” the causes.

It’s also critical to check all your bases. Once you have evaluated and categorized the different potential causes to a problem, use the following as a checklist to ensure you’re covering all areas of where and how this problem happened. Be sure to identify any changes or recent events that might have occurred that could have impacted the problem.

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• Demographics : is the problem happening to one specific demographic? Only happening to iPhone users? Users in a specific location?
• Time specific : when did the problem happen? Is it continuing to happen? Did the problem only occur during a specific time? You might discover that the problem is related to a time-specific cause, like a release or outage
• User journey : did anything change within the user journey? Map the workflow to determine if any new developments have occurred
• External factors : is this an issue with a third party integration? Did a competitor launch a successful new feature that might be taking business from you? Some of these external factors could be out of your control, but important to recognize
• Internal factors : how many feature releases happened during this time frame? Was there any product downtime or maintenance at that time?

3. Identify the evidence that supports your causes

Collecting evidence is a key part of a root cause analysis. Without evidence, your problem causes are based on assumptions and potentially harmful biases.

Start evaluating any data you might have available. Using session replay tools like LogRocket can help you collect evidence of the problem. Here are a couple of examples of the type of data that can be used to collect evidence:

• User count — number of users impacted by the problem
• Usage — daily, weekly, or monthly active users and a decrease or increase in session time
• Decrease or increase in events — for example, a decrease in users selecting the Add to cart button from a page or an increase in error pages
• Error tracking and user frustration — tools like LogRocket can help track where things are going wrong in your product and surface critical issues
• Qualitative evidence — run user interviews or user-submitted feedback with tools like Loom. Are multiple users running into the same roadblock? Are you seeing the same complaint from multiple users in feedback tickets?

4. Create a root cause analysis report and set up your action plan

Collect your evidence and root cause evaluation into an RCA template. Once you have your causes identified and your discovery efforts into one root cause analysis report, you can start creating a plan to address the problem and prevent it from happening in the future.

Collaborate with a team to brainstorm solutions and discuss which options might address multiple causes. Evaluate if you need both a short-term and long-term solution, depending on the level of effort and urgency required. As part of your analysis report, discuss how you can avoid this problem again in the future and any other risk mitigation plans.

Root cause analysis template

You can use this root cause analysis template on Google Sheets to organization your investigation, collect your evidence, and share with your team to determine next step solutions:

Root cause analysis example

Below is an RCA for Company B, a tax preparation product that experienced an increase in dropped customer calls.

Company B experienced an increase of 60 percent of customers on hold that ended up dropping their call. They also experienced an increase in NPS dissatisfaction and have concerns about losing customers.

After going through a root cause analysis, they discovered an 80 percent increase in user calls during tax season. This increase of call volume indicated much longer wait times to speak to a live agent.

After investigating some of the customer call reasons, they discovered that numerous customers had simple questions that could be answered quickly without too much support.

More great articles from LogRocket:

• How to implement issue management to improve your product
• 8 ways to reduce cycle time and build a better product
• What is a PERT chart and how to make one
• Discover how to use behavioral analytics to create a great product experience
• Explore six tried and true product management frameworks you should know
• Advisory boards aren’t just for executives. Join LogRocket’s Content Advisory Board. You’ll help inform the type of content we create and get access to exclusive meetups, social accreditation, and swag.

Company B gathered call logs that confirmed their suspicions. They brought the logs together that demonstrated the simplicity of repeated questions and gathered records of customers that dropped off after a certain amount of time on the phone.

Company B implemented a conversational AI chatbot that could answer generic questions and direct more complex questions to a live agent. Further, they implemented tooltips throughout the tax process flow to help users that appeared to be stuck.

Through the RCA process, you might discover that some parts of the user’s experience are confusing and create a plan to address minor UI challenges.

These solutions helped Company B improve their accessibility and scalability needs during an increase in call volume, without having to add more employee support. Going forward, Company B can plan to monitor call times and continuously evaluate customer service topics to determine where users might need further support and guidance in the future:

Common mistakes to avoid

There are a number of easy-to-fall-into traps when performing root cause analysis, including:

• Don’t rely on assumptions when determining root causes. Use evidence to support to disprove a cause
• Don’t limit your investigation. Go beyond one Five Why framework and be sure to exhaust all possibilities to avoid leaning on the first cause
• Don’t rely on the first idea — come up with multiple solutions to solve a problem
• Don’t work alone. Collaborating with a team will help you come up with a variety of potential solutions or new opportunities
• Don’t think this is a one-time thing. Prepare for the future and discuss risk management and mitigation if you expect this problem to happen again, especially with issues that might be related to factors out of your control. What’s the worst that can happen, and what can we do about it to make sure the problem is addressed quickly with minimal interruption?

Final thoughts

A root cause analysis can be a great tool to help you uncover the true causes of a problem and reduce any reliance on assumptions or biases. With the right investigation and evidence collection, you can learn more about how and why a problem happened and identify causes below the surface.

RCA can ensure your solutions address the root problem and help you better plan for the future.

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Root Cause Analysis

Tracing a problem to its origins.

By the Mind Tools Content Team

In medicine, it's easy to understand the difference between treating the symptoms and curing the condition. A broken wrist, for example, really hurts! But painkillers will only take away the symptoms; you'll need a different treatment to help your bones heal properly.

But what do you do when you have a problem at work? Do you jump straight in and treat the symptoms, or do you stop to consider whether there's actually a deeper problem that needs your attention? If you only fix the symptoms – what you see on the surface – the problem will almost certainly return, and need fixing over and over again.

However, if you look deeper to figure out what's causing the problem, you can fix the underlying systems and processes so that it goes away for good.

What Is Root Cause Analysis?

Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why the problem occurred in the first place. It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

• Determine what happened.
• Determine why it happened.
• Figure out what to do to reduce the likelihood that it will happen again.

RCA assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, you can discover where the problem started and how it grew into the symptom you're now facing.

You'll usually find three basic types of causes:

• Physical causes – Tangible, material items failed in some way (for example, a car's brakes stopped working).
• Human causes – People did something wrong, or did not do something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing).
• Organizational causes – A system, process or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid).

RCA looks at all three types of causes. It involves investigating the patterns of negative effects, finding hidden flaws in the system, and discovering specific actions that contributed to the problem. This often means that RCA reveals more than one root cause.

You can apply RCA to almost any situation. Determining how far to go in your investigation requires good judgment and common sense. Theoretically, you could continue to trace the root causes back to the Stone Age, but the effort would serve no useful purpose. Be careful to understand when you've found a significant cause that can, in fact, be changed.

Frequently Asked Questions

Why is root cause analysis important.

RCA allows you to get to the true source of a problem, and stop it in its tracks. This is more effective than simply remedying the symptoms. By identifying and alleviating the root cause of a problem, you can prevent an issue from occurring again in the future.

What is the 5 Whys technique?

The 5 Whys is a common problem-solving technique. You simply ask "why" something is happening until you get to the source of the issue.

Though a useful tool in its own right, the 5 Whys method can be used during a Root Cause Analysis to help you quickly identify different causal factors of a problem.

What are the five steps of a root cause analysis?

RCA has five identifiable steps:

• Define the problem.
• Collect data.
• Identify causal factors.
• Identify root cause(s).
• Implement solutions.

Read on to learn how to carry out each step in your own root cause analysis.

How to Perform a Root Cause Analysis

Step one: define the problem.

Ask yourself the following:

• What do you see happening?
• What are the specific symptoms?

Step Two: Collect Data

• What proof do you have that the problem exists?
• How long has the problem existed?
• What is the impact of the problem?

You need to analyze a situation fully before you can move on to look at factors that contributed to the problem. To maximize the effectiveness of your RCA, get together everyone – experts and frontline staff – who understands the situation. People who are most familiar with the problem can help lead you to a better understanding of the issues.

A helpful tool at this stage is CATWOE . With this process, you look at the same situation from different perspectives: the Customers, the people (Actors) who implement the solutions, the Transformation process that's affected, the World view, the process Owner, and Environmental constraints.

Step Three: Identify Possible Causal Factors

• What sequence of events leads to the problem?
• What conditions allow the problem to occur?
• What other problems surround the occurrence of the central problem?

During this stage, identify as many causal factors as possible. Too often, people identify one or two factors and then stop, but that's not sufficient. With RCA, you don't want to simply treat the most obvious causes – you want to dig deeper.

5 Whys Root Cause Analysis

Use the 5 Whys tool to identify the root causes of a problem quickly. Just ask "Why?" until you reveal each causal factor.

If you need a more in-depth technique to identify possible factors, try these other tools that can help you dig further into each cause:

• Appreciation – Use the facts and ask "So what?" to determine all the possible consequences of a fact.
• Drill Down – Break down a problem into small, detailed parts to better understand the big picture.
• Cause and Effect Diagrams – Create a chart of all of the possible causal factors, to see where the trouble may have begun.

Step Four: Identify the Root Cause(s)

• Why does the causal factor exist?
• What is the real reason the problem occurred?

Use the same tools you used to identify the causal factors (in Step Three) to look at the roots of each factor. These tools are designed to encourage you to dig deeper at each level of cause and effect.

Step Five: Recommend and Implement Solutions

• What can you do to prevent the problem from happening again?
• How will the solution be implemented?
• Who will be responsible for it?
• What are the risks of implementing the solution?

Analyze your cause-and-effect process, and identify the changes needed for various systems. It's also important that you plan ahead to predict the effects of your solution. This way, you can spot potential failures before they happen.

One way of doing this is to use Failure Mode and Effects Analysis (FMEA). This tool builds on the idea of risk analysis to identify points where a solution could fail. FMEA is also a great system to implement across your organization; the more systems and processes that use FMEA at the start, the less likely you are to have problems that need RCA in the future.

Impact Analysis is another useful tool here. This helps you explore possible positive and negative consequences of a change on different parts of a system or organization.

Another great strategy to adopt is Kaizen , or continuous improvement. This is the idea that continual small changes create better systems overall. Kaizen also emphasizes that the people closest to a process should identify places for improvement. Again, with Kaizen alive and well in your company, the root causes of problems can be identified and resolved quickly and effectively.

Tips for Performing Effective Root Cause Analysis

Collaborate with other teams . Gain a diverse range of experiences and expertise by working with relevant people from other teams. They can likely offer different perspectives that will help to find the various causes of the problem.

Don’t play the blame game! Root cause analysis is a tool that helps you and your team overcome problems, but it shouldn’t be used to criticize or blame someone. Instead, try to create a blame-free culture, so that your co-workers feel confident in sharing ideas and insights. This will help you to diagnose the issue quickly and effectively.

Keep your questions open-ended. Leave any assumptions you have about the potential causes of the problem at the door. RCA is a chance to look at a problem with fresh eyes, so use open-ended questions as you work through the five steps. This will allow you to reveal things you didn’t already know, and find the most effective solution.

• Root Cause Analysis is a useful process for understanding and solving a problem.
• Figure out what negative events are occurring. Then, look at the complex systems around those problems, and identify key points of failure. Finally, determine solutions to address those key points, or root causes.
• You can use many tools to support your RCA process. Cause and Effect Diagrams and 5 Whys are integral to the process itself, while FMEA and Kaizen help minimize the need for RCA in the future.
• As an analytical tool, RCA is an essential way to perform a comprehensive, system-wide review of significant problems as well as the events and factors leading to them.

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ROOT CAUSE ANALYSIS

“Nothing is at it seems.”

― Pearl Jam

Time for root cause analysis , which incorporates prioritization , hypotheses , hypothesis trees, disaggregation , deductive and inductive logic, and questions .

What is a root cause?

When there are issues such as decreasing sales, increasing costs, poor quality, inefficiencies, or poor morale you have to understand the root cause of the issue. Only by addressing the root cause can a problem be fixed. Time and again, organizations don’t put the necessary resources into understanding and addressing root causes. And in doing so, they often misdiagnose situations and apply the wrong antidote, often exacerbating the issues.

You often have to do a lot of digging to get to the root of an issue. Usually, when you examine a problem, what you typically initially see are the symptoms of a problem, and only by digging into the actual causes of the symptoms can you find the root cause.

A great example is uncovering the root cause of an issue we had at a product company on returns. Here is how the deductive inquiry went over a few days:

• Question: “Why are our margins decreasing?” • Answer: “The main culprit is increasing return costs.”

• Question: “Why are our return costs increasing so much?” • Answer: “Looks like a high return rate of our larger portable rechargers.”

• Question: “Why do we have a high return rate for our larger portable rechargers?” • Answer: “The batteries only have a shelf life of 3 to 6 months, and customers aren’t recharging them.”

• Question: “Why do the batteries only have a shelf life of 3 to 6 months?” • Answer: “Well the batteries actually have a shelf life of 1 to 2 years, but the circuitry on the rechargers is drawing down the batteries during storage.”

• Question: “Why does the circuitry on the recharges decrease the shelf life by 50-80%? • Answer: It looks like a poor design, and we can probably redesign the circuitry and the firmware to increase the shelf life to over 1 year.

Once we got down to the root cause that our margins were decreasing because of a poor design in our circuitry and firmware, we could actually fix the problem. Any other solution would only be a temporary Band-Aid to the problem. And, trust me, we had a lot of Band-Aids to the problem and a ton of downstream costs, in returns, customer defection, lost sales due to short shelf life, obsolete inventory, and costs to replace batteries.

How do you diagnose root causes?

You know when you finally get down to a root cause when there is no other explanation for the issue or situation. Many of the tools in this problem solving module are helpful for root cause analysis. Root cause analysis necessitates framing the problem correctly through problem statements, hypothesis trees , disaggregation, and then using deductive and inductive logic, prioritization and questions. Analytical root cause analysis necessitates analytics to baseline a situation, prove or disprove hypotheses, and determine causal factors through statistics .

Some of the best practices for root cause analysis include:

• Ask 5 Whys. As in the example above, one of the best tools is simply using iterative Why questions, until you get to the root issue. You can always iterate a sixth or seventh Why, but typically 5 Whys is all you need.
• Utilize the problem solving toolkit. Often, root causes aren’t singular, but instead multi-faceted. In these instances, you can use the use problem solving tools we’ve outlined.
• Conduct a Pareto analysis. Pareto analysis is one of the analytic tools to assist root cause analysis. Pareto analysis is rank-ordering issues by their magnitude. In the case of the Goal Zero example, we found that over 80% of our return costs were confined to less than 20% of our product SKUs. You’ll see this 80/20 phenomenon all across businesses.
• Utilize lean and six sigma . Lean is a great methodology for understanding the bottlenecks and inefficiencies in a process. While six sigma, especially the DMAIC process (Define, Measure, Analyze , Improve, and Control) is a strong statistical-based methodology to drive to root causes.

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Root Cause Analysis, Ishikawa Diagrams and the 5 Whys

Published: June 11, 2018 by Matthew Barsalou

Root cause analysis (RCA) is a way of identifying the underlying source of a process or product failure so that the right solution can be identified. RCA can progress more quickly and effectively by pairing an Ishikawa diagram with the scientific method in the form of the well-known plan-do-check-act (PDCA) cycle to empirically investigate the failure. Often, failure investigations begin with brainstorming possible causes and listing them in an Ishikawa diagram. This is not necessarily wrong, but often the ideas listed do not clearly contribute to the failure under investigation.

Write a Problem Statement

Once a problem-solving team has been formed, the first step in an RCA is to create a problem statement. Although critical for starting an RCA, the problem statement is often overlooked, too simple or not well thought out. The problem statement should include all of the factual details available at the start of the investigation including:

• What product failed
• The failure observations
• The number of failed units
• The customer’s description of the failure

The customer’s description does not need to be correct; it should reflect the customer’s words and be clear that it is a quote and not an observation. For example, a problem statement may start as, “Customer X reports Product A does not work.” The rest of the problem statement would then clarify what “does not work” means in technical terms based upon the available data or evidence. A good problem statement would be: “Customer X reports 2 shafts with part numbers 54635v4 found in customer’s assembly department with length 14.5 +/-2 mm measuring 14.12 mm and 14.11 mm.”

Create an Ishikawa Diagram

An Ishikawa (or fishbone ) diagram should be created once the problem statement is written and data has been collected. An Ishikawa diagram should be viewed as a graphical depiction of hypotheses that could explain the failure under investigation. It serves to quickly communicate these hypotheses to team members, customers and management. Hypotheses that have been investigated can also be marked on the Ishikawa diagram to quickly show that they are not the cause of the failure (Figure 1).

How Did the Failure Happen?

Elements in the Ishikawa diagram should be able to explain how the failure happened. For example, “lighting” is a typical example under “environment”; however, it is seldom clear how lighting could lead to the failure. Instead, the result of bad lighting should be listed and then empirically investigated. In this example, lighting could cause an employee to make a mistake resulting in a part not properly installed. Therefore, the part not properly installed would be listed in the Ishikawa diagram. Simply investigating the lighting could take time and resources away from the investigation so the first step would be to see if a part is installed.

Causes of a part not being installed can be listed as sub-branches, but the priority should be on determining if the part was installed or not. If a part is not correctly installed, then use the 5 Whys on that part of the Ishikawa diagram for investigation. The lighting may be a contributing cause, but it should not be the first one investigated. The Ishikawa diagram should be expanded each time 5 Whys is used. For example, the branch may end up as: material → part not installed → employee skipped operation → work environment too dark → poor lighting → light bulbs burned out.

In this example, the use of 5 Whys led to the true cause of the failure – the light bulbs burned out. Had the 5 Whys not been used, then the employee may have been retrained, but the same employee or somebody else may have made the same or a different mistake due to the poor lighting. Each time a cause is identified, the 5 Whys should be used to dig deeper to find the true underling cause of the failure. Failing to use the 5 Whys risks a recurrence of the failure – the corrective action may only address symptoms of the failure.

Other Potential Causes

Potential causes that do not directly explain the failure, but theoretically could have caused it, can be listed in the Ishikawa. This ensures they will not be forgotten; however, better explanations should be prioritized for investigation. Tracking and monitoring investigation are related actions can be facilitated by copying the Ishikawa items into a spreadsheet such as the one shown in Figure 2.

Here, each hypothesis from the Ishikawa diagram is prioritized and the highest priority hypotheses are assigned actions, a person to carry them out and a due date. This makes it easier for the team leader to track actions and see the results of completed actions. Such a tracking list can also be used to communication the team’s progress to management and customers. New insights may be gained as the investigation progresses. For example, somebody checking the length of a part may have observed damage. This damage could then be entered into an updated Ishikawa diagram and then transferred to the tracking list.

The Scientific Method

The scientific method should be used when investigating the failure. According to biophysicist John R. Platt’s Strong Inference , the scientific method consists of:

• Devising alternative hypotheses
• Devising a crucial experiment (or several of them) with alternative possible outcomes, each of which will, as nearly is possible, exclude one or more of the hypotheses
• Carrying out the experiment so as to get a clean result
• Recycling the procedure, making sub-hypotheses or sequential hypotheses to refine the possibilities that remain and so on

Each item in the Ishikawa diagrams should be viewed as a hypothesis that could explain the cause of the failure under investigation. A good hypothesis should be simple, general, avoid making too many assumptions and should be able to make refutable predictions. A simpler hypothesis is more likely to be correct. In general, it is best to look for the cause closest to the problem and then work back from there using the 5 Whys. The ability to make predictions is essential for testing the hypothesis ; a hypothesis that can’t be tested should not be trusted as there is no way to be sure that it is correct. As Dutch psychologist and chess master Adriaan de Groot said, “Where prediction is impossible, there is no knowledge.”

Integrate the Scientific Method

The scientific method can be integrated into RCA by using cycles of PDCA . The planning phases consist of describing the problem, collecting data and forming a hypothesis.

• P : Whether freshly formed or taken from an Ishikawa diagram, the hypothesis should make some form of prediction (or plan ), such as “measurement deviation” predicting “parts will be measured out of specification.”
• D : The next step is do – where the hypothesis is evaluated. This could be as simple as measuring a part or as elaborate as designing a new type of test method.
• C : The check phase is where the results are evaluated and conclusions are formed.
• A : Act is where the conclusions are acted upon. A hypothesis may be rejected or modified based on new evidence or the results of the testing, or a plan may be created to confirm a supported hypothesis.

If the hypothesis is not supported, then the next one in the prioritized tracking list should be selected and evaluated.

Using Ishikawa diagrams and the scientific method can serve as a standalone methodology for RCA or be used as part of any RCA process that uses Ishikawa diagrams. This approach is completely compatible with methodologies such as 8D and A3 reports.

• de Groot, Adriaan D. 1969. M ethodology: Foundations of Inference and Research in the Behavioral Sciences . The Hague: Mouten.
• Platt, John R. 1964. “Strong Inference.” Science 146, no. 3642: 347-353.
• Quine, W.V. and J.S. Ullian. 1978. The Web of Belief . (10th ed.), New York: Random House.

About the Author

Matthew Barsalou

3 Root Cause Analysis Templates (and Examples)

By Status.net Editorial Team on May 8, 2023 — 7 minutes to read

Root Cause Analysis (RCA) is a powerful tool used by organizations and professionals to identify, understand, and address the core issues behind recurring problems. By analyzing and addressing the root cause of a problem, you can ensure that the issue will not repeat itself, enhancing your organization’s overall performance, safety, and efficiency. This article will give you an overview of root cause analysis templates and examples to help you adopt this approach for your own processes.

To launch a successful root cause analysis, you need to start by defining the problem clearly. This ensures that your team remains focused on addressing the correct underlying issue. Next, explore various strategies to identify the root cause of your problem. This may involve brainstorming, data analysis, or consultations with experts. Once the root causes have been identified, you can develop targeted solutions to eliminate them and prevent future occurrences.

Related: Root Cause Analysis (RCA) Methods for Effective Problem Solving

5 Whys: How to Uncover Root Causes [Examples]

Root Cause Analysis Template

Five whys technique.

To apply the Five Whys Technique in root cause analysis, begin by stating the problem and then, ask “why” the problem occurred. Keep asking “why” until identifying the root cause. This method works best when working with simpler, specific problems. As an example, consider the following problem and its subsequent analysis:

• Problem: Production is delayed.
• Why? There’s a machine breakdown.
• Why? The machine’s belt is damaged.
• Why? The belt has worn out due to extended use.
• Why? Maintenance and replacement schedules were not followed. (Root cause)

Learn more: 5 Whys: How to Uncover Root Causes [Examples]

Fishbone Diagram

A Fishbone Diagram, also known as an Ishikawa Diagram or Cause and Effect Diagram, is a visual tool used to identify and organize possible causes for a specific problem. To create a Fishbone Diagram, follow these steps:

• Write down the problem statement at the head of your diagram.
• Identify main categories of potential causes (e.g., people, processes, environment, equipment).
• Add these categories as “ribs” branching off the main “spine” of the fishbone.
• Brainstorm specific potential causes under each category.
• Analyze and prioritize the identified causes to determine the root cause(s).

As a simple example, suppose the problem is “late product deliveries.” Categories could include:

• People: staff shortages, lack of training
• Processes: inefficient processes, lack of communication
• Environment: disruptions due to weather, shipping provider issues
• Equipment: outdated equipment, vehicle breakdowns

Learn more: Fishbone Diagram (Components, Factors, Examples) and Ishikawa Diagram: Examples and Applications

Pareto Analysis

Pareto Analysis is a decision-making tool that helps prioritize the most significant causes contributing to a problem. It’s based on the 80/20 rule, which states that about 80% of the effects come from 20% of the causes. To perform a Pareto Analysis:

• List all possible causes of the problem.
• Assign values (e.g., frequency, cost, or time) to each cause.
• Rank the causes in descending order based on the assigned values.
• Calculate the cumulative percentage for each cause.
• Create a Pareto chart with causes on the x-axis and assigned values on the y-axis, and draw a line representing the cumulative percentage.
• Identify the causes contributing to 80% of the problem (starting from the highest value) to address and fix the problem.

When using a Pareto Analysis in root cause analysis, focus on the top contributing causes to solve the most significant aspects of the problem. This technique is especially valuable when dealing with complex problems or when resources are limited.

Related: What is Poka-Yoke? [Examples, Principles, Methods]

Root Cause Analysis Examples

• Example 1: Manufacturing Defects Problem Statement: The production line of a manufacturing company is experiencing a high number of defects in their products.

Root Cause Analysis:

• The first step is to gather data and identify the problem. The data shows that the defects are occurring in a specific area of the production line.
• The team then conducts a brainstorming session to identify possible causes of the problem. They identify that the machine used in that area may be malfunctioning.
• The team then conducts further investigation and finds that the machine is not being maintained properly and is causing the defects.
• The team then develops a plan to fix the machine and improve maintenance procedures to prevent similar issues in the future.
• Example 2: Employee Turnover Problem Statement: A company is experiencing high employee turnover rates.
• The first step is to gather data and identify the problem. The data shows that the highest turnover rates are in a specific department.
• The team then conducts a survey to identify the reasons why employees are leaving. The survey results show that employees are leaving due to lack of growth opportunities and poor management.
• The team then conducts further investigation and finds that the department has not had any promotions or job rotations in the past year, and the manager has received multiple complaints from employees.
• The team then develops a plan to provide growth opportunities for employees and address the management issues to improve employee retention.
• Example 3: Customer Complaints Problem Statement: A company is receiving an increasing number of customer complaints.
• The first step is to gather data and identify the problem. The data shows that the majority of complaints are related to a specific product.
• The team then conducts a survey to identify the reasons for the complaints. The survey results show that customers are experiencing issues with the product’s durability and performance.
• The team then conducts further investigation and finds that the product was recently redesigned to reduce costs, but the changes resulted in lower quality.
• The team then develops a plan to improve the product’s quality and durability to address the customer complaints and prevent similar issues in the future.
• The team also decides to conduct regular quality checks and involve customers in the product development process to ensure their needs are met.

These examples show how root cause analysis can be used to identify the underlying cause of a problem and develop a plan to address it. It involves gathering data, conducting investigations, and using problem-solving techniques to identify the root cause and develop solutions. By addressing the root cause of a problem, organizations can prevent similar issues from occurring in the future.

Guidelines for Effective Root Cause Analysis

Gathering information.

To perform a successful root cause analysis, begin by gathering information about the problem. Collect data from diverse sources, including employees, documents, and other relevant records. Organize this information systematically to gain a clear understanding of the issue at hand. Key steps in gathering information:

• Identify the problem and clarify its scope
• Gather data from relevant sources (e.g., documents, personnel, external experts)
• Organize data systematically for easy analysis

Identifying Possible Causes

After gathering information, work to identify possible causes of the problem. This step requires examining the data closely and using analytical methods, such as brainstorming, fishbone diagrams, and flowcharts.

Consider multiple probable causes for the issue rather than focusing on a single explanation. These potential causes can be refined and ranked by probability and impact later in the analysis process. Some tips for identifying possible causes:

• Use various analytical techniques (brainstorming, fishbone diagrams, flowcharts)
• Consider multiple causes and don’t focus on one explanation
• Keep an open mind and avoid jumping to conclusions

Evaluating Data

Once the possible causes have been identified, the next step is to evaluate the data to pinpoint the root cause of the problem. Assess the impact and probability of each potential cause, then determine the most likely root cause(s).

Investigate the relationships between causes and the problem to understand the underlying mechanisms that need to be addressed. This step may require further data collection or revisiting previously gathered information. Key aspects of evaluating data:

• Assess the impact and probability of each possible cause
• Determine the most likely root cause(s)
• Investigate relationships between causes and problem to understand underlying mechanisms

Benefits of Root Cause Analysis

Continuous improvement.

Root cause analysis (RCA) encourages continuous improvement in your organization by identifying the underlying causes of problems and implementing solutions. When you conduct RCA, you build a foundation for long-term improvement that goes beyond simple fixes.

Preventive Action

Another benefit of root cause analysis is its focus on preventive action. When you identify and address the root causes of problems, you can prevent similar issues from occurring in the future. This proactive approach helps your organization improve its performance and reduce the likelihood of encountering the same issues again. Not only does this save time and effort, but it also fosters a culture of problem-solving and accountability.

Cost Savings

Finally, root cause analysis can lead to significant cost savings for your organization. By identifying and resolving the root causes of problems, you can avoid the expenses associated with repeated failures, downtime, and operational inefficiencies. Moreover, a well-executed RCA provides valuable insights that inform better decision-making and resource allocation. As a result, your organization can operate more efficiently, ultimately cutting costs and improving its bottom line.

See also: Root Cause Analysis (RCA) Methods for Effective Problem Solving

Fishbone Diagram (Components, Factors, Examples)

Ishikawa Diagram: Examples and Applications

What is Poka-Yoke? [Examples, Principles, Methods]

• Root Cause Analysis (RCA) Methods for Effective Problem Solving
• Steering Committee: Complete Guide with Examples & Templates
• 30 Employee Feedback Examples (Positive & Negative)

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How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review

Jimmy martin-delgado.

a Atenea Investigation Group, Fundación para el Fomento de la Investigación Sanitario y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain

Alba Martínez-García

b Department of Health Psychology, Universidad Miguel Hernández, Alicante, Spain

Jesús María Aranaz

c Preventive Medicine Service, Hospital Ramon y Cajal, Madrid, Spain

José L. Valencia-Martín

José joaquín mira.

d Alicante-Sant Joan d'Alacant Health District, Alicante, Spain

The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs).

A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies.

Twenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; n = 18), and the type of incident most analysed was AAEs, in 71% ( n = 15) of the cases; 47% ( n = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs.

Conclusions

RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.

Significance of the Study

• Root cause analysis is a widespread technique used in the last two decades to investigate latent causes of adverse events.
• Lack of expertise and time and a weak legal framework are some of the difficulties in fulfilling action plans from root cause analysis.
• It is not clear if root cause analysis is effective in preventing the recurrence of adverse events.

Introduction

Root cause analysis (RCA) emerged in the health care field almost 20 years ago. This technique is used worldwide to understand the remote and direct factors favouring the occurrence of an avoidable adverse event (AAE) [ 1 ], and improvement of patient safety [ 2 ].

Three studies have analysed the utility and limitations of this technique [ 3 , 4 , 5 ], all agreeing that barriers to implementing RCA correctly remain, and most of these were focused on active errors and not latent causes. The published results invite us to reflect on whether the impact of this technique in practice is proving to be all that is theoretically expected, first, because substantial resources and human talent are required [ 5 ], and, second, because many of the recommendations made in the framework of this technique are not applied failing to prevent the same incidents from recurring [ 6 ].

It is one thing to perform a multidisciplinary and multicausal analysis of why an incident occurred, and another, totally different thing to ensure that the proposals derived from this analysis to avoid the recurrence of safety incidents are implemented successfully. The usefulness of RCA may depend on the safety culture of health institutions, decision-making procedures and middle management leadership styles. The objective of this study was to assess the usefulness (i.e., its capacity to improve patient safety) of RCA in health care practice in order to avoid recurrence of AAEs.

We conducted a systematic review of studies published in scientific journals from database creation until December 2018 on the practical usefulness of RCA in the reduction of recurrent AAEs.

Eligibility Criteria

Only studies that analysed the efficacy of RCAs in the improvement of patient safety and studies that analysed the views of professionals on its feasibility were included. This study was designed to address whether the results of RCA improve patient safety, whether the RCA methodology has been fully carried out, and whether health professionals consider it feasible.

The MOOSE protocol was followed. Studies published in scientific journals were included to describe the AEs commonly analysed and the practical usefulness of RCA in the reduction of AAEs or its limitations in improving patient safety. No exclusions were made based on the year of publication, the design of the study, or language. Both quantitative and qualitative studies were included. Research taking a descriptive approach was also included.

Search Strategy

The review of published studies was carried out on MEDLINE, Scopus and EMBASE. The search strategies were defined based on the combination of keywords related to RCA ((“root cause analysis”[MeSH Terms] OR (“root”[All Fields] AND “cause”[All Fields] AND “analysis”[All Fields]) OR “root cause analysis”[All Fields]) AND (“delivery of health care”[MeSH Terms] OR (“delivery”[All Fields] AND “health”[All Fields] AND “care”[All Fields]) OR “delivery of health care”[All Fields])) AND (“patient safety”[MeSH Terms] OR (“patient”[All Fields] AND “safety”[All Fields]) OR “patient safety”[All Fields]), and using the Boolean operators “AND” and “OR.”

In a complementary manner, we conducted manual searches in Google Scholar for the identification of grey literature using the same search equation. We also carried out a manual search based on the bibliographic references of the selected publications.

Data Extraction

J.M.-D. and A.M.-G. independently reviewed all potentially relevant studies. When no consensus was achieved between them, a third researcher (J.J.M.) reviewed the study to reach a consensus. All reviewers were capable of understanding Spanish, English and French, and studies were included in local languages if they included an English abstract, which allowed the authors to decide whether they had to be included for full text reading. No unpublished studies were found, nor was there a need to contact any of the authors of the studies included. Data extracted from each study included country, review committee, inclusion of managers, inclusion of personnel involved, design, database used, employee review method, sample (RCA number, recommendations, audits or interviews conducted), the type of event analysed and the main findings. In addition, where possible, information was extracted on the applicability of the RCAs and the interest of health professionals in the RCA.

Data Synthesis

For each of the above variables, categories of possible options were generated and the presence or absence of information in each variable was coded. Heterogeneity in the methods and measures applied was described when possible. Numbers of participants and AEs were also included. AAEs were classified as sentinel where applicable.

Quality Evaluation

For the assessment of quality of the included studies, J.M.-D. and A.M.-G. used the Mixed Methods Appraisal Tool (MMAT) [ 7 ]. The results led to an overall score for methodological quality, varying from 40–60% (moderate quality) and 80% (considerable quality) to 100% (high quality). None of the studies were excluded based on the quality assessment.

A total of 169 studies were identified, of which 127 remained after exclusion of duplicates. Seventy-seven were excluded as these studies did not include results concerning the effectiveness of RCA in decreasing the number of AAEs. Finally, 21 papers meeting all inclusion criteria were included (Fig. ​ (Fig.1 1 ).

Study selection flow diagram. RCA, root cause analysis.

The samples of the studies show a high variability, from 20 to 1,707 subjects with analysed data (RCA number, recommendations, audits or interviews conducted). The studies were mainly conducted in North America (52%; n = 11), Australia (19%; n = 4) and Europe (14%; n = 3); 57% were quantitative studies (6 longitudinal and 6 cross-sectional), 1 study was a randomised controlled trial, and the rest were qualitative analyses. The most common setting was hospitals (86%; n = 18). The type of incident most analysed was AAEs, in 71% ( n = 15) of the studies, where sentinel events represented 13% ( n = 2) of the AEs, and serious AEs classified as Severity Assessment Code 1 (for Queensland Health) or 3 (for the Department of Veterans Affairs) accounted for 20% ( n = 3), while for the remaining 10 studies, information about severity was not disclosed. Incidents related to safety made up 5% ( n = 1), and in the rest of the included studies, interviews or mock-ups were implemented.

In only 5 studies (24%) were managers or coordinators included, and in only 1 study were personnel from the service taken into consideration. Independent hospital databases and national or regional databases were mostly used, each accounting for 29% of the studies. Although the Veterans Affairs National Center for Patient Safety database was used in 5 of the studies (24%), they also examined individuals. For the rest of the cases, databases were not used.

Of the 21 articles, 9 were rated as having a moderate quality (MMAT 40–60%), 5 were rated as having a considerable quality (MMAT 80%), and 7 were rated as high quality (MMAT 100%). The key features of each study are presented in Table ​ Table1 1 [ 3 , 4 , 5 , 6 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ].

Main findings and features of the studies reviewed

RCA, root cause analysis, MMAT, Mixed Methods Appraisal Tool; NCPS, National Center for Patient Safety.

Utility of RCA

Only in 2 studies (9%) could it be established that RCAs contributed to the improvement of patient care to some extent. In these studies, only 54 RCAs were reviewed. In 3 other studies (15%), the authors did not conclude that their implementation contributed to the improvement of patient safety, and in 10 (50%) of them, the recommendations made were weak, which did not lead to a reduction of AEs.

Some studies warned that sometimes poorly designed action plans and measures may generate new risks and may be insufficient to prevent the occurrence of new events [ 5 , 6 , 10 , 16 ]. In the study carried out by Hibbert et al. [ 4 ], in which the effectiveness and sustainability of the proposals arising from 227 RCAs were analysed, it was found that 72% of the recommendations categorised as relevant were not formulated and that the most common recommendations did not refer to latent causes in clinical practices but to active errors. Likewise, other studies [ 3 , 6 ] stated that most of the proposed recommendations focused on active errors and neglected latent causes, which provides short-term solutions but only partially helps to avoid future incidents. However, 1 study (5%) did demonstrate the usefulness of RCA and its recommendations [ 20 ].

Three studies (15%) showed that the RCA method was not applied properly [ 3 , 5 , 25 ]. François et al. [ 5 ] stated that only 23% of the 98 events selected for in-depth analysis covered all the domains defined by the method. Singh [ 3 ] pointed out that 65% of the RCAs carried out were not properly completed. In 5 studies (25%), the involvement of the professionals in the realisation of the RCA was analysed. While these appear to suggest a consensus that the relevance of RCA to establishing improved procedures caused it to be perceived as a beneficial analytical instrument, the researchers concluded that professionals encounter difficulties in conducting RCAs [ 8 , 14 ].

The literature collected analysed the usefulness of RCA as a process that allows the determination of factors that contribute to the occurrence of AAEs. Most of these were caused by communication problems among professionals [ 3 , 13 , 14 , 19 ], human error [ 9 ] and, finally, faults in the organisation of the health care process [ 3 , 22 ].

Weaknesses in Using RCA

Despite the fact that for professionals, RCA is a tool that allows improvements to the safety culture through the prevention of future AAEs [ 3 , 5 ], studies have identified the main weaknesses diminishing the usefulness of RCA in the framework of patient safety [ 5 ]. RCA is an extensive process that requires proper qualifications and attitudes. Studies have shown that the RCA method is often not properly applied, which directly affects the rigor and depth of the analysis of this tool [ 3 , 5 , 25 ]. The most common difficulties are a lack of time and resources of the work teams. Although none of the studies reviewed refers to how much time is needed to perform an RCA, in the study conducted by McGraw and Drennan [ 26 ], the results of an RCA investigation of pressure ulcers showed that a nurse can take up to 20 h to complete it. These factors directly affect the RCA process, hindering its complete execution [ 5 ].

Lack of time does not seem to be the only element that hinders the performance of RCAs; describing the events from a perspective different from individual error is challenging to professionals, who are sometimes reluctant to participate because of the distrust generated by possible future consequences. The belief that there is a culture focused on searching “those responsible” − in addition to creating tension in the work environment that may cause interprofessional problems [ 5 , 18 ] − is one of the main reasons for professionals refusing to participate in incident reporting systems [ 27 ].

Impact on Reducing AAEs

None of the studies reviewed assessed the ability of this process to reduce future AAEs. Moreover, in the study by Lee et al. [ 23 ], difficulties were found in determining whether the improvement actions implemented after the RCA were able to reduce the occurrence of AAEs, as the action plans did not follow a pattern of controlled implantation. On the other hand, Morse and Pollack [ 24 ] and Sauer and Hepler [ 22 ] were the only ones that found sufficient follow-up time, which allowed the determination of whether the recommendations agreed on in the RCA reduced the occurrence of AAEs to some degree. In order to increase the commitment and interest of health professionals in carrying out RCA, some studies have evaluated the usefulness of a mock RCA as prior training to provide medical staff with basic knowledge about patient safety and the methodology of this tool. The results showed that its use raised their confidence in being able to perform RCA and decreased their anxiety in the face of a possible AE [ 10 , 18 ]. This is supported by Boussat et al. [ 28 ], who found that professionals who were involved in Experience Feedback Committees had better scores on the Hospital Survey on Patient Safety Culture, especially in non-punitive response to error, communication and organisational learning dimensions.

Improvements in Introducing Changes

The studies reviewed show that managers and the personnel involved in AAEs had a low participation in the committees in charge of carrying out RCA. Peerally et al. [ 25 ] pointed out the need to professionalise the investigation of incidents by involving experts, as well as patients and family members, who can provide a unique perspective on the care received. Including those professionals who have been directly involved in the event also seems to have positive consequences, as it can contribute to the recovery of second victims by making them part of the solution [ 29 ]. Despite the progress and improvement in quality of care, the involvement of report systems such as RCA, especially the implementation of measures adopted, does not seem to be successful. Most of the included countries have so-called apology laws (39 states of the USA have Medical Professional Apologies Statutes; e.g., the Maryland Courts and Judicial Proceedings Code Ann. §10-92041), which aim to improve the relationship with the patient and their families, allowing them to provide information that improves the quality of care [ 27 ]. However, the presence of the professionals involved in an AE in RCA committees was mentioned in only 1 study [ 6 ], and in none of the cases were relatives present.

Although AEs are sometimes inevitable and part of the uncertainty of medical practice, the ultimate goal of the RCA is to help to produce solutions and apply necessary measures to ensure they do not happen again, that there is a lower probability of their occurrence, or that if they occur the possible consequences are mitigated. Although some studies have demonstrated the usefulness of RCA and its recommendations [ 24 ], most published studies found that just over half of the recommendations that resulted from RCA were not useful enough to prevent the same incidents from recurring in the future [ 6 , 14 , 25 ]. For this reason, researchers have proposed RCA-based tools that seek greater involvement of frontline professionals in the implementation of proposals to prevent the recurrence of serious AEs [ 30 ]. The non-existence of a formalised system that allows these recommendations to be addressed in a specific period of time, as well as the limited power of RCA committees to ensure compliance with these improvement actions [ 17 ], hinders implementing the proposed actions. It must be borne in mind that, normally, the people who will have to assume the responsibility of approving the measures suggested by the RCAs and the professionals who must implement these measures are usually not those who participated directly in the RCA. This makes it difficult for the proposals to be carried out.

It seems, therefore, that RCA is a process with considerable validity through which much may be learned about incidents [ 12 , 15 ]. However, it does not seem to produce enough benefits to address and resolve the problem [ 23 , 25 ] and, thus, to avoid possible AAEs. As explained by Najafpour et al. [ 13 ], RCA is a reactive method for investigating an event and finding its underlying factors. This method could provide answers to questions related to what happened, and how and why it happened, and should be used to design preventive interventions. It should be performed using an outlined framework process of investigation and analysis of clinical incidents performed by professionals with experience in patient safety and should include at least one manager and one of the personnel involved in it.

Limitations

Some of the limitations encountered are that most of the published data related to RCAs pertain to analysing the method of determining whether RCA is being implemented. Only reported results and quotations were assessed. Finally, little of the scarce evidence available regarding the impact − which was our objective − of carrying out RCAs can actually contribute to reducing the recurrence of the same incident, which may be due to the limited decision-making power of committees or to the proposed plan of action not being followed up in time.

Although early studies suggested that RCAs are effective in promoting ideas for preventing recurrence, more recent studies do not confirm these findings. A common gap that limits the effectiveness of this tool lies in the fact that RCAs are not usually accompanied by subsequent control of whether the devised improvement plan is carried out. Further research should focus on how to translate the results of ACR recommendations into practice to prevent recurrence of AAEs.

Statement of Ethics

For this systematic review, the MOOSE protocol was followed.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This research was funded by the PROMETEO Research Program, Consellería de Educación, Investigación, Cultura y Deporte, Generalitat Valenciana (Prometeu173).

Author Contributions

The conception and design were made by J.J.M.; the data were collected by A.M.-G. and J.M.-D.; the article was supervised by J.J.M.; all the authors contributed to writing, revising and approving the final draft.

Scientific Method and Root Cause Analysis

Is the Scientific Method the ONLY Root Cause Analysis Method?

I had someone tell me that the ONLY way to do root cause analysis was to use the scientific method. They said: “After all, that is the way that all real science is performed.”

Being an engineer (rather than a scientist), I had a problem with this statement. After all, I had done/reviewed thousands of root cause analyses and I had never used the scientific method even once. Was I wrong? Is the scientific method really the only  answer? Is the scientific method even a good answer?

Definition of the Scientific Method

First, what is the definition of the scientific method?

Some say the scientific method was invented in the 17th century and was the reason that we progressed beyond the dark ages. Others claim that the terminology “scientific method” is a 20th-century invention. Who cares when it was invented. How is it defined?

That isn’t an easy question to answer. There are many definitions (methods that call themselves “the scientific method”). Google “scientific method.” See how many different models you find. I found 981,000,000 results with various models. The one at the top of this page is from wikipedia  and was the highest ranked search result image for scientific method on the day I did the Google search.

Video Discussion About Scientific Method

Before I share the complete article, here is a video by Benna Hughes and Ken Reed that discusses the topic…

Now for the rest of the article…

Scientific Method for Root Cause Analysis

The most common way to use the scientific method for root cause analysis is to do a little digging (evidence collection), develop a hypothesis, and then continue gathering evidence to either prove or disprove your hypothesis. That’s the method declared as the ONLY way to perform root cause analysis by the expert who was schooling me.

But there is a problem with that method…

Confirmation Bias and the Scientific Method

What’s the problem with this hypothesis testing model? People aren’t good at it. There’s even a scientific term for the problem that people have disproving their own hypothesis. It’s called CONFIRMATION BIAS .

Now, Google “Confirmation Bias” and then read for hours. NO – wait – STOP! There is a short description of the problem:

When people develop a hypothesis that they believe in, they tend to selectively gather evidence to prove what they believe and disregard evidence that is contrary to their hypothesis. This is a natural human tendency – think of it like breathing. You can tell someone not to breath, but they will breath anyway.

But some believe you can overcome this problem. They think you can teach people to disprove all other theories and also look for evidence to disproves their theory. That’s what my expert friend explained to me.

First, telling yourself not to fall into the trap of only seeing the evidence you want to see probably won’t work.

But what about developing all possible hypotheses and then checking them? That doesn’t work either. Why? How long would it take you to develop ALL possible theories and prove or disprove them? And do you have the knowledge to hypothesize ALL possible ways something could happen? REALLY?

The biggest problem that accident investigators face is limited knowledge .

Limited Knowledge

For a decade we took a poll at the start of each root cause analysis class that we taught. We asked:

“How many of you have had any type of formal training in human factors or why people make human errors?”

The answer was always less than 5%. In a 20 person class, we might have one person with some previous training.

Then we asked:

“How many of you have been asked to investigate incidents that included human errors?”

That answer was always close to 100%.

Think about this:

How many of these investigators could hypothesize ALL the potential causes for a human error and how could they prove or disprove them ALL?

That’s one simple reason why the scientific method is not the only way, or even a good way , to investigate incidents and accidents.

Need more persuading? Read these articles by other authors on the problems with the scientific method:

The End of Theory: The Data Deluge Makes the Scientific Method Obsolete

The Scientific Method is a Myth

What Flaws Exist Within the Scientific Method?

Is the Scientific Method Seriously Flawed?

What’s Wrong with the Scientific Method?

Problems with “The Scientific Method”

That’s just a small handful of the articles that you could read. I hope that is enough to convince you.

Famous People Who Got the Wrong Answer Using the Scientific Method

Let me assume that you didn’t read any of the articles posted above. Therefore, I will provide a convincing example of what’s wrong with the scientific method.

Isaac Newton, one of the world’s greatest mathematicians, developed the universal law of gravity. Supposedly he did this using the scientific method. And it worked on apples and planets. The problem is, when atomic and subatomic matter was discovered, the “law” of gravity didn’t work. There were other forces that governed subatomic interactions.

Enter Albert Einstein and quantum physics. A whole new set of laws (or maybe you called them “theories”) that ruled the universe. These theories were proven by the scientific method. But what are we discovering now? Those theories aren’t quite “right” either. There are things in the universe that don’t behave the way that quantum physics would predict. Thus, Einstein was wrong!

So, if two of the smartest people around – Newton and Einstein – used the scientific method to develop answers that were partially right but wrong and almost everyone believed what they “proved” … what chance do you and I have to develop the right answer during our next incident investigation? Could we “prove” a cause that really was not a cause?

Scientific Method Isn’t Needed for Root Cause Analysis

Now for the good news.

Being an engineer, I didn’t start with the scientific method when developing the TapRooT® Root Cause Analysis System .

Instead, I took an engineering approach. But you don’t have to be an engineer (or a human factors expert) to use it to understand what caused an accident and what you can do to stop a similar accident from happening in the future.

Being an engineer, I had my fair share of classes in science. Physics, math, and chemistry are all part of an engineer’s basic training. But engineers learn to go beyond science to solve problems (and design things) using models that have limitations. A useful model can be properly applied by an engineer to design a building, an electrical transmission network, a smartphone, or a 747 without applying the limitations of quantum mechanics.

Also, being an engineer I found that the best college course I ever had that helped me understand accidents wasn’t an engineering course. It was a course on human factors. A course that very few engineers take.

By combining the knowledge of high-reliability systems that I gained in the Nuclear Navy with my knowledge of engineering and human factors, I developed a model that could be used by people without engineering and human factors training to understand:

• what happened during an incident,
• how it happened,
• why it happened, and
• how it could be prevented from happening again.

We have been refining this model (the TapRooT® System ) for over thirty years. Making it better and more usable. Using the feedback from tens of thousands of users around the world to constantly improve it. We have seen it applied in a wide variety of industries to effectively solve equipment and human performance issues. We have used it to improve safety, quality, production, and equipment reliability. These are real-world tests with real-world success (see the Solution tab above and the Industries section for the success stories for each industry).

Better Way to Find Root Causes

So, the next time someone tells you that the ONLY way to investigate an incident is the scientific method, just smile and know that they may have been right in the 17th century, but there is a better way to do it today.

If you want, you can suggest they try the TapRooT® Root Cause Analysis System. Tell them to learn about it by attending a TapRooT® Course . There is the Essential Course – a  2-Day Course. Or, if they want to learn more, there is  5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training . See the schedule for public courses HERE . Or CONTACT US about having a course at your site.

Expert Should Disprove His Own Hypothesis

Back to the expert that said the scientific method was the ONLY way to perform a root cause analysis and that you should overcome confirmation bias by trying to disprove your own hypothesis.

He should try it!

His hypothesis is that the scientific method is the ONLY way to find root causes.

He could DISPROVE his hypothesis by attending a TapRooT® Course .

Then he could see that there is another way … a more reliable way … to find root causes. That would disprove his hypothesis.

The only problem is that he probably will never try it. Which disproves his hypothesis (that he can overcome confirmation bias by thinking about it).

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One Reply to “Scientific Method and Root Cause Analysis”

The main problem with the scientific method is that it is all about confirmation bias. No one theory can account for all the data an experiment produces. Science is about selecting the data that conforms to a theory and calling the rest of the data “noise.”

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Can You Perform Root Cause Analysis Using the Scientific Method?

• September 28, 2020

Can you perform a good root cause analysis following the scientific method? Some think it provides the only true answer. The scientific method can be applied to almost all fields of study as a problem-solving method and has been used for centuries to explore observations and answer questions.

The 6 Steps of the Scientific Method

The Scientific Method follows these six steps:

• Observation
• Asking a question
• Forming a hypothesis to test
• Making a prediction based on the hypothesis
• Testing the prediction
• Using the results to make new hypotheses

Sounds logical for investigating an incident . . .  but is it a good method?

RELATED: How to Prepare for a Major Incident Investigation

The Problem with Using the Scientific Method for Root Cause Analysis

The problem with this hypothesis testing model is that people aren’t good at disproving their own hypothesis. There’s even a scientific term for this problem: confirmation bias.

When investigators develop a hypothesis that they believe in, they tend to selectively gather evidence to prove what they believe happened, and disregard evidence that is contrary to their hypotheses. This is a natural human tendency.

Some believe you can overcome this problem. They think you can teach people to disprove all other theories, and also look for evidence that disproves their theory. However, telling others not to fall into the trap of only seeing the evidence they want to see is ineffective.

This, in part, is due to limited knowledge. Most do not have formal training in human factors and why people make errors. Even if they do have training, think about this:

How many investigators who have human factors training could hypothesize all the potential causes for a human error, and how could they prove or disprove them all ?

YOU MIGHT ALSO LIKE: The Secret to Conducting Effective Interviews for Incident Investigations

Even Famous Scientists Got the Wrong Answer Using the Scientific Method

Isaac Newton, one of the world’s greatest mathematicians, developed the universal law of gravity. Using the scientific method worked on apples and planets. The problem is, when atomic and subatomic matter was discovered, the “law” of gravity didn’t work. There were other forces that governed subatomic interactions.

Enter Albert Einstein and quantum physics. A whole new set of laws (or maybe you called them “theories”) that ruled the universe. These theories were proven by the scientific method. But what are we discovering now? Those theories aren’t quite “right” either. There are things in the universe that don’t behave the way that quantum physics would predict. Thus, Einstein was wrong.

So, if two of the smartest people around – Newton and Einstein – used the scientific method to develop answers that were only partially right and almost everyone believed what they “proved” … what chance do you and I have to develop the right answer during our next incident investigation? Could we “prove” a cause that really was not a cause?

That’s the simple reason why the scientific method is not the only way,  or even a good way , to investigate workplace safety incidents and accidents. So, the next time someone tells you that the only way to investigate an incident is the scientific method, just smile and know that they may have been right in the 17th century, but there are better ways to do it today.

Learn More about Incident Investigation and Incident Management

See how Cority’s safety incident management software can help you collect comprehensive incident data, identify root causes, implement corrective actions, and ensure proper incident notification.

• Incident Investigation , Incident Management

Mark Paradies

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The TQM Journal

ISSN : 1754-2731

Article publication date: 22 February 2013

In implementing Six Sigma and/or Lean Six Sigma, a practitioner often faces a dilemma of how to select the subset of root causes from a superset of all possible potential causes, popularly known as root cause analysis (RCA). Generally one resorts to the cause and effect diagram for this purpose. However, the practice adopted for identification of root causes is in many situations quite arbitrary and lacks a systematic, structured approach based on the rigorous data driven statistical analysis. This paper aims at developing a methodology for validation of potential causes to root causes to aid practitioners.

Design/methodology/approach

Discussion has been made on various methods for identification and validation of potential causes to root causes with the help of a few real life examples for effective Lean Six Sigma implementation.

The cause and effect diagram is the frequently adopted method for identifying potential causes out of a host of methods available for such identification. The method of validation depends on the practitioners’ knowledge on the relationship between cause and effect and controllability of the causes.

Originality/value

The roadmap thus evolved for the validation of root causes will be of great value to the practitioners as it is expected to help them understand the ground reality in an unambiguous manner resulting in a superior strategy for cause validation and corrective actions.

• Root cause analysis
• Potential cause
• Test of hypothesis
• Lean Six Sigma
• Cause and effect analysis

Ashok Sarkar, S. , Ranjan Mukhopadhyay, A. and Ghosh, S.K. (2013), "Root cause analysis, Lean Six Sigma and test of hypothesis", The TQM Journal , Vol. 25 No. 2, pp. 170-185. https://doi.org/10.1108/17542731311299609

Emerald Group Publishing Limited

Copyright © 2013, Emerald Group Publishing Limited

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