Root Cause Analysis

Motivation, Process, Tools and Perspective

Summary

Root Cause Analysis (RCA) is a structured investigative process that aims to identify
the true cause of a problem, and the actions necessary to eliminate, or mitigate that
problem.. The trigger to start an RCA can be a major accident or incident, or an overall
improvement program in the areas of safety, quality, or production/maintenance. The
article starts with an example of a major railway accident whereby root causes needed
to be investigated. A discussion of the RCA process is next, followed by an
investigation of available RCA tools, and the role of RCA in improvement programs.
The article ends with references for further reading on this subject.

SKF Reliability Systems

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Root Cause Analysis

GSO203
Gerard Schram
16 Pages
Published May 2002
Revised September 2004

Table of contents

1.

Introduction ........................................................................... 3

2.

Importance of RCA ................................................................. 4

2.1.

Example: Railway Accident ................................................................... 4

3.

RCA Process ........................................................................... 6

4.

RCA Tools/Methods ................................................................ 7

4.1.

Problem Identification/Understanding..................................................... 7

4.2.

Possible Cause Generation and Consensus Reaching ................................ 7

4.3.

Problem and Cause Data Collection ........................................................ 7

4.4.

Possible Cause Analysis ........................................................................ 8

4.5.

Cause-Effect Analysis ........................................................................... 9

4.6.

Tool Selection ....................................................................................11

5.

The Wider Perspective of RCA .............................................. 11

5.1.

Role in HAZOP ....................................................................................11

5.2.

Role in TQM / Six Sigma ......................................................................11

5.3.

Role in TPM ........................................................................................12

5.4.

Role in Asset Management ...................................................................12

5.5.

Role in (S) RCM ..................................................................................12

5.6.

A Survey among Maintenance Professionals ...........................................13

6.

The Consequences Of RCA .................................................... 13

7.

Commercial Methods/Software ............................................ 14

7.1.

PROACT.............................................................................................14

7.2.

Taproot .............................................................................................15

8.

Conclusion ............................................................................ 15

9.

Acknowledgements .............................................................. 15

10.

References ........................................................................... 15

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1.

Introduction

The greatest tragedy underlying errors and

resultant failures is that many of them are
avoidable. Yet, one of the best effective
concepts for improving reliability in
engineering is often neglected. That concept is
the learning and continuous improvement
from (historical) case analysis. Well-studied
examples are failures in civil engineering
structures, such as the collapse of various
suspension bridges (Tacoma Narrows bridge in
oscillating mode due to wind, 1940).

cause-and-effect chain and creates the

problem.

NASA defines so called "direct" or

"proximate" causes as:
The

The event(s) that occurred, including any

condition(s) that existed immediately before the
undesired outcome, directly resulted in its
occurrence and, if eliminated or modified, would
have prevented the undesired outcome.

Aeronautical and aerospace failures are also

the subject of much attention, especially in
the mass media. Nuclear and chemical
engineering incidents can have major impacts
too. Mechanical engineering failures generally
result in somewhat less life-threatening
situations, but can cause massive recall
campaigns and product liability suits. It is
obvious then, that recognizing and
understanding failure (or a near failure) plays
a key role in error-free design and operation.
This understanding is necessary to eliminate
the same causes and effects in the future.

Regarding an "undesired outcome", the NASA

provides examples such as: failure, anomaly,
schedule delay, broken equipment, product
defect, problem, close call, mishap, etc. Then
as definition of root cause, the NASA states:

Apart from physical failures, safety incidents,

quality defects, customer complaints, etc., can
be the reason for a thorough investigation into
their causes. In general, we can state that a
problem is a deviation from what is defined
normal, with negative impact. A problem is
not always recognized (it can be perceived as
normal). However, with an open-minded team
and/or internal or external benchmarking,
problems can be identified. Problem solving
consists of identifying causes, and finding
ways to eliminate them and prevent them
from recurring. In other words, identifying the
cause/s is often half the answer.

NASA defines Root Cause Analysis (RCA) as:

A problem is often the result of multiple

One of multiple factors (events, conditions or

organizational factors) that contributed to or
created the proximate cause and subsequent
undesired outcome and, if eliminated, or
modified would have prevented the undesired
outcome. Typically multiple root causes
contribute to an undesired outcome.

A structured evaluation method that identifies the

root causes for an undesired outcome and the
actions adequate to prevent recurrence.
American Society for Quality (ASQ) defines
Root Cause Analysis (RCA) as:
The

RCA is a structured investigation that aims to

identify the true cause of a problem, and the
actions necessary to eliminate it.

causes at different levels. The root cause is the

evil at the bottom" that sets in motion the

In fact, RCA is a collective term used to

describe a wide range of approaches, tools,
and techniques used to uncover and model

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causes to problems. RCA is a method that

helps professionals determine what happened,
how it happened, and why it happened. It
allows learning from past problems, failures,
and accidents. RCA can be applied to any
organizational, production, and administrative
(etc.) problem.
There exist slightly different terms, including
Failure Analysis (FA) and Root Cause Failure
Analysis (RCFA).

Failure Analysis refers to the

observation, categorization, and possibly

documentation of a failure. As such it does not
necessarily intend to find the root causes that
resulted in that failure (how it failed).

Root

Cause Failure Analysis includes the investigation

towards root causes, but is somewhat limited
to the term "failure." The term failure is
biased to physical failures, while root cause
analysis is applicable to many more situations,
such as safety incidents, quality problems,
etc.
Finally, Failure

Mode Effect Analysis (FMEA) is a

more hypothetical analysis to determine how a

component or process could fail (failure
modes), including their risks and
consequences. FMEA can be considered a
proactive way to avoid problems that have not
occurred before. On the other hand, RCA is
generally initiated when an unplanned
problem is happening. It then focuses on
preventing reoccurrence in the future. The
preventive actions effect on risks and
consequences are generally not taken into
account.

2.

Importance of RCA

Why perform a RCA? If achievements from

eliminating the problem and its consequences
are larger than the efforts put into a RCA, this
seems obvious. Although eliminating risk of
recurrence of similar situations looks
admirable, it could be perceived as the
"program of the month." Resolving

Root Cause Analysis

emergencies when they occur, while RCA aims

to eliminate root causes and reduce the
maintenance persons responsibilities, may
recognize a maintenance person.
Therefore, it is extremely important to align
everyone in the same direction, both at
management level and production and
maintenance personnel. Creating the right,
open environment for learning from failures is
essential [Latino, 2001].

2.1.

Example: Railway Accident

A real example shows how small root causes

can lead to serious damage. This example
originates from SKF Belgium. A goods train
traveled from Antwerp harbor to a factory in
France. After 30 km the train passed a station
where the temperature of the axle boxes is
measured to detect possible hot boxes.
Everything was normal. 35 km further the
train derailed. 8 wagons were destroyed, and
damage was done to the rails and overhead
electrical cabling. The goods traffic was
stopped for several hours.
The accident happened in Belgium, the goods
were French owned, and the railway wagons
were property of the German State Railways.
The wagon in question was overhauled just
before the accident. (By international
agreement, the Belgian Railways paid
damages: > US $1,000,000.)
Figure 1. Relevant Locations within Belgium.
Starting point

The remains of the failed axle box, equipped

with two spherical roller bearings Hot
SKFbox
229750
J/C3R505 (Y 25 bogie 20-ton axle load
design)
are shown in Figure 2. We are looking
derailmen
for the root cause, as we want to eliminate
this problem forever!
50 km

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Figure 4. The Axle Box as part of the Boogie.

Figure 2. Remains of the Axle Box Bearings.

The wagons were equipped with Y25 bogies,

with axle boxes with double spring
suspension. Maximum authorized axle load is
20 tons. The axle boxes incorporated spherical
roller bearings SKF 229750 J/C3R505.

Figure 5. Technical Drawing of the Axle Box with Two

Spherical Roller Bearings and the Spacer Ring.

Figure 3. The Wagons.

In the analysis of root causes, one can clearly

see that this was more than a hot runner. To
some extent, the inside bearing was
completely deformed from red-hot running. In
fact, there are clues to indicate what
happened:

Root Cause Analysis

There is a gap between the (inside

bearing) outer ring and the labyrinth seal.

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The inside bearing moved towards the

outside
In principle, this should not be possible.
For a 20 ton/axle arrangement, the
distance ring on the axle between bearings
is 35 mm wide, and regulates the precise
bearing location
The width of the distance ring - called the
spacer ring - was 14 mm
In fact, there are TWO different executions
of this axle box: 20 ton / axle payload axle box with a 35 mm spacer between
bearings. And, a 22.5 ton / axle payload, a
similar but slightly narrower axle box, with
a 14 mm spacer between bearings
Somehow, the maintenance personnel
installed the wrong spacer ring
The bearing assembly was allowed to slide
to the outside, which resulted in heavier
axle load, more axle bending, material
fatigue, and final collapse. The bearing
was running at more than red hot, and
was completely deformed.
The train derailed just for a spacer!

This example shows the necessity of finding

problem root causes with the goal of
eliminating them from recurring. Human
mistakes or erroneous procedures can be the
root cause, but we should acknowledge the
errors and learn from the mistakes.

3.

Problem Identification: The problem should

be recognized and assigned a name. If a
problem is perceived as normal, it never
improves. In the case of engineering
constructions, the problem can be
identified by symptom analysis and
equipment inspections. In general, internal
or external benchmarking can also identify
problems (or opportunities)

Root Cause Analysis

Problem Understanding: It is necessary to

understand the nature, or essential failure
modes, of the problem

Root Cause Identification: Find the correct

root cause(s). This includes brainstorming
and investigating possible root causes, and
cause-effect relationships

Root Cause Elimination: Eliminate the root

cause(s) to prevent the problem from
recurring

Symptom Monitoring: Monitor symptoms to

show the presence or elimination of the
problem. Regularly take performance
checks

Generally, a team performs the RCA process.

As stated before, it is essential to create the
right environment for an open, trustful
approach. The following roles are
distinguished within a manufacturing plant
(2001):

Executives: Put a stamp of approval on

RCA, including expectations and time
lines. They should be fully educated in RCA

RCA Champions: Administer, support, and

ensure the RCA effort from a management
standpoint. They should be a mentor to
the drivers and analysts, and should have
the authority to protect persons in case of
politically sensitive facts. They set
performance expectations

RCA Process

The following steps are generally found in a

RCA procedure:

RCA Drivers: Team leaders who organize all

details. The team meets, analyzes,
hypothesizes, verifies, and draws factual
conclusions. They develop
recommendations to eliminate root causes

Structured RCA effort intends to be a

proactive task, so it should reside under the
control of a reliability department. In the
absence of such a department, RCA should be
controlled by operations or engineering. The
RCA effort should not be placed under the

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control of a reactive maintenance department,

as their role is to respond to day-to-day
activities in the field.

4.

RCA Tools/Methods

The American Society for Quality distinguishes

tools and methods by their specific purposes
(2000):

Problem identification/understanding
Possible cause generation and consensus
reaching
Problem and cause data collection
Possible cause analysis
Cause-and-effect analysis

We briefly mention the various techniques.

Please refer to detailed publications, such as
the original work of Ishikawa of the Asian
Productivity Organization.

4.1.

Problem
Identification/Understanding

Problem identification and understanding

includes tools to identify and gain solid
understanding of the problem.

Flowcharts: Many problems are connected to

business or work processes. A process
flowchart is an appropriate first step to
illustrate where problems occur, and to
provide an understanding of processes that
contain or influence problems.

Critical Incident: A method to explore the most

(business) processes compares with other

organizations or departments (benchmarking).
It compares and determines which problems
are most critical from an external viewpoint.

Performance Matrix: Used to illustrate the

performance and importance of problems and
causes. High importance, high performance
impact problems and causes are only selected.

4.2.

Possible Cause Generation

and Consensus Reaching

The following section covers idea-generating

tools to determine possible problem causes
and tools to reach an agreement in case of
disputes or different views.

Brainstorming: Generic process of generating

a list of problem areas, consequences, causes,
and ways to eliminate them. It can be
structured or unstructured.

Brain Writing: Similar to brainstorming, brain

writing uses written cards or a gallery of white
boards or flip charts. It is preferred, as it
reduces problem complexity, dominating
people, or the possible anonymity.

Nominal Group Technique: A kind of

brainstorming in which all participants have
the same vote when selecting solutions /
causes. Ideas are first generated, and then
participants rank them individually. By totaling
the points, a consensus is reached.

critical issues in a situation. A collection of

people from different departments or
functional areas is asked about most critical
incidents. The answers are collected, sorted,
and analyzed based on frequency. The most
critical ones are the starting point for RCA.

Paired Comparisons: Instead of comparing

Spider Chart: The spider chart gives a graphical

impression of how the performance of

Here we include tools and techniques to collect

reliable root cause analysis data.

Root Cause Analysis

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ideas all at once, they are compared pair-wise

to reach a consensus.

4.3.

Problem and Cause Data

Collection

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Sampling: Sampling draws conclusions about a

4.4.

Possible Cause Analysis

larger group based on a smaller sample. A

minimum understanding of statistics is
required to perform reliable sampling.

Possible cause analysis covers techniques for

analyzing the impact of different causes.

Surveys: Used to collect data about attitudes,

distribution and variation of a data set. The

diagram helps to identify patterns or
anomalies. The frequency of occurrence is
depicted vertically, while the classes are
ordered along the horizontal axis.

feelings, or opinions, such as customer

satisfaction, needs, and/or expectations.

Check Sheets: A check sheet table used to

systematically register data.
Cause of
Machine
Trouble
unbalance
misalignment
bearings
.

Jan

II
I

Feb

I
III
II

Histogram: A bar chart used to visualize the

25

Totals
per
cause
3
4
2

20
15
shutdown

10
5
0
<1hr

1-4hr 5-8hr 8-24hr

Table 1. Example of a Simple Check Sheet.

A Computer Maintenance Management System

(CMMS) is another good source for data (data
entering is properly done). For example,
statistics may be derived on breakdowns and
possible causes. Again, a representative set of
data should be present.
Like the CMMS, other documentation on
health/safety/environmental (HSE) accidents
and incidents can be a valuable data source.
Possibly, extra fields can be added to these
systems to better trigger and track problems.

Figure 6. Histogram Example.

Pareto Chart: The Pareto principle states that

most effects, often 80 percent, are the result
of a small number of causes, often 20 percent.
The main purpose of the chart is to show the
causes sorted by the degree of seriousness,
expressed as the frequency of occurrence,
cost, performance, etc. It shows which causes
need further attention. Figure 7 is a simple
example, in which two causes cover 80% of
the problem.

Relevant data may also be found in general

databases with reliability data (often referred
to as RAM data). A few example databases:

OREDA for Offshore Reliability Data, with

turbines, compressors, etc.
http://www.oreda.com
Process Equipment Reliability Database
(PERD) of the American Institute of
Chemical Engineers http://www.AIChe.org

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Relations Diagram: A tool to identify logical

F re q u e n c y

C u m u la tiv e %
100%

20

relationships between different ideas or issues

in a complex or confusing situation. The
factors under investigation are distributed in
an empty chart area, and arrows illustrate the
relationships between them.

Affinity Diagram: A chart approach that helps

identify seemingly unrelated ideas, causes, or
other concepts so they might collectively be
further explored. A way to handle and
brainstorm about causes in a qualitative way
rather than quantitative.

10

0%
cau se 1

cau se 3
cau se 2

cau se 5
cau se 4

Figure 7. Pareto Chart Example.

Scatter Charts: Illustrate relationships between

two causes or other variables in a problem
situation. This is achieved by plotting at least
30 samples of data pairs in one figure.
Possible logarithmic axes may also be used.
The data may be generated by experiments of
changing variables and plotting the effects.

4.5.

Cause-Effect Analysis

The last stage is the cause-effect analysis. A

few tools are mentioned here.

Cause-Effect Chart: This is a well-known

technique used to relate possible causes to a
problem. It is also called the Ishikawa diagram
or fishbone diagram.
After completing the cause-effect diagram,
examples / facts can also be entered. These
illustrate the relationships, and provide an
idea about their strength.

Paper thickness

The cause-effect diagram shows that multiple

causes can result in the same problem. The
diagram can be used as a discussion aid to
determine which causes are considered the
primary (root) causes of the actual problem. If
enough data is available, a probabilistic
approach could yield the most likely root
causes.

"knob A"

Figure 8. Scatter Chart Example.

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level cause, or a root cause. The chains of

causes can be drawn in a simple chart. The
rule of thumb is that the method often
required five rounds of the question why.

Advanced Tools: There are various other ways

Figure 9. Cause-Effect Diagram (Fishbone).

Fault-Trees: Another visual way to represent

cause-effect relationships. The fault tree starts
with faults / problems. Causes (can be
different layers) are then depicted with arrows
indicating the relationships.

Matrix Diagram: A visual technique for

arranging possible causes by their contribution
to the problem. Problem characteristics are
ordered vertically, and possible causes
horizontally. The contributions of the cause to
problem characteristics are depicted in the
matrix. By accumulating individual
contributions, you get an idea of which causes
are most significant. It is also sometimes
referred to as a cause-effect matrix.

to model cause-effect relations based on

(statistical) correlations or regression
techniques. However, they fall outside the
scope of this introduction article on RCA.
Other advanced techniques stem from artificial
intelligence, such as artificial neural networks,
fuzzy models, logical decision trees, and other
network representation. The cause-effect
networks are used to reason forward or
backward. The network, together with
reasoning capacity, forms a so-called expert
system, or knowledge-based system.
These tools can be tuned by both "data" and
"heuristics." For example, the Bayesian
network is used to model cause-effect
relations, where the strength of the
relationship is modeled as probabilities. SKF
applies the Bayesian network to support
bearing failure or damage investigations.

Five Whys: The main purpose is to keep asking

"why" when a cause is identified. Each cause
is questioned whether it is a symptom, a lower

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Figure 10. A Bayesian Network Used to Model Relations Between Causes and Effects. The Arrows Denote
relationships, While Numbers and Red Bars Denote Probability of Occurrence.

4.6.

Tool Selection

These tools and methods are aids to get to the

goal, rather than the solution. In the general
RCA process, the tools support problem
understanding and root cause identification
steps. The American Society for Quality
further outlines the particular strengths and
weaknesses of the tools (2000). In general,
the selection is very situation dependent.
Doggett (2004) concludes after investigating
three RCA tools (Cause and Effect Diagrams,
Interrelationship Diagrams, and Current
Reliability Trees), that none of the tools were
perceived significantly better in terms of
finding root causes. On the other hand, the
complexity of the tools varies, and as such the
training requirements.

5.

The Wider Perspective of

RCA

part of a bigger improvement program, such

as safety, quality, or maintenance
improvement programs. RCA identifies
problems (opportunities to improve) and finds
root causes.

5.1.

Role in HAZOP

A Hazard and operability (HAZOP) study is a

methodical review of a defined operation
system to identify potential hazards and
operability problems. It identifies and defines
process and design deficiencies, the potential
for, and consequences of human and
organizational error, accidents from
neighboring plant or activities, natural
occurrences and catastrophes, and the
possibilities of equipment component failures.
As such, many RCA tools and methods can
play a role in a HAZOP study.

5.2.

Role in TQM / Six Sigma

Root cause analysis can be used after a major

incident or accident like the railway problem
outlined earlier. However, RCA can also be

Total Quality Management (TQM) and Six

Sigma stand for a stream of programs aimed

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to tackle major causes of quality defects. We

can state that RCA originates from quality
improvement philosophies, and many RCA
tools / methods are present in TQM and Six
Sigma. Some RCA tools can be embedded in a
plant's quality procedures, as one main goal is
achieving a continuous process of quality
improvement. For example, critical incidents
investigation, performance spider charts, etc.,
can be done on regular basis.

5.3.

Role in TPM

Total Productive Maintenance (TPM) stands for

an improvement program that covers both
production and maintenance functions. It is
founded on the concept of ownership and
complete integration of the production and
maintenance functions.
The prime driver for TPM is the concept of
Overall Equipment Effectiveness (OEE). The
philosophy hinges on making equipment
effectiveness the concern of everyone in the
organization. OEE requires strict attention to
the measurement and quantification of losses.
When identifying big losses and their root
causes, RCA tools play a useful role. As such,
RCA tools can be part of a TPM program.

5.4.

Role in Asset Management

Asset Management (AM) tries to attain the

lowest life cycle cost with maximum
availability, performance efficiency, and
quality (maximum OEE). In other words, AM is
the systematic planning and control of a
physical asset throughout its life. An outcome
of AM is the defining what specific
maintenance practices need to be undertaken
while considering the optimum means of
implementing them. This is where RCA tools
can again play a useful role.

Root Cause Analysis

5.5.

Role in (S) RCM

Reliability Centered Maintenance (RCM) and

SRCM are structured processes to proactively
identify equipment modifications and/or safety
devices required to avoid any significant
consequence as a result of equipment failure.
Consequences can be operational loss, safety,
health, or environmental. By RCM study, all of
the potential modes of failure are uncovered
and a maintenance strategy is devised to
mitigate the consequences of the failure based
on the criticality of the failure mode. In RCM,
these failure modes are identified as the root
cause(s) of the failure.
This is where the main difference lies. The
purpose of RCA is to uncover the underlying
reasons (root causes) why an event (not just
equipment related events, but any type of
event) is occurring so that the necessary steps
can be taken to eliminate the event in its
entirety. This is accomplished by analyzing
the modes (the point at which RCM stops).
RCA uses for example a logic tree that
stresses verification at every level. The
advantage is that the actual root causes that
are uncovered are facts that have been
derived from the verification process. RCM is
driven by deriving a maintenance strategy,
while RCA is driven by maintenance
prevention.
Within RCM, FMEA stands as the central
vehicle; however, the RCA tools and methods
can be of additional help when performing
FMEA in the need of deeper investigation of
the failure modes. Secondly, RCA is to be used
in the process of updating (on periodic basis)
the derived maintenance strategy from RCM
such that a continuous improvement of the
maintenance strategy is achieved.

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5.6.

A Survey among Maintenance

Professionals

A survey of the use of RCA techniques by

maintenance professionals was conducted on
the Plant Maintenance Resource Center in
2000. See the results at:
http://www.plantmaintenance.com/articles/rca-survey-01.shtml
The key findings are:

59% of respondents indicated that they

use some form of RCA process
Of those who indicated that they used
some form of RCA, 79% indicated that
they used formal, structured processes
Those using formal processes considered
that the overall effectiveness of their
approach was significantly better than did
those people using informal processes.
Supervisory and technical staff are more
likely to be involved in RCA than shop floor
personnel.
The greatest benefits appear to be in the
area of improved equipment availability
and reliability.
60% of respondents indicated that they
used external consultants to assist with
their RCA implementation.
55% of respondents indicated that they
used software to assist with their RCA
process.

that the structured process of RCA is key to

make RCA become effective.

6.

The Consequences Of RCA

To prevent the problem from recurring, the

root cause(s) should be eliminated. The root
cause investigation results necessary actions
are considered the outcome of RCA. It is
essential to know cause-effect relationships to
prevent problems from recurring.
The assessment of these actions is generally
not addressed within the RCA context. This is
typically the second part of an FMEA process,
whereby possible actions are assessed after
their effect, in terms of risk or consequence
decrease. It is worthwhile to consider this
approach when assessing alternative actions.
@ptitudeXchange provides articles on FMEA
for further reading.
In order to arrive at a continuous
improvement situation, RCA needs to be
embedded into the normal work processes. As
an example, within the SKF concept of
Proactive Reliability MaintenanceTM (PRM), an
improvement loop is defined (Figure 11).
Starting with an operational review, a
predictive maintenance program is set-up.
Where critical anomalies are detected, RCA is
applied, providing corrective actions to
prevent anomalies from occurring again.
Formulating a number of key performance
indicators monitors the process.

The survey shows that RCA is quite wide

spread amongst maintenance functions, and

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Figure

11:

Proactive

These types of work processes generally

need adjustment in the standard job plans.
For example, anomalies detected during
predictive maintenance should feed/start
RCA procedures. RCA results have to be
documented extensively (see e.g. Reed,
2003), and recorded appropriately in CMMS
for keeping good machinery history.
Corrective work (e.g., cleaning, repair) or
adjustments in maintenance strategy (e.g.,
preventive vs. predictive) needs to be
planned and scheduled.
In case of large changes, a change
management project may follow RCA. For
example, when changing organizational
structure or major responsibilities, a
structured management of change is needed
(Schram & Yolton, 2004).

7.

Commercial
Methods/Software

Just two of the many tools are mentioned

here. Most commercial tools are tools with
which cause-failure trees can be made or
searched through, and then visualized. It

Root Cause Analysis

Reliability

MaintenanceTM

should again be emphasized that RCA is

more a process than a tool - the tool
supports the structuring of the process.

7.1.

PROACT

Reliability Center Inc. offers a method called

PROACT accompanied with a software tool.
PROACT stands for:
PReserving event data

Ordering the analysis team

Analyzing event data
Communicating findings and
recommendations
Tracking for bottom line results

The method is clear, and a great deal of

attention is spent on human organizational
errors. Many other software tools only focus
on (modeling) the mechanical issues. More
information can be found at:
http://www.reliability.com/

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7.2. Taproot

System Improvements Inc. offers a software

suite called TapRoot.
The suite of tools includes Root Cause Tree
software, which provides the investigator
with a fairly comprehensive list of causes
that should be considered for any incident.
Each causal factor that contributed to the
incident should be analyzed one at a time. A
dictionary provides explanations and
definitions of each part of the root cause
tree. This allows for consistent, nonoverlapping root causes that create trending
in a database. It also includes a checklist
that ensures consideration of the most
frequently occurring human performance
contributors to an incident, which helps
narrow down the seven basic cause
categories. It also helps keep the
investigator's mind open and focused.
A second software, Equifactor was created in
cooperation with Heinz Bloch's equipment
troubleshooting techniques. These
techniques include:

Equipment Troubleshooting Tables

Component Troubleshooting Tables
FRETT Analysis
Equipment 7 Cause Categories

More information can be found at:

http://www.taproot.com/

Summary: PROACT is a process with an

empty, supportive tool, while TapRoot is a
step-by-step search in a database with
tables and trees.

8.

Conclusion

Root Cause Analysis (RCA) is a structured

investigation that aims to identify the true
cause of a problem, the cause-effect

Root Cause Analysis

relationships, and the actions necessary to

eliminate it. The trigger to start an RCA can
be a major accident or incident, or an overall
improvement program in the areas of safety,
quality, or production / maintenance. The
RCA process consists of problem
identification / understanding. The outcomes
of RCA are recommendations for change and
monitoring to keep the problem from
reoccurring. Several tools and methods
exists that can support the RCA process.

9.

Acknowledgements

The author would like to thank Wayne Reed

for his contributions to this paper.

10.

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