Fundamentals for Root Cause Analysis

Fundamentals for Root Cause Analysis

During analysis of the problem, a number of root causes will be identified. Some of the identified root causes will be within the workplace or the department wherein the problem has occurred whereas some will be outside the workplace or the department wherein the problem has occurred.

Now the root causes that have been identified as not within the workplace / department should also be addressed. But as they do not lie under the jurisdiction of the workplace / department, they have less control on the same. Identifying such root  causes  may turn the investigation report into a blame game wherein one department blames the other. What will happen to image of the organization if such a report is sent to the leagal/ regulatory authorities? It may lead to feud between departments – which is not the intention of the investigation. Hence such causes are normally mentioned as contributory causes as the concerned department does not have direct control over the same.

Hence basically, the root cause cannot be outside the workplace or the department wherein the problem has occurred.

Let us go back to the fatality case of person B in the previous article and analyse again

a.       The number of housekeeping staff has been cut short as part of the cost cutting procedures in the company. – Concerned Department –Admin/ finance

b.      Enough wet floor boards were not available. - Concerned Department –Admin/ finance /stores

c.       The opening through which B fell down was made by workers working in the area for ease of shifting materials between levels. The supervisors were unaware of the practice. - Concerned Department – Same

d.      Mobile phones were not restricted in the plant. People talking on mobile while working was a common sight in the plant. Concerned Department – Self

e.      The person was not trained to use fall protection devices or to work at height. - Concerned Department –Self

f.        Proper risk analysis was not carried out before the start of the work. Concerned Department – Self

Hence the causes identified in c,d,e and f will be termed as root causes and the others will be the contributory causes.

But the root cause which has now been reduced to a contributory cause will be forwarded to the department responsible for the same. This contributory cause will now become a trigger point for the root cause analysis in the department responsible wherein they will have to close out the factor by implementing CAPA.

Root causes are those which can reasonably be identified. No hypothesis and assumptions please J.

Root causes are those over which the management has control. ‘The day was humid’ or the ‘day temperature was more than 50 degree centigrade’ does not become a root cause. In turn you can find that ‘There were no effective measures in place to control the humidity or temperature’ can be added as a root cause.

Root causes are those over which effective recommendations can be generated.  The recommendation shall produce a CAPA and should not fly off in the air resulting in waste of time and money.