RCA is a part of Problem Management and basic tool for Problem and Error Control.
This document should help you to understand Root Cause Analysis more closely
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2. Scope:
•Problem control, error control and proactive Problem Management are all within the
scope of the Problem Management process. In terms of formal definitions, a
'Problem' is an unknown underlying cause of one or more Incidents or of a Major
Incident, and a 'Known Error' is a Problem that is successfully diagnosed and for
which a Work-around or FIX has been identified.
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3. Input and Output of Problem Management
Inputs:
• Incident details from Incident Management
• Configuration details from (CMDB)
• Any defined Work-around (from Incident Management).
Outputs:
• Known Errors
• A Request for Change (RFC)
• An updated Problem record (Work-around / Fix)
• for a resolved Problem, a closed Problem record
• Response from Incident matching to Problems and Known Errors
• MIS
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4. Root Cause Analysis – Review by Application Owners
RCA provided by
PM team
Problem
Sent to the
and Error
Application
Control
owners
(slide 5)
RCA analysis by
application
owners
Approved Yes
No
Request to PM team for rectified
RCA based on App owners
recommendations
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5. Problem & Error Control
PM
Problem
Identify and Record
Identification and
Error
Recording
Problem
Asses Errors
Classification
CM
Problem
Record Error
Investigation and
Resolution RFC
Diagnosis
Root Cause Detected Close Error
record and
KEDB Associated Change successfully
Updated Problem(s)
Implemented
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6. Root Cause Analysis - a REACTIVE method of identifying event(s) causes
General principles of RCA:
• To be effective, RCA must be performed systematically, and root
causes identified backed up by documented evidence.
• There may be more than one RC for an event or a problem
• The purpose of identifying all solutions to a problem is to prevent
recurrence at lowest cost in the simplest way, the simplest or
lowest cost approach is preferred.
• To be effective, the analysis should establish a sequence of events
or timeline to understand the relationships between contributory
(causal) factors, root cause(s) and the defined problem or event to
prevent in the future.
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7. Root Cause Analysis - evaluation
1st : Is it readable?
If it is readable it will be grammatically correct, the sentences will
make sense, it will be free of internal inconsistencies, terms will be
defined, it will contain appropriate graphics, and the like.
2nd : Does it contain a complete set of all of the causal relationships?
If it did contain a "complete set of all of the causal relationships"
one could (at least):
◦ 1. Trace the causal relationships from the harmful outcomes to
the deepest conditions, behaviors, actions, and inactions.
◦ 2. Show that the important attributes of the harmful outcomes
were completely explained by the deepest
conditions, behaviors, actions, and inactions.
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8. Root Cause Analysis – Level of Causes
Physical cause – Specific physical item that if corrected/replaced would fix
the problem
System cause – Possible underlying cause of physical failure
Problem
sympto
ms
Physical
cause
System
cause
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9. Root Cause Analysis – Barriers
Cognitive laziness – Instead of taking the optimum result, we take the
first sufficient result
Overconfidence – perusing evidences supporting our own belief rather
than allowing the idea to represent the truth
Recency bias – Assume the same cause for two recent problem
symptoms and therefore not performing a more rigorous investigation
Availability bias – Rely on available data rather than collecting /
gathering more relevant or reliable data
Anchoring bias – latching on to the first data and its indication while
ignoring possibility conflicting evidence
Confirmation bias – Looking for and accepting only data that confirms
our preexisting assumption of the cause
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10. Root Cause Analysis – 7 Step problem solving model
Identify the List possible ID most likely
Problem Root causes Root cause
Select and
Evaluate effect ID potential
Implement
of solution solutions
solution
Standardize
process
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11. Root Cause Analysis – Use 5 Why’s to understand the issue
5 Why’s Problem: Car will not start
This is the simplest method to Why: Dead battery
find out the Root cause
Why: Bad alternator
Drill deeper into problem until
a Root cause is found Why: Alternator’s belt broken
Why: Belt achieved end of life
Why: Recommended maintenance
not performed
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