1. ROOT CAUSE ANALYSIS

2. Outlines What is root causes analysis RCA RCA history RCA importance basic elements of RCA

3. What is Root Cause Analysis? Process for identifying contributing/ causal factors that underlie variations in performance associated with adverse events or near- miss/close calls Process that features interdisciplinary involvement of those closest to and/or most knowledgeable about the situation

4. Where Did RCA Come From? Derivative of Failure Mode Effect Analysis (FMEA) – US Military(1949) to determine effect of system and equipment engineering failures FMEA use by NASA for Apollo space program (1960s) US Auto Industry FMEA Standards implemented (1993)

5. Purpose of a Root Cause Analysis Establish the facts i.e. what happened (effect), to whom, when, where, how and why Look for improvements rather than to apportion blame Establish how recurrence may be reduced or eliminated Formulate recommendations and an action plan Provide a report and record of the investigation process & outcome

6. RCA Procedure

7. RCA Steps Charter an inter-disciplinary team (4-6 people) – Those familiar and un-familiar with the process Flow diagram of “what happened?” – Triggering questions to expand this view – Site visits and simulation to augment – Interviews with those involved or those with similar job Resources (articles, online databases) Root cause/contributing factors developed – Five rules of causation to guide/push the team deep enough – Cause and Effect Diagram, etc

8. RCA TECHNIQUE The Five Why’s technique Cause and Effect charting (fish bone diagram)

9. THE FIVE WHY’S For each primary cause ask the group “Why is this a cause of the original problem?” This should generate further and deeper reasons as to why the problem exists. Map the process on a flip chart or white board. At this point you can be reasonably confident that you have identified the core (i.e. root) of the problem. As a rule of thumb this method normally requires five rounds of the question “Why?” to elicit the root of a problem. However this is not cast in stone and you will frequently find the numbers of rounds of WHY varies.

10. Fishbone Diagrams

11. Causal Analysis using Fishbone Diagrams The Advantages it provides a structured and semi-comprehensive system for considering those influences on performance in an incident fishbone diagrams are easily constructed and understood by the novice investigator it allows more reliable improvement strategies to be developed, as they are based on verified causal information. The Disadvantages contributory classification systems have not been formally validated, the data which has not been verified may lead to inappropriate improvement strategies being implemented not all investigators feel comfortable with the fishbone diagram format.