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Root cause analysis is a logical sequence of steps that leads the investigator through the process of isolating the facts or the contributing factor surrounding an event or failure. Once the problem has been fully defined, the analysis systematically determines the best course of action that will resolve the event and assure that it is not repeated. A contributing factor is a condition that influences the effect by increasing the probability of occurrence, hastening the effect, and increasing the seriousness of the consequences. But a contributing factor will not cause the event. For example, a lack of routine inspections prevents an operator from seeing a hydraulic line leak, which, undetected, led to a more serious failure in the hydraulic system. Lack of inspection didn’t cause the effect, but it certainly accelerated the impact.

There is a distinction between failure analysis, root cause failure analysis and root cause analisis.

Root Cause Analysis: Implies the conducting of a full‐blown analysis that identifies the Physical, Human and Latent Root Causes of HOW any undesirable event occurred. The word “Failure” has been removed to broaden the definition to include such non‐mechanical events like safety incidents, quality defects, customer complaints, administrative problems (i.e. – delayed shutdowns) and the similar events.

Failure Analysis: Stopping an analysis at the Physical Root Causes. This is typically where most people stop, what they call their “Failure Analysis”. The Physical Root is at a tangible level, usually a component level. We find that it has failed and we simply replace it. I call it a “parts changer” level because we did not learn HOW the “part failed.”

Root Cause Failure Analysis: Indicates conducting a comprehensive analysis down to all of the root causes (physical, human and latent), but connotes analysis on mechanical items only. I have found that the word “Failure” has a mechanical connotation to most people. Root Cause Analysis is applicable to much more than just mechanical situations. It is an attempt on our part to change the prevailing paradigm about Root Cause and its applicability.

RCA can be done reactively (after the failure – RCFA) or proactively (RCA). Many organizations miss opportunities to further understand when and why things go well. Was it the project team involved? The change management methodology applied during implementation? The vendor used or the equipment selected? I would argue that performing RCA on successes is just as, if not more, important for overall success than performing RCFAs on failures

The objectives for conducting a RCA are to analyze problems or events to identify:

 What occurred

 How it occurred

 Why it occurred

 Actions for averting reoccurrence that can be developed and implemented

The root cause analysis process – RCA has five identifiable steps.

1 Define the problem

2 Collect data

3 Identify possible causal factors

4 Identify the root cause

5 Recommend and implement solution