JOURNAL OF ENGINEERING MANAGEMENT AND COMPETITIVENESS (JEMC)

Vol. 1, No. 1/2, 2011, 16-20

EFFECTIVE ROOT CAUSE ANALYSIS AND CORRECTIVE ACTION

PROCESS

Branislav TOMIĆ1, Vesna SPASOJEVIĆ BRKIĆ2

1
Bombardier Aerospace, Toronto, Canada.
2
University in Belgrade, Faculty of Mechanical Engineering, 11000 Belgrade, Kraljice Marije 16, Republic of Serbia.
Corresponding author. E-mail: [email protected]

Accepted 11 October, 2011

Root Cause Analysis and Corrective Action process are absolutely essential for the improvement of
the quality management system and increasing the quality of the final product or service. This
article has intention to briefly highlights the major steps that should be taken in the right sequence
in order to successfully and permanently resolve any problem from problematic process. It has two
major areas which are mutually interrelated and cannot function without each other – root cause
analysis and corrective action process. The first one serves the purpose to detect the right root
cause of the problem which is the source of the issues and the other one is a set of actions to
permanently eliminate the root cause with the proposed solutions that directly attack it in order to
completely remove it from the process.

Keywords: root cause, corrective action, effectiveness, process

INTRODUCTION Identifying root causes is the key to preventing

similar recurrences. An added benefit of an effective
Root Cause Analysis and Corrective Action Process RCA is that, over time, the root causes identified
is a set of steps, in certain sequence, to identify, across the population of occurrences can be used to
detect the cause and successfully rectify the issues target major opportunities for improvement. If, for
that have been experienced in any field of example, a significant number of analyses point to
manufacturing or servicing systems. procurement inadequacies, then resources can be
focused on improvement of this management
Root cause analysis (RCA) is a process designed for system. Trending of root causes allows development
use in investigating and categorizing the root causes of systematic improvements and assessment of the
of events with safety, health, environmental, quality, impact of corrective programs. Effective RCA
reliability and production impacts. The term “event” process serves the purpose to find the root causes of
is used to generically identify occurrences that unwanted event and facilitating effective corrective
produce or have the potential to produce these types actions to prevent recurrence.
of consequences. Simply stated, RCA is a tool
designed to help identify not only what and how an Corrective Action (CA) is an action that
event occurred, but also why it happened. Only organization should take to eliminate the root cause
when investigators are able to determine why an of nonconformities in order to prevent recurrence.
event or failure occurred will they be able to specify Corrective actions have to be appropriate to the
workable corrective measures that prevent future effects of the nonconformities encountered.
events of the type observed. Understanding why an Corrective action process should review
event occurred is the key to developing effective nonconformities, determine the causes of
recommendations. Usually RCA has got mixed with nonconformities, evaluate the need for action to
the accurate description of what happened and how ensure that nonconformities do not occur, determine
it happened. However, if the analysts stop there, it is and implement action needed, record the results of
not probed deeply enough to understand the reasons taken action, review taken corrective action,
for the problem. Therefore, it is not known what to flowdown the corrective action requirements if
do to prevent it from occurring again. required to the place of problem’s origin, and take
specific actions where timely and/or effective

ISSN 2217-8147
©2012 University of Novi Sad, Technical faculty “Mihajlo Pupin” in Zrenjanin, Republic of Serbia
Available online at http://www.tfzr.uns.ac.rs/jemc
 JOURNAL OF ENGINEERING MANAGEMENT AND COMPETITIVENESS (JEMC) 17

corrective actions are not achieved. In other words, specific enough to allow management to make
CA is a process of identification and elimination of effective changes. Management needs to know
the root causes of a problem, thus preventing its re- exactly why a failure occurred before action can be
occurrence. taken to prevent recurrence. It is also important to be
identified a root cause that management can
Establishing a corrective action process includes influence.
also steps how to effectively determine where action
is needed, how to quickly assemble a knowledgeable 4. Root causes are those for which effective
and capable team to work on the case, and recommendations can be generated.
predictably produce results and improvements Recommendations should directly address the root
within the imposed or acceptable time frame causes identified during the investigation. If the
(Ingram, 1997) analysts arrive at vague recommendations such as,
“Improve adherence to written policies and
ROOT CAUSE ANALYSIS procedures,” then they probably have not found a
basic and specific enough cause and need to expend
It’s very hard to precisely define the term root cause. more effort in the analysis process.
There is a substantial debate on the definition of the
root cause, but these four cover all aspects of this The RCA is a four-step process involving the
phenomenon (Rooney and Heuvel, 2004): following:
1. Root causes are specific underlying causes of 1. Data collection.
observed problem; 2. Causal factor charting.
2. Root causes are those that can reasonably be 3. Root cause identification.
identified and therefore fixed; 4. Recommendation generation and
3. Root causes are those states that depend on implementation.
management and management has control to fix
them; 1. Step one - Data collection. The first step in the
4. Root causes are those for which effective analysis is to gather data. Without complete
recommendations for preventing recurrences can information and an understanding of the event, the
be generated and hence eliminate the effect that causal factors and root causes associated with the
they produce. event cannot be identified. The majority of time
spent analyzing an event is spent in gathering data.
1. Root causes are underlying causes of observed
problem. The investigator’s goal should be to 2. Step two - Causal factor charting. Causal factor
identify specific underlying causes called root charting provides a structure for investigators to
cause(s). The more specific the investigator can be organize and analyze the information gathered
about why an event occurred, the easier it will be to during the investigation and identify gaps and
arrive at recommendations that will prevent re- deficiencies in knowledge as the investigation
occurrence. progresses. The causal factor chart is simply a
sequence diagram with logic tests that describes the
2. Root causes are those that can reasonably be events leading up to an occurrence, plus the
identified and therefore fixed. Occurrence conditions surrounding these events. Preparation of
investigations must be cost beneficial. It is not the causal factor chart should begin as soon as
practical to keep valuable manpower occupied investigators start to collect information about the
indefinitely searching for the root causes of occurrence. They begin with a fishbone chart that is
occurrences. Structured RCA helps analysts get the modified as more relevant facts are uncovered. The
most out of the time they have invested in the causal factor chart should drive the data collection
investigation. The good representative of this process by identifying data needs. Data collection
approach is Kepner-Tregoe’s technique, when not continues until the investigators are satisfied with
the best but optimal root cause is sufficient and the the thoroughness of the chart (and hence are
most economical way to resolve the problem. satisfied with the thoroughness of the investigation).
When the entire occurrence has been charted out, the
3. Root causes are those states that depend on investigators are in a good position to identify the
management and management has control to fix major contributors to the incident, called causal
them. Analysts should avoid using general cause factors. Causal factors are those contributors (human
classifications such as operator error, equipment errors and component failures) that, if eliminated,
failure or external factor. Such causes are not would have either prevented the occurrence or
18 Tomić and Spasojević Brkić

reduced its severity. In many traditional analyses, 2. Implement effective corrective action that will
the most visible causal factor is given all the eliminate identified root cause(s) of the problem.
attention. Rarely, however, is there just one causal
factor; events are usually the result of a combination This two-step approach may appear deceptively
of contributors. When only one obvious causal simple but people frequently underestimate the
factor is addressed, the list of recommendations will effort that is needed to find the real root cause of the
likely not be complete. Consequently, the problem. This is the major obstacle in successful
occurrence may repeat itself because the root cause analysis and corrective action process
organization did not learn all that it could from the since the incorrect root cause(s) may mislead the
event. team to implement inadequate corrective action(s)
and not to achieve the effect that is needed, so the
3. Step three - Root cause identification. After all problem will appear again and again.
the causal factors have been identified, the
investigators begin root cause identification. This According to Performance Review Institute (2006)
step involves the use of a decision diagram to the Root cause analysis represents the squared part
identify the underlying reason or reasons for each of the following flow chart for the entire root cause
causal factor. The diagram structures the reasoning corrective action process (Figure 1).
process of the investigators by helping them answer
questions about why particular causal factors exist or CORRECTIVE ACTION
occurred. The identification of root causes helps the
investigator determine the reasons the event Corrective action (CA) is a simply solution meant to
occurred so the problems surrounding the reduce or eliminate an identified problem.
occurrence can be addressed. Corrective Action is defined as an action that
organization should take to eliminate the root cause
4. Step four - Recommendation generation and of nonconformities in order to prevent recurrence.
implementation. The next step is the generation of
recommendations. Following identification of the Corrective Action can also be thought of as
root causes for a particular causal factor, achievable sustaining, as you can not prevent the event at this
recommendations for preventing its recurrence are juncture, it has already happened. Actions taken now
then generated. The root cause analyst is often not are to prevent recurrence of the event. They focus on
responsible for the implementation of breaking the cause chain completely by fixing the
recommendations generated by the analysis. contributing causes and the root cause. A
However, if the recommendations are not contributing cause, if not addressed, could be a
implemented, the effort expended in performing the future root cause. Corrective Action is a series of
analysis is wasted. In addition, the events that actions that positively change or modify system
triggered the analysis should be expected to recur. performance. It focuses on the systemic change and
Organizations need to ensure that recommendations the places in the process where the potential for
are tracked to completion. The important step in failure exists. Corrective Action does not focus on
resolving any issue is assembling appropriate team individual mistakes or personnel shortcomings.
of specialist that will with synergetic effect
contribute to the final resolution. According to Lee In determining solutions it is necessary to consider
et al. (2010), in the team shouldn’t be the individuals the following:
who have one or more the following characteristics: 1. Feasibility: The solutions need to be within the
1. People too close to the incident company’s resources and schedule;
2. People who do not have sufficient time to 2. Effectiveness: The solutions need to have a
participate in the RCA process reasonable probability of solving the problem;
3. People who “already know the answer” 3. Budget: Solution costs must be within the budget
4. People positioned too high up in the management of the company and appropriate for the extent of
the problem;
Andersen and Fagerhaug (2009) state that beneath 4. Employee Involvement: The departments and
every problems lies a cause for that problem. personnel affected by the problem need to be
Therefore, when trying to resolve the problem, the involved in creating the solution;
simple approach should be taken: 5. Focus on Systems: The solutions should be
1. Identification of the root cause(s) of the problem focused on systemic issues;
and 6. Contingency Planning: All solutions are
developed with a certain expectation of success.
 JOURNAL OF ENGINEERING MANAGEMENT AND COMPETITIVENESS (JEMC) 19

considerations when selecting the best alternative.

Effective corrective action according to Beecroft et They consider the extent to which:
al. (2003) includes the selection of one solution until − A particular alternative will solve the problem
several alternatives have been proposed. Having a without causing other unanticipated problems;
standard with which to compare the characteristics − All the individuals involved will accept the
of the final solution is not the same as defining the alternative;
desired result. A standard allows evaluating the − Implementation of the alternative is likely;
different intended results offered by alternatives. − The alternative fits within the organizational
When it’s tried to build toward desired results, it’s constraints.
very difficult to collect good information about the
process. Considering multiple alternatives can Managers or team leaders may be called upon to
significantly enhance the value of final solution. order the solution to be implemented by others,
Once the team has decided the “what should be” “sell” the solution to others or facilitate the
model, this target standard becomes the basis for implementation by involving the efforts of others.
developing a road map for investigating alternatives. The most effective approach, by far, has been to
Brainstorming and team problem-solving techniques involve others in the implementation as a way of
are both useful tools in this stage of problem minimizing resistance to subsequent changes.
solving. Many alternative solutions should be Feedback channels must be built into the
generated before evaluating any of them. A common implementation of the solution, to produce
mistake in problem solving is that alternatives are continuous monitoring and testing of actual events
evaluated as they are proposed, so the first against expectations. Problem solving, and the
acceptable solution is chosen, even if it’s not the techniques used to derive elucidation, can only be
best fit. If we focus on trying to get the wanted effective in an organization if the solution remains in
results it is missed the potential for learning place and is updated to respond to future changes.
something new that will allow for real improvement.
Skilled problem solvers use a series of

Figure 1: Flow Chart of the Root Cause Analysis and Corrective Action process (Performance
Review Institute, 2006)
20 Tomić and Spasojević Brkić

CONCLUSION documenting these steps will allow demonstrating

this compliance. All of these requirements are met
Root cause corrective action for non-conformances within a root cause corrective action process that
has long been a requirement in any industry. It is a addresses:
process of determining the causes that led to a − Containment actions;
nonconformance or event, and implementing − Problem definition;
corrective actions to prevent a recurrence of the − Root Cause Analysis;
event. The requirements for corrective action have − Possible Solutions and the selection of the right
been imposed by industry standards for decades and one(s);
while not new, may not have been aggressively − Assessment and Effectiveness of the RCCA
enforced. In order to be successful in this process, it process.
is necessary to implement the following steps:
− Establishment and maintenance of documented Root Cause Analysis and Corrective Action process
procedures for implementing corrective and are absolutely essential for the improvement of the
preventive action; quality management system and increasing the
− Corrective or preventive action taken to quality of the final product or service.
eliminate the causes of actual or potential
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