Certain issues in most engineering phenomena tend to reoccur in the future. As a result, there is a need for a systematic approach to be followed in identifying such eventual concerns and developing a plan to prevent their recurrence in the future. In such a case, root cause analysis is the best systematic strategy to take. Most businesses react to situations that require quick fixes. Nevertheless, because these firms are always reliant on quick repairs, employees are frequently obliged to perform the same work of resolving emergent difficulties in order to maintain the status quo (Horev 90). Hence dwelling on the short-term solutions may not always give satisfactory results for increased returns and organizational growth. This paper, therefore, elucidates briefly how the Root Cause Analysis is implemented in solving various problems on a long-term basis.
Root Cause Analysis
Root Cause Analysis tool is simply designed to assist the investigators in describing the exact incidence that occurred and the manner in which it. For instance, when the staffs spend most of their time extinguishing workplace fires, there may be an illusion of how busy people are accomplishing their tasks. The aspect of working faster and harder allows the energy and rhythm of the environment to deceit the workers on how they are working to their level best to increase efficiency and productivity. However, this is not true due to the diminishing returns law. The productivity and efficiency cannot be increased by working harder only. However, analyzing critically beyond the observable factors, to determine the root cause can result in an enhanced efficiency and improved profitability. Through a structured approach, then Root Cause Analysis gives a high level of confidence that the solution to the underlying problem would be achieved (Robitaille 33).
Further steps undertaken in this analysis are explained in detail. Usually, a timeline for various events is typically set to assist in the identification of the sensitive areas that may be the primary source of the problem or the event, as well as the establishment of the relationship between the factors found to be the reason for the occurrence and the causal factors. Therefore the Root Cause Analysis is a practical method of addressing non-conformance or a problem with the aim of getting the "Root Cause" of the problem (Robitaille 34). It helps in the correction or elimination of the cause, and after that preventing the recurrence of the problem.
Root Cause Analysis constitutes a well-defined process. The operation begins with problem identification and definition, then understanding the problem to identify the major cause, the development of a corrective action, and finally monitoring the system. The four significant steps of Root Cause Analysis are; data collection, Causal factor Charting, root cause identification, and generation of recommendation and implementation (Vanden 55).
In the first step, the event is identified, and data is gathered to provide enough preliminary information on the event and causal factor to aid in the identification of the root causes.
This is where the majority of time is spent as far as RCA is concerned since detailed information of the sequence of events is needed. The events subject to investigation are obtained from various sources such as risk management referral, incident report, resident, staff, and others. The events that led to significant harm or death are prioritized. Similarly, "close to call" or "near miss" events are also considered under the highly prioritized events (Okes 15).
The second step involves Causal factor charting which provides an investigative structure for organizing and evaluating the collected information in order to identify the existing knowledge gaps and deficiencies as the investigation process continues.
The preparations of this chart commence immediately the investigators start to gather the data and information concerning the event. A skeleton chart is normally drawn with the most relevant information included and modified in case any is left uncovered. Usually, this chart should drive the process of data gathering through identification of necessary needs. Moreover, the use of causal factors charting techniques provides a structured and systematic framework that helps in the collection of detailed information by ascertaining the existence of gaps in comprehending of the underlying chain of events. The aforementioned sequencing techniques work best in ascertaining critical actions and events, when used along with other methods such as Fault Tree Analysis, Change Analysis, and Barrier Analysis.
The investigators continue with the data gathering process until the chart becomes thorough.
After charting out all the occurrences, then the investigators can proceed with the identification of causal factors which are the major contributors to the events. The causal factors are defined as the contributors, mainly component failures and human errors that, if eradicated, would either prevent the occurrence or lessen the severity of the occurrence (Vanden 56). Traditionally, the causal factors which were visible were accorded a lot of attention. However, most of the events are usually caused by a combination of several causal factors. Therefore all the causal factors are traditionally looked at holistically and not singly (Okes 16).
The third step mainly involves identification of the root cause.
This step entails massive utilization of decision diagram generally referred to as Root Cause Map to help in the identification of the core reasons for every causal factor. The contributing factors are usually the ones that are examined to trace the root causes. This decision map usually structure the investigator's reasoning process since it helps them to be able to answer questions on particular causal factors occurrence or existence. The investigator repeatedly poses "why" questions pertaining the contributing factors. This identification helps the investigator establish the exact reasons as to why specific events occurred and the problems surrounding them (Forck and Kristen 43).
Apart from the why questions, an investigator may also use the Pareto principle which involves the performance of 20% of the work that can produce 80% of the advantage of the entire job done.
This Pareto analysis is a formal technique that mainly involves identification of the changes that would yield the highest benefits. This analysis is fundamental in the situations where the courses of actions compete for the investigator's attention and hence need for prioritizing.
The fourth step mainly entails generation and implementation of the necessary recommendation.
Once the investigator has identified the root cause for a given causal factor, then the attainable recommendation applicable for the prevention of its reappearance is then generated. The analyst or investigator is not the one responsible for the recommendation implementation. However, failure to implement these recommendations, then all the efforts of the analyst go to waste (Horev 91-92). Therefore the events that prompted the analysis have a likelihood of reoccurring. Thus, there should be a strict follow-up on the recommendations to ensure they are implemented.
There is always a need for corrective actions in this step.
Some of the corrective actions intended to change the system and reduce the tendency of the errors are normally the strongest (Andersen and Tom 6). These strongest activities include, Engineering controls incorporated into the system; standardization of the process or equipment; changing of physical surroundings; simplification of the process and elimination of some unnecessary steps; and testing of devices' usability prior purchasing. The standard corrective actions include software modifications or enhancement; elimination or reduction of distraction; enhanced communication or documentation; cognitive or checklist aid; decrease in workload or increased staffing; and "Read back" to guarantee clear communication. The weakest corrective actions include training, double checks, warnings and labels, new procedure or policy or memorandum, and additional analysis or study (Andersen and Tom 6-7)
Mechanisms to collect the data for gauging the success of the aforementioned corrective actions are established concomitantly with the implementation of those action plans.
To evaluate whether those ideas are successful, one considers on whether the goal was achieved regarding the changes in the process and the recurrence of events. If the analyst becomes confident that the change is permanent then, the Root Cause Analysis was a success (Andersen and Tom 8).
Conclusion
In the RCA presentation, Fault Tree may be used as a graphical representation which offers description backed up by several combinations of possible happenings in a given system. Furthermore, Fault Tree has a possibility of producing undesirable outcomes combining the human and system failures. The arrangement of such faults may be from top to bottom or even right to left depending on the preferences of the analysts. Therefore, Fault Tree Method complements Root Cause Analysis in ascertaining events and actions that are critical especially in engineering applications.
Works Cited
Andersen, Bjorn, and Tom Fagerhaug. Root Cause Analysis: Simplified Tools and Techniques. Milwaukee, Wis: ASQ Quality Press, 2016, pp. 6-10.
Forck, Fred, and Kristen Noakes. Cause Analysis Manual: Incident Investigation Method & Techniques. , 2016, pp. 42-40.
Horev, Menachem. Root Cause Analysis in Process-Based Industries. Victoria, BC: Trafford, 2012, pp. 90-100.
Okes, Duke. Root Cause Analysis: The Core of Problem Solving and Corrective Action. Milwaukee, Wiz: ASQ Quality Press, 2009, pp. 15-22.
Robitaille, Denise. Root Cause Analysis: Basic Tools and Techniques. Chico, CA: Paton Press LLC, 2014, pp. 30-40.
Vanden, Heuvel L. N. Root Cause Analysis Handbook: a Guide to Efficient and Effective Incident Investigation, Third Edition. Brookfield, Conn: Rothstein Associates Inc., 2013, pp. 54-62.
