PROACT, TapRoot, 5-Why, Fishbone Diagrams, Apollo, etc, etc.  We’ve heard and utilized some or all of the methods in an attempt to solve problems.  As practitioners for well over a decade, we’ve implemented all of the above methods and others for organizations.  Whether you call it Root Cause Analysis (RCA) or Root Cause Failure Analysis (RCFA), the determining factor for success requires a holistic approach to integrating your preferred technique into a continuous improvement cycle.  Quite simply, a Plan-Do-Check-Act (PDCA) can help to bring focus, clarity, purpose, and benefits to your company’s efforts in this discipline.


The ‘Plan’ stage of RCA is where the majority of thought and foresight should be given to your program.  This stage should address several issues including:

    • What type of recurring failures/events should trigger an RCA?
      • Cost of repair (plus failure)
      • Mean Time Between Failure
      • Reliability rates
    • What type of sporadic/one-time critical events should trigger an RCA?
      • Cost of repair (plus failure)
      • Service provision to client/customer
      • Internal controls
      • Regulatory requirements
    • What should success look like for any specific or all RCA’s?
    • How can we measure success of the RCA initiatives?
    • What controls can/do we have in place to measure RCA impacts?
    • How to handle failures that don’t meet a trigger point.

These questions and others must be addressed as part of your company’s RCA program implementation.  The mission and aim of the RCA Program should be a clear and integral part of your overall culture that’s demonstrated within each RCA Event.  The participants of the RCA should understand clearly the scope, aim, and full deliverables of the RCA; otherwise the probability of success of any specific analysis and the overall program could diminish.  This is necessary because resources are limited and typically have a full plate of responsibilities in their daily activities.

A very important hurdle to address prior to moving forward in an RCA is asking the question ‘Should we do an RCA?’  Any investment of resources (costs, materials, time, personnel) will most certainly become a drain on the company if the prospect of doing the RCA will not reap the benefits of reduced occurrence of failures.  Having a toll gate in your RCA program at this point helps to ensure unnecessary work and resources are not expended as you move forward to the next stage.


The ‘Do’ step in the cycle involves two distinct sub-steps:

Info & Analysis

    • Evidence Collection – interviews, actuarial data, and visual evidence.
    • Method Analysis – apply the evidence collection to the RCA methodology utilized within your organization.  Use only facts at this stage and avoid opinions.
    • Gap/Causal Factors – clearly document all events, data, and other information identified as contributors to the failure that spurred the RCA event.   Look for causal factors in the areas of:
      • Physical
      • Human
      • Latent (Procedural)
    • Hypothesis - summary of probable events that cause failure to occur.  RCA must be based upon causal factors, physical evidence, and in alignment with the laws of physics.
    • Recommendations – clearly document the advised actions needed in order to prevent or reduce the frequency of occurrence for the failure.  The recommendations must be detailed and in direct alignment with causal factors.  Recommendations must be endorsed and approved by Leadership in order to gain the necessary resources to implement.
    • Picture Success – Before moving to the next stage of Do, it is vital to have a clear means to measure and visualize the level of success of the recommendations approved.  This can come in many forms (failure data, costs, resource allocation trends, etc) but is a must if your recommendations to be implemented align with actual, measured performance indicators.

Work Management

      • Plan – a detailed procedure is needed to ensure the recommendation is accurately and competently carried out to its full intent
      • Schedule – the activity to accountable parties and provide sufficient time to accomplish the task
      • Execute – physically implement the recommendation
      • Document – capture actions taken, observations made, actual information in conducting the work (time spent, materials consumed, tools used)
      • Validate Measures – ensure the means to track and measure every approved recommendations are in place
      • Communicate – provide information to all stakeholders on the status of action taken items implemented


At defined periods of time, a process check should be made to:

  • Review status of approved recommendations
  • Work to clear any roadblocks that have prevented recommendations from being implemented
  • Compare desired outcome of implemented actions to the actual outcome
  • Determine if more time is needed to analyze the impact of desired versus actual This is important as some patience may be needed in some cases whereas immediate countermeasures are needed in others
  • Conduct follow-on analysis and action items for those items not meeting desired outcome
  • Identify any actions taken that can be leveraged in other departments and business processes



The Act Stage should be utilized to:

  • Communicate to all Stakeholders – The current status of the RCA Event.  This is not a stopping point but rather a means to inform all parties of where things stand.  This communication should highlight both success and shortcomings (along with gap closure actions) for the RCA.
  • Publish – The state of the RCA must be pushed to all resources within the organization in order to learn from the analysis as well as provide any input that can be used to close gaps.
  • Leverage – Act on any learnings that can be implemented for beneficial results.
  • Improve – Find ways to continuously enhance all means of the RCA program. This can be anything from improving the means in which evidence is collected, to streamlining analyses time and clarifying actions to implement for the workforce.

Root Cause Analysis is a continuous improvement effort that should be leveraged as a means to permanently fix failures rather than trying to fix the same thing constantly.