YOUNUS AHAMED SHAIK
Quaification : M.tech(EPS)
Certificates : Nebosh IGC,HABC IADT,IOSH, AGT & others.
Experience : HSE officer,Electrical Safety,Graphic designer,Site Engineer
ROOT CAUSE
The management system
breakdown that permitted the
substandard action or
condition (immediate cause)
to occur.
Root Causes may also be
referred to as System Causes
or Underlying Causes.
WHAT IS ROOT CAUSE
ANALYSIS (RCA)
Root cause analysis (RCA) is a method that is use to
address a problem or non-conformance , in order to get
the “root cause” of the problem. It is used so we can
correct or eliminate the cause, and prevent the problem
from occurring.
A STANDARD PROCESS OF:
Identifying a problem containing and analyzing the problem
Defining the root cause
Defining and implementing the actions required to eliminate the root cause
Validating that the corrective action prevented recurrence of problem
Identifying a problem Define root cause implementing the actions Validating the action
IDENTIFYING THE PROBLEM
When problem solving, identify the
causes of the problem in order to
solve it.
Identify causes of the problem
Look at the current situation, rather
than its history
Do not consider the "trouble" it
creates whether now or in the future.
List and organize the causes of the
problem
DEFINING THE PROBLEM
CONSIDER THESE QUESTIONS
What is the problem?
If this is an old problem, what's wrong with the previous solution?
Does it need an immediate solution, or can it wait?
Can I risk ignoring it?
Does the problem have ethical dimensions?
Causes!
problem? limmediate solution ? Problem dimensions ?
DEFINING THE ROOT CAUSE ANALYSIS
Principles in defining Root Cause
Analysis;
Specific
Measurable
Actions oriented
Realistic
Time constrained
ROOT CAUSES OF THE INCIDENT CAN BE IDENTIFIED FROM
THE FOLLOWING;
People
Resources
Environment
Processes, procedures and rules
Vocabulary/terminology/concepts
Check the information, obtaining real data regarding the problem
gaining a clear understanding of the issues.
PEOPLE
Due to individual unsafe acts / behavior
Due to incompetency /unskilled workers
Due to lack of trainings
Due to horse playing, etc.
individual behavior incompetency lack of training horseplay
RESOURCES:
Due to lack of equipment’s to use
Due to lack of skilled workers to perform the specific task
Due to lack of appropriate tools to use
Due to lack of appropriate PPE for the specific job, etc.
Lack of equipment Lack of skilled workers Lack of tools Lack of PPE
ENVIRONMENT:
Due to limited space or working environment
Due to unsafe working places , poor housekeeping, poor access and
egress
Due to simultaneous activities performing in one area
Due to extreme weather conditions ,i.e. heavy wind /sandstorm,
heavy rain, darkness (poor visibility),etc.
Limited work space Unsafe work place Simultaneous activities Extreme weather
PROCEDURES AND RULES:
Due to approved work procedures not followed
Due to procedures and rules not understand by workforce . Not
covered in TBT
Due to NO Hazards and Risk Assessment / JSA’s for the Job to
be perform
Due to approved Risk assessment / JSA’s not followed, etc.
Procedure not followed Ineffective TBT No risk assessment JSA not followed
VOCABULARY/TERMINOLOGY/CONCEPTS :
Due to poor communications
Due to Poor instructions
Due to multi lingual differences
Due to wrong interpretation/understanding , etc.
Poor communication Poor instruction Language barriers Wrong understanding
WHY DETERMINE ROOT CAUSE?
To prevent problems from recurring
To reduce possible injury to personnel
To reduce rework and scrap
To increase competitiveness
To promote happy customers and stockholders
To ultimately, reduce cost and save money
WHEN SHOULD ROOT CAUSE ANALYSIS BE PERFORMED?
SIGNIFICANT OR CONSEQUENTIAL EVENTS
REPETITIVE HUMAN ERRORS ARE OCCURRING DURING A SPECIFIC
PROCESS
REPETITIVE EQUIPMENT FAILURES ASSOCIATED WITH A SPECIFIC
PROCESS
PERFORMANCE IS GENERALLY BELOW DESIRED STANDARD
HOW TO DETERMINE THE REAL ROOT CAUSE ?
ASSIGN THE TASK TO A PERSON (TEAM IF NECESSARY)
KNOWLEDGEABLE OF THE SYSTEMS AND PROCESSES INVOLVED
DEFINE THE PROBLEM
COLLECT AND ANALYZE FACTS AND DATA
DEVELOP THEORIES AND POSSIBLE CAUSES - THERE MAY BE
MULTIPLE CAUSES THAT ARE INTERRELATED
SYSTEMATICALLY REDUCE THE POSSIBLE THEORIES AND
POSSIBLE CAUSES USING THE FACTS
HOW TO DETERMINE THE REAL ROOT CAUSE ?
CONTINUATION:
Develop possible solutions
Define and implement an action plan (e.g., improve communication,
revise processes or procedures or work instructions, perform
additional training, etc.)
Monitor and assess results of the action plan for appropriateness
and effectiveness
Repeat analysis if problem persists- if it persists, did we get to the
root cause?
RISK MATRIX WILL HELP IN DETERMINING RCA PROJECT IMPORTANCE
CORRECTIVE ACTION
Implement temporary counter measures at place of the problem.
Determine and prioritize the most probable underlying causes of
the problem as the temporary counter measures may not resolve
the root cause
Take corrective actions to at least mitigate or preferably eliminate
the causes.
THREE (03)TYPES OF CORRECTIVE ACTIONS
Immediate action – is the action taken to quickly fix the impact of the
problem so the “customer” is not further impacted
Permanent root cause corrective action- is the action taken to eliminate
the error on the affected process or product
Preventive (Systemic) root cause corrective action- is the action taken to
Prevent the error from recurring on any process or product
CORRECTIVE ACTION
Solutions to prevent incident / accident:
Provide skilled / trained workers to perform the specific task.
Provide competent supervision
Provide appropriate equipment’s / tool’s
Provide appropriate PPE
Provide appropriate trainings to all personnel's
Provide a safe working environment
Follow the approve methodology of work ,JSA’s
Disseminate information (i.e. SDS , new methodology of work, etc.) to
workforce
Provide a recommended precautionary measures to eliminate /prevent the
presence of hazard and risk
Proper communication and supervision ,etc.
PROBLEM SOLVING PROCESS
WHAT DOES GOOD RCA LOOK LIKE?
TO BE THOROUGH A ROOT CAUSE ANALYSIS MUST INCLUDE:
Determination of human & other factors.
Determination of related processes and systems Analysis of underlying
cause and effect systems through a series of why questions
Identification of risks & their potential contributions
Determination of potential improvement in processes or systems
Human factor Why factor Identify risks Improvements
MONITOR THE SYSTEM
CONTROL MEASURES:
Review the Risk assessment Identify the hazards present at
work location
Review the JSA’s and ensures it is in
accordance with the work Conducts continuous education through
awareness training to workforce and
Review previous incidents root
supervision.
causes and corrective actions
Conducts a regular safety Audit Ensures a safe working environment ,
/Inspections at work location good housekeeping, etc.
Conducts regular safety monitoring
and strict implementations of safety
procedures , policies and guidelines.
EXAMPLE OF ROOT CAUSE ANALYSIS (RCA)
IDENTIFY PROBLEM
A manager walks past the assembly line and notices a puddle of water on
the floor. Knowing that the water is a safety hazard, she asks the supervisor
to have someone get a mop and clean up the puddle. The manager is proud
of herself for “fixing” a potential safety problem
IMMEDIATE ACTION
Knowing that the water is a safety hazard, the manager asks the supervisor to
have someone get a mop and clean up the puddle
BUT WHAT IS THE ROOT CAUSE?
The supervisor looks for a root cause by asking
‘WHY?’ PUDDLE OF WATER ON FLOOR
LEAK IN OVERHEAD PIPE
WATER PRESSURE IS SET TOO HIGH
WATER PRESSURE VALVE IS FAULTY
VALVE IS NOT IN A PREVENTIVE MAINTENANCE
PROGRAMFAULTY
