Root Cause Analysis

From Dar

According to Bill Wilson's site, "Root cause analysis (RCA) is a methodology for finding and correcting the most important reasons for performance problems. It differs from troubleshooting and problem-solving in that these disciplines typically seek solutions to specific difficulties, whereas RCA is directed at underlying issues."

Denham Grey wrote a blog entry extracting the questions which need to be reflected upon when a situation suitable for RCA is encountered.

Eight Questions for Insight:

• 1. What were the most important consequences? Actual, expected, potential?
• 2. What makes this event significant?
• 3. What set them up for it?
• 4. What triggered it?
• 5. What made it as bad as it was?
• 6. What kept it from being a lot worse?
• 7. What should be learned from it?
• 8. What should be done about it?

Some other questions:

• What is it about the way business is done that makes events like this inevitable?
• What were the earlier, better, safer, cheaper ways that we could have found the causal factors of this one without having the event?
• What's wrong with this picture, i.e., the news story?
• What do you think were the non-consequential precursors to this Real McCoy?
• Can you think of some negative causes for this one?
• Which accidents in your industry does this remind you of?
• Which related accidents does this remind you of?