Root Cause Analysis

Root Cause Analysis (RCA) is a problem-solving method used for identifying the root causes of faults or problems. It can help define corrective, prevent incident/accident recurrence, and mitigate operational risk with an effective predictive maintenance solution. Additionally, it can provide great support to attention on how the safety management system "allowed” deficiencies to exist, rather than individual blame or equipment failure. Therefore, RCA can be a very useful method for learning from incidents/accidents and ensuring preventative measures being put in place to keep all relevant stakeholders safer in the future.

To apply root cause analysis in an incident/accident investigation, it is necessary to understand three terminologies: Immediate Causes, Underlying Causes, and Root Causes.

Immediate Causes are the direct and obvious causes of an incident and are often referred to as “direct causes”.
Example-If an employee is injured by items falling off shelving, the items falling and striking the employee is an immediate cause.
It is always good to approach immediate causes from the very point of harm when identifying causes. It is often too easy to assume immediate causes are already known and confuse them with underlying causes, moving too quickly towards judgment.

Underlying Causes are effectively contributory breaches, which may not have caused harm in themselves, but did have a significant impact on the incident or accident.
Example-Poor maintenance of the shelving could be an underlying cause.
When you identify underlying causes, you may identify more than one reason why a problem exists. In the above example, you might find a faulty shelf or incorrect stacking of materials.

Root Causes are the earliest, most basic and fundamental causes of the incident or accident.
All three stages of analysis are vital to understanding how and why incidents or accidents occur and how to prevent reoccurrence. Example – The failure to supervise the shelving/racking maintenance programme is a root cause.
By addressing the root cause, you effectively remove the key reason why the events were allowed to develop for the incident/accident to occur. By only addressing immediate and underlying causes, you leave the fundamental management deficiencies unresolved, resulting in recurrence more likely.

RCA is a system-level investigation to identify where the inadequacies existed in the current procedures and processes (including design, manufacturing, installation, commissioning, operation management, etc.) that contributed to the failure occurrence.

Techniques frequently used by RCA practitioners include 5-Why, Eight Disciplines (8D) and Fishbone (Ishikawa) Diagram. A common starting point is to brainstorm the potential causes based on the symptoms. Gathered evidence is then used to iteratively rule in or out the various options until the likely root cause is determined. As with any expert-led process, there is always a concern that the RCA is run in a consistent and reliable manner. Effective RCA requires the input of high-level specialist skills which are not common to all experts.

• Oskefer’s in-house experts have a rich and varied experience in RCA and are able to apply that successfully across many industries.
• Our reports provide clear direction to determine the liability of involved parties.
• We advise the client of countermeasures of preventing similar failure, incident or accident or minimizing failure rate.
• Our report can be used as expert evidence for litigation matters and/or insurance claims (if applicable).