The document discusses root cause analysis (RCA) as a systematic methodology for identifying underlying causes of adverse events to prevent their recurrence. It introduces concepts such as different layers of causal analysis, the significance of critical thinking in problem-solving, and presents the 'Apollo root cause analysis' approach, emphasizing a continuous exploration of causes and effects. The document outlines a structured RCA process including problem definition, analysis, and solution identification to enhance effective problem resolution.

1. Root Cause Analysis-
Methodology
Sandeep Gupta
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2. Root Cause Analysis
Root Cause Analysis is a systematic process
• Which helps
in identification of causes behind an adverse event
• In a way
that causes so identified are root causes not mere immediate obvious causes
or symptoms
• Normally applied to
Analyze past adverse events
• With an objective to
find out solutions to prevent recurrence of adverse event in future
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3. 3
Root Cause Analysis

4. 4
Roots Lies in different Layers
Causes themselves may root from
some other deeper / latent causes
Primary -
Physical Cause
Secondary - Causes
related human Errors
Tertiary - Causes
related to System
deficiencies / policies
Root Cause Analysis

5. Let us ask ourselves a couple of questions ?
1. Are we really interested ONLY in finding out root
cause ?
2. Should we really be interested ONLY in finding
out root cause ?
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Root Cause Analysis

6. In most of the cases our reply to these questions is a
“Yes”
But this “Yes” itself limits our capability to get to
“RIGHT” root causes?
Why ??
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Root Cause Analysis

7. Because
if we try to get to root causes only, we generally end up with “GENERIC” root
causes
- the root causes which can not be acted upon to prevent recurrence of problem
However
Our ultimate objective is NOT to find out the root causes of the problems
(adverse events already occurred)
Rather
It is to find out the solution(s) so that the same problem do not recur
Hence
we should reach up to those causes of the adverse event which could be
controlled with our actions (solutions)
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Root cause Analysis Problem Solving
Root Cause Analysis

8. Questions which come into everybody’s mind
• Why we need to be trained separately in problem solving
techniques when we know our subjects very well ?
• What exactly problem solving / root cause analysis skill is and
how it can help me ?
• Doesn’t this skill come naturally to all intelligent persons ?
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Root Cause Analysis

9. The way we think of a problem, is in itself, a deciding factor
for possibility of getting solution(s) as outcome
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Root Cause Analysis

10. What is wrong with our usual way of thinking ?
We assume some MYTHS as REALITY
• Myth : There is a single root cause for each problem. A linear
relationship exists between “Focus Event” and “Root Cause” ( 5 why
method)
• Myth : Believe in existence of “prime root cause” which is not
preceded by any other cause. There is an end point to “cause and
effect” chain.
• Categorical, “fitting into pattern” thinking instead of critical
thinking. Tendency to categorize causes into fixed types, patterns,
stereotypes which we have learned through our experience
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Root Cause Analysis

11. What is wrong with our usual way of thinking ?
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Passing the buck to someone
The buck stops here
Root Cause Analysis

12. What is wrong with our usual way of thinking ?
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Illusion of common sense / being too obvious
• Too obvious to question / to ask for further detail
• Perception that “what is being viewed by me” is the “only
absolute & complete reality” and is also being viewed by
others in same way
Root Cause Analysis

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Everything happens due to a reason (cause). Nothing happens on
its own “by chance”.
The notion of causality (cause and effect) is fundamental to our
quest for understanding of events happening around us. Modern
science had evolved around the same basic principle of “cause and
effect”
Around 350BC, Greek philosopher Aristotle said that there are four
types of causes (explanatory factors) behind everything we see
around us
Root Cause Analysis

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Aristotle’s doctrine of four causes in metaphysics
Root Cause Analysis

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Modern interpretation of cause and effect principle
Root Cause Analysis

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Modern interpretation of cause and effect principle
Necessary elements of cause and effect relationship between two events
Root Cause Analysis

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This modern interpretation of “Cause and effect” principle is adapted by Dean
L. Gano for investigating event based problems occurring in industries or
elsewhere.
Adaptation of this basic “cause and effect” principle is given the name of
“Apollo Root cause analysis”. There are four basic premises of this principle
1. Cause and effect are same thing
2. Causes and effects are part of an infinite continuum of causes
3. Each effect has at least two types of causes – contributing
conditions and trigger action
4. An effect exists only if its causes exist at the same point in
time and space
Root Cause Analysis

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Premise 1 : Cause and effect are same thing
The same event can be seen as “effect” of its predecessor event and “cause”
of its successor event. They are like two faces of the same coin.
Root Cause Analysis
Effects Causes
Pain Caused By Injury
Injury Caused By Fall
Fall Caused By Oil on surface
Oil on surface Caused By Leakage from oil pump
Leakage from oil pump Caused By Shaft Seal failure
Shaft Seal failure Caused By Oil seal not changed
from last two years

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Premise 2 : Causes and effects are parts of an infinite continuum of causes.
We always start with an effect (having adverse consequences), that we want
to prevent from recurring. We continue to identify causes, till the time, we
reach at a point, where we can not find answers to question “why”. This point
is called “point of ignorance”
The effect, where we start at, is called “primary effect” or “Focus Event”
Which effect should be considered as primary effect depends on our
perspective. Primary effect is a point in the “cause –effect” chain, where we
choose to focus and begin asking “why”
Root Cause Analysis
Perspective Objective behind RCA Primary effect
Safety engineer To prevent recurrence of similar injury Injury
Maintenance
engineer
To prevent recurrence of pump seal
failure
Seal failure

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Root Cause Analysis
The more we know, the more we
realize that we don’t know.
As every time we ask “why”, and
proceed along a cause path, we
come to our point of ignorance.
At this point, we no longer have
answers, but that is only due to
limitation of our knowledge &
understanding of the phenomena
in hand.
This premise says that each cause
effect chain extends up to infinity;
hence denies the existence of
“Absolute root cause”

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Root Cause Analysis
Within one set of effect-causes there exist more effect-cause sets.
The more deeply we understand relationship between the effect and
its cause, more we discover intermediate causal sets, called baby
steps
Every causal relationship can be broken into smaller and smaller
pieces with each shortening of the reference time frame. They are
there, but are forgotten or unknown to all observers.
Baby steps are found by looking between the causes, but they are
often elusive. The more we ask why, the closer we get to
understanding specific causal relationships; but the fact is, we will
never know all of them.

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Root Cause Analysis

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Premise 3 : Each effect has at least two types of causes – contributing
conditions and trigger action.
Action causes are causes that interact with conditions to cause an effect.
Conditions are causes that exist in time prior to an action bringing them
together to cause an effect
Action causes are most easily recognized whereas condition causes are
normally ignored either these being too trivial, too obvious or our lack of
understanding of that phenomena
Root Cause Analysis

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Root Cause Analysis
“Why Open Fire?” we see that three
condition al causes exist in the form of
1. Match Exists
2. Combustible Material Exists and
3. Oxygen Present.
However the fire is created only at the
moment the match strike occurs.
In this example, a match strike is the
action cause ; and as soon as that
match strike happens, we have a
fire.
It takes all three conditions and one
action for fire to happen.

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Premise 4 : An Effect Exists Only if Its Causes Exist in the Same Space and
time Frame.
Every effect, we observe in the physical world is caused by at least one action
cause coming together with existing conditional causes in the same relative
space.
A causal relationship is made up of conditional causes with a history of
existence over time combining with another cause in some defined time frame
to create an effect
The range of the “time and space frame” has to be judged with respect to type
of effect. If somebody throws a stone in this classroom and at the same time a
glass pane of car in USA gets shattered then it does not make “throwing
stone” a valid cause of “shattering pan“ in USA
Root Cause Analysis

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Root Cause Analysis
If all these causes did not exist at the same time frame and space, the spoon
would not have fallen. For example if
1. Had the spoon already been on the floor OR
2. The girl is sitting in a space shuttle where there is no gravity OR
3. If the girl had not freed it from her grip
At the same time frame and space, the effect of falling of spoon would occur
Effect : Spoon fell off on the floor from a little girl’s hand
while taking her dinner.
This effect has at least three causes
1. Gravity exists
2. The condition of holding the spoon at some height
exists
3. Her action of letting the spoon free from grip

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Root Cause Analysis

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Root Cause Analysis

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RCA should be performed as systematic investigation using an established RCA
method (Apollo Root cause analysis method) with the outcome of root causes
and solutions.
Root Cause Analysis
The RCA Process
Step Tasks to be performed
Define the
problem
Define the primary effect. Collect data and the facts of what
happened, where, when and significance.
Analysis &
Validation
Use Apollo RCA reality charting method to establish cause and effect
relationships. Validate the different causes with evidence
Find possible
solution
Identify the causes which can be acted upon to control them.
Identify as much solutions as possible ( A solution is a set of actions
which can be taken to remove a particular cause to prevent
recurrence of primary effect). Establish the best feasible solution(s).
Implement
solutions
Make action plan to implement solution with time line and
responsibility. Review the implementation status periodically

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Facilitator to define and state the problem (primary effect). Do not assume
that everybody in the room knows all the facts of the problem occurred.
Root Cause Analysis
The RCA Process – Define the problem

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A complete problem definition should include four elements
1. What is the problem ?
2. When did it happen ?
3. Where did it happen ?
4. What is significance of the problem ?
The what of the problem is the adverse consequence of the event. This is the
effect we do not want to recur. Hence we call it as primary effect. It is a
noun verb statement such as “kiln stopped”, “person injured”, fan stopped”
The when of the problem is time when the primary effect occurred.
The where of the problem is location of primary effect
The significance of the problem the value the primary effect has on the
organization.
Root Cause Analysis
The RCA Process – Define the problem

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Create and Apollo cause and effect chart
This has four steps
1. Start what caused the primary effect to happen
2. Look for causes in actions and conditions
3. Connect all causes with “caused by”
4. Support causes with evidence or use “?”
As causal relationship is developed, continue to ask and answer “why” until you either reach point
of ignorance or choose to stop.
Root Cause Analysis
The RCA Process – Analysis and validation

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Root Cause Analysis
The RCA Process – Analysis and validation
The action cause is expressed as noun ( computer) and verb ( failed).
The conditional causes are normally are of the form “ (noun) Exists” or “(noun)
present”
When expressing cause and effect relationships, we should always attempt to
follow these conventions.

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Root Cause Analysis
The RCA Process – Analysis and validation
Creating the Apollo cause and effect chart is an iterative process.
Follow “square One Loop”
It means follow a single cause path of Apollo cause and effect chart until collective
point of ignorance is reached, and then starting over again with the primary effect
(back to square one) and repeating the process
Each cause should be supported by evidence of its existence in Apollo causes and
effects chart. Assign someone to find more facts, for each cause that does not
have evidence ( represented with a question mark “?” temporarily)
Often it is beneficial to start the chart by listing all possible causes. As causes may
not have evidence at this time, the connecting logic may be “OR” rather than
“AND”.
As evidences for causes are collected and established, the “OR” logic disappears
and final “AND” logic should only remain i.e. the primary effect is caused by “cause
A” AND “Cause B” AND “Cause C” and so on

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Root Cause Analysis
The RCA Process – Find Possible Solutions
Solution act on one or more causes in the cause and effect chart. The causes, which
can be acted upon by possible solutions, need not be at the extreme right of cause
effect chart. They can be located anywhere in the Apollo cause effect chart.
Solutions must meet the following criteria
1. Prevent recurrence
2. Should be within our control
As there are a no. of causes , hence there are a no. of solutions
Start on the right side of the cause and effect chart and begin challenging the causes
to find out possible solutions. Following question should be asked to find out
solutions.
1. Why that cause exists ?
2. What we could do to remove , change or control it such that the primary effect
does not occur
If no possible solution could be found for causes on extreme right side, move to the
causes located next on left side of the chart and repeat same exercise.

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Root Cause Analysis
The RCA Process – Find Possible Solutions