Root Cause Analysis and Corrective Actions

Read full reportwww.pro-sapien.com • EHS software on SharePoint Intended as a guide only • Slide 1
Root Cause Analysis and
Corrective Action
5 Methods of Root Cause Analysis and How To Follow Up Effectively

www.pro-sapien.com • EHS software on SharePoint
Root Cause Analysis (RCA)
• Used as part of an incident investigation to problem solve
• Asks four key questions
• What happened?
• How did it happen?
• Why did it happen?
• What needs to be corrected?

What an RCA will find
• A sequence of failures and causal factors that lead to an undesired
event
• A factor is considered a root cause if its removal from the sequence
prevents the event from recurring
• A factor is considered causal if it affects the outcome but its removal
will not prevent recurrence with certainty

Methods of Root Cause Analysis
There are dozens of researched and well-documented methods of
carrying out a systematic root cause analysis.
There are strengths and weaknesses of each. 5 of the most popular are:
• 5-Whys
• Fishbone Diagram
• Bowtie Analysis
• Tripod Beta
• Fault Tree Analysis

5-Whys
• A simple tool for solving low-risk
problems
• A series of “Why” questions to
drill into the cause of an event
• “Why?” is asked as many times
as required (typically five)
• Usually used in conjunction with
other methods

Fishbone Diagram
• Resembles the skeleton of a fish
• Splits analysis into categories that stem out from the “head” (a
statement of what happened)
• There are a few well-
known category sets
• 8 Ms of
Manufacturing
• 4 Ps of Production

Bowtie Analysis
• Visualizes multiple possible scenarios within a single model
• Resembles a gentleman’s bow tie
• Closely associated with the Swiss
cheese theory of causation
• Consists of the Top Event, Hazard,
Barriers, Threats, Consequences
and Escalation Factors
• Analysts can find a route that risk
can take that leads to the Top
Event

Tripod Beta
• Based on the Human Error theory
• Much like Bowtie, it identifies a causation path
• Consists of the Event, Hazard and
Object in a “head trio”
• Failed barriers are used to identify
immediate causes, preconditions,
and latent failures
• Can be used on a small
or a large scale (Tripod Tree)

Fault Tree Analysis
• Uses Boolean logic in a very mathematical process
• Resembles a workflow with “gates” and events
• Consists of Undeveloped Events, Base Events and Intermediate Events
• Aims to find the Minimum Cut Set (a group of basic events whose
occurrence will cause the event to occur)
• Can get very complex

Which method?
Ask questions:
1. How severe is the incident you are investigating?
• High severity incidents are best suited to Bowtie or Fault Tree
2. What is the make up of the team?
• Fault Tree perhaps too complex for limited skills
• Fishbone works best in a team setting where members can brainstorm
3. What are your objectives for the investigation?
• What/who are the objects involved? How many variables are there roughly?
E.g. Fault Tree may get out of hand when analysing patient reactions in
healthcare

What next?
• Regardless of method, confirm you’ve found the root causes by
walking backwards through the “causation path(s)”
• Document findings in a central, digital location
• Assign corrective actions based on findings
• Track action progress and confirm their completion
• Analyze performance in the months following action implementation
• Has there been any changes in performance? Are there less incidents/hazards
onsite?
• Communicate the positive consequences across the business

Corrective and Preventive Actions
• Sometimes referred to in Corrective and Preventive Actions (CAPAs)
• An action to address a root cause may be corrective or preventive
• Corrective – addresses the immediate causes, usually carried out onsite
• Preventive – addresses preconditions and latent failures, typically handled by
management and can take time to implement
• Assign a CAPA to every root cause
• All actions should be
• Prioritized appropriately
• Organized
• Automated
• Analyzed

Prioritizing CAPAs
• Take heed of the Pareto principle 80/20 rule: 80% of the problems can
be attributed to 20% of the issues
• Priority should be determined, not decided
• Calculate priority by:
Priority = easiness x importance x urgency
• Assign a level to each corrective action to break down the workload

Organizing CAPAs
• Each action should have an
Owner, Due Date and
Priority
• Action Manager software
integrated with your IMS
greatly improves efficiency
• House action items in the
one place for management
oversight

Automate reminders of CAPAs
• Action Manager software can send automated reminders to action
owners
• Send reminders on a set number of days out
• Automatically escalate up the chain of command when an action
becomes overdue
• Require evidence that an action has been completed

Analyze the results
• View root cause analysis and CAPA information in dashboards
alongside incident/hazard trends
• E.g. following a series of CAPAs the
number of hazards being observed
onsite may fall over time
• This is a clear opportunity to
communicate the effectiveness of
CAPAs to the wider business
• Positive results are encouraging to
both workers and management

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5 Methods of Root Cause Analysis for EHS Incidents
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Root Cause Analysis and Corrective Actions

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