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Presentation transcript:

Root Cause

Information Technology Infrastructure Library - Root cause analysis 1 Others have since developed more advanced root cause analysis methodologies, some with corresponding software applications.

Information Technology Infrastructure Library - Root cause analysis 1 Benefits from employing a standard, structured root cause analysis methodology include:

Information Technology Infrastructure Library - Root cause analysis 1 Common terms, language, and structure with respect to root cause analysis

ITIL - Root cause analysis 1 Others have since developed more advanced root cause analysis methodologies, some with corresponding software applications.

ITIL - Root cause analysis 1 * Common terms, language, and structure with respect to root cause analysis

Root cause analysis 1 'Root cause analysis' ('RCA') is a method of problem solving that tries to identify the root causes of faults or problems.

Root cause analysis 1 RCA practice tries to solve problems by attempting to identify and correct the root causes of events, as opposed to simply addressing their symptoms. Focusing correction on root causes has the goal of preventing problem recurrence. RCFA (Root Cause Failure Analysis) recognizes that complete prevention of recurrence by one corrective action is not always possible.

Root cause analysis 1 Conversely, there may be several effective measures (methods) that address the root causes of a problem. Thus, RCA is an iterative process and a tool of continuous improvement.

Root cause analysis 1 Root cause analysis is not a single, sharply defined methodology; there are many different tools, processes, and philosophies for performing RCA. However, several very-broadly defined approaches or schools can be identified by their basic approach or field of origin: safety-based, production-based, process- based, failure-based, and systems-based.

Root cause analysis 1 Despite the different approaches among the various schools of root cause analysis, there are some common principles. It is also possible to define several general processes for performing RCA.

Root cause analysis - General principles of root cause analysis 1 # The primary aim of root cause analysis is to identify the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes (consequences) of one or more past events in order to identify what behaviours, actions, inactions, or conditions need to be changed to prevent recurrence of similar harmful outcomes and to identify the lessons to be learned to promote the achievement of better consequences

Root cause analysis - General principles of root cause analysis 1 # To be effective, root cause analysis must be performed systematically, usually as part of an investigation, with conclusions and root causes that are identified backed up by documented evidence. Usually a team effort is required.

Root cause analysis - General principles of root cause analysis 1 # There may be more than one root cause for an event or a problem, the difficult part is demonstrating the persistence and sustaining the effort required to determine them.

Root cause analysis - General principles of root cause analysis 1 # Root causes identified depend on the way in which the problem or event is defined. Effective problem statements and event descriptions (as failures, for example) are helpful, or even required.

Root cause analysis - General principles of root cause analysis 1 # To be effective, the analysis should establish a sequence of events or timeline to understand the relationships between contributory (causal) factors, root cause(s) and the defined problem or event to prevent in the future.

Root cause analysis - General principles of root cause analysis 1 # Root cause analysis can help transform a reactive culture (that reacts to problems) into a forward-looking culture that solves problems before they occur or escalate. More importantly, it reduces the frequency of problems occurring over time within the environment where the root cause analysis process is used.

Root cause analysis - General principles of root cause analysis 1 # Root cause analysis is a threat to many cultures and environments. Threats to cultures often meet with resistance. There may be other forms of management support required to achieve root cause analysis effectiveness and success. For example, a non-punitive policy toward problem identifiers may be required.

Root cause analysis - General process for performing and documenting an RCA-based Corrective Action 1 RCA (in steps 3, 4 and 5) forms the most critical part of successful corrective action, because it directs the corrective action at the true root cause of the problem. Knowing the root cause is secondary to the goal of prevention, but without knowing the root cause, it is not possible to determine what an effective corrective action for the defined problem would be.

Root cause analysis - General process for performing and documenting an RCA-based Corrective Action 1 # Classify causes into causal factors that relate to an event in the sequence and root causes, that if eliminated, can be agreed to have interrupted that step of the sequence chain.

Root cause analysis - General process for performing and documenting an RCA-based Corrective Action 1 # Identify all other harmful factors that have equal or better claim to be called root causes. If there are multiple root causes, which is often the case, reveal those clearly for later optimum selection.

Root cause analysis - General process for performing and documenting an RCA-based Corrective Action 1 # Implement the recommended root cause correction(s).

Root cause 1 A 'root cause' is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, 'root cause' is used to describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an undesirable outcome.

Root cause 1 In plain English a root cause is a cause (harmful factor) that is root (deep, basic, fundamental, underlying or the like).

Root cause 1 The term 'root cause' has been used in professional journals as early as

Root cause 1 Paradies (2005) has defined a root cause as follows: The most basic cause (or causes) that can reasonably be identified that management has control to fix and, when fixed, will prevent (or significantly reduce the likelihood of) the problem’s recurrence.

System safety - Root cause analysis 1 Others are Event and Causal Factor Analysis (ECFA), Multilinear Events Sequencing, Sequentially Timed Events Plotting Procedure, Savannah River Plant Root Cause Analysis System.

Event correlation - Root cause analysis 1 Root cause analysis is the last and most complex step of event correlation

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