10 Root Cause Analysis Examples

Root cause analysis (RCA) is a problem-solving approach that helps to uncover the underlying causes of an issue or nonconformance to avoid its reoccurrence.

It’s an organized way of addressing issues and seeking out why they happened, not just what occurred and how.

By pinpointing the root cause of any problem, appropriate corrective actions can be taken to ensure similar problems don’t arise again.

The essential steps involved in RCA include:

• Identifying a difficulty
• Performing the root cause analysis
• Creating restorative measures
• Monitoring and verifying results.

As an example, if there has been a surge in customer grievances about delivery times within a transport business, this could be investigated further through root cause analysis.

This approach may identify communication gaps between dispatch staff and drivers as being at fault – leading them to implement better comms systems/training, thus helping prevent future occurrences from happening too often.

Ultimately, root cause analysis proves its worth by uncovering both the ‘what’ and ‘why’ that lie behind problems in order to reach viable outcomes.

Definition of Root Cause Analysis

Root cause analysis (RCA) is an invaluable systematic approach to identifying the source of issues, faults, or nonconformances and delivering lasting solutions.

It involves investigating what initiated a particular event rather than merely tackling its symptoms – making it suitable for industrial accidents, medical errors, and social/behavioral change communication initiatives (Charles et al., 2016).

According to Attar (2022),

“RCA assumes that it is much more effective to systematically prevent and solve underlying issues rather than just treating ad hic symptoms and putting out figures” (p. 87).

In the science and engineering fields, this method has successfully been used as a troubleshooting tool that eliminates root causes associated with any fault or issue.

Similarly, healthcare investigations related to severe adverse events also benefit from RCA using techniques like cause-mapping and templates designed specifically for such purposes.

As stated by Singh and colleagues (2021),

“…root cause analysis has important implications in helping healthcare organizations study events that resulted in patient harm or undesired clinical outcomes and identify strategies to reduce future error and improve patient care and safety” (p. 5).

At the end of it all – thorough root cause analysis can result in effective strategies to prevent future recurrences while simultaneously improving process performance, quality standards, and safety protocols.

In simpler terms, root cause analysis helps us understand why something happened instead of just finding out what occurred along with how it did.

To go broader, see my article on 45 examples of analysis

10 Examples of Root Cause Analysis

• Manufacturing: A computer parts manufacturer identified that their products were failing rapidly due to an underlying design flaw in one of the microchips. So, RCA was conducted, resulting in the development of a new chip designed to eliminate this problem and prevent its recurrence.
• Healthcare: After a patient experienced an unfortunate fall while inside hospital premises, RCA revealed that they weren’t wearing non-slip socks – leading to policy changes ensuring all patients are now provided with these for added safety measures.
• Education: Low student performance on standardized tests triggered an RCA which discovered teachers were not adequately teaching test material. As such, the said institution implemented additional training and support for improved outcomes going forward.
• Software Development: Customer complaints about the software crashing unexpectedly during use called for investigation via RCA, where it became clear there existed bugs causing them. So company enforced rigorous testing processes before any product release was authorized from then onwards.
• Construction: Delay completion of the project necessitated another round of analysis, revealing critical components had been delivered late – prompting the instigation of stricter procurement process protocols guaranteeing timely delivery every time.
• Retail: A retail store notices that their shelves are frequently out of stock. RCA is conducted to identify the root cause, and it is discovered that the store’s ordering process is inadequate, leading to frequent ordering delays. As a result, the store has implemented a new ordering process to eliminate delays and keep shelves fully stocked.
• Aerospace: An airline experienced engine failures following comprehensive investigations finding defects within designs and manufacturing alike. Thus airline took the initiative to work hand-in-hand with the manufacturer on redesigns eliminating errors altogether.
• Energy: Energy providers faced frequent outages due to equipment maintenance neglect. So, they conducted RCA and implemented extra staff dedicated solely to servicing gear, and enacted stringent compliance regulations.
• Finance: Financial institutions’ loss of customers market correlated with negative customer service record. So, remedial action entailed better personnel coaching aiming to enhance satisfaction standards.
• Food Service: A restaurant experiences frequent food safety issues. RCA is conducted to identify the root cause, and it is discovered that employees are not adequately trained in food safety procedures. As a result, the restaurant implements additional training and oversight to ensure compliance with food safety regulations and prevent future issues.

Approaches to Root Cause Analysis

The most common approaches to Root Cause Analysis include the Five Whys, Fishbone Diagrams, Fault Tree Analysis (FTA), Root Cause Mapping, and Pareto Analysis.

Let’s have a look at each of these approaches:

1. Five Whys

The first and the most popular technique in RCA is the Five Whys approach. This simple method involves asking “why” five times until the underlying cause of a problem is revealed (Serrat, 2017).

To illustrate, if a manufacturing company has high product defects, then through a 5 ‘whys’ analysis, it might be determined that there’s no budget allocated because management didn’t make one.

2. Fishbone Diagrams

Alternatively, Fishbone Diagrams or Ishikawa diagrams can identify leading causes by breaking them down into categories or sub-causes (Shinde et al., 2018).

So, in cases where customer satisfaction at restaurants is low due to service quality, food quality, atmosphere, location, and so on being taken into account.

These subbranches are later used to analyze the main reason for customer dissatisfaction.

3. Fault Tree Analysis (FTA)

Fault Tree Analysis (FTA), meanwhile, provides an even more complex route that uses graphical data points representing different possible sources behind problems (Boryczko et al., 2022).

Suppose that an oil rig explodes. So, the FTA would identify all the possible causes, such as equipment failure, human error, procedural problems, environmental factors, etc.

4. Root Cause Mapping

Root Cause Mapping takes a visual tool-based path using human factors, equipment-related issues, process-connected ones, and environmental aspects when analyzing multi-faceted situations (Vanden et al., 2014).

So, if a psychologist analyzes the reason for a child’s depression, they may take into account not only current challenges in their lives but also early childhood, explore how their parents behave, their habits, etc.

5. Pareto Analysis

Last but not least, Pareto Analysis is a statistical technique that quantifies 20% of certain factors accounting for 80% of all mistakes and problems (Vanden et al., 2014).

It makes the decision-making process quite simple by prioritizing what requires improvement first.

Let’s take a restaurant for example: if it experiences constant customer complaints, Pareto analysis may reveal that only a few menu items are responsible for most of them.

Four Steps of Root Cause Analysis

Root cause analysis (RCA) typically involves four main steps – identifying the problem, gathering data, identifying the root cause of the issue, and developing and implementing solutions (Dahlgaard-Park, 2015).

Here is a detailed description of each of these stages:

• Identify the problem/event: To start, it’s crucial to identify the problem or event at hand and involve all relevant stakeholders to clearly understand its scope and impact.
• Gather data: Gathering data is the second step, which includes reviewing documentation, interviewing those involved in the situation, observing processes as well as analyzing available information so that a comprehensive view can be developed.
• Identify the root cause(s): Thirdly comes identifying root causes. So, various tools such as Five Whys Methodology, Fishbone Diagrams, and Pareto Analysis are used here to analyze collected data before devising solutions addressing each underlying factor identified. This could include process changes/updates training staff or introducing new technologies into play.
• Develop and implement solutions: Last but importantly, we must monitor our chosen strategies’ effectiveness over time by adjusting where necessary if similar issues arise again later down the line.

Pros and Cons of Root Cause Analysis

Root cause analysis (RCA) is an invaluable problem-solving tool that can benefit organizations in numerous ways.

On the pros side, it offers a preventative approach to tackling issues at their source and eliminating them for good.

Plus, its utilization leads to improved processes, better decision-making as well as increased understanding between teams which helps promote collaboration and efficient resource allocation.

Furthermore, addressing root causes also aids customer satisfaction levels by reducing complaints.

Despite all these advantages, though, RCA has some drawbacks.

It takes up time, costs money if specialist tools or outside expertise is required, is quite resource-intensive, has limited scope of effectiveness when dealing with complex problems, and may evoke resistance.

All things considered, however – the benefits provided by root cause analysis significantly outweigh the downsides–particularly in preventing the recurrence of challenges while simultaneously enhancing efficiency.

Conclusion

Root Cause Analysis (RCA) is an invaluable tool for pinpointing the original source of a problem, thus helping to stop it from resurfacing. By getting to its core cause, we can put in place appropriate preventative actions and measures.

It’s widespread across multiple sectors such as healthcare, manufacturing, software engineering, education, construction & retail industries, aerospace/energy, finance, and food service businesses – just to name a few!

To effectively carry out RCA processes, specific approaches could be implemented, like the Five Whys methodology, Fishbone Diagrams, Fault Tree Analyses, Root Cause Mapping, and Pareto Analysis.

All of them provide great insight into why the problem occurred in the first place and allow us to comprehend it thoroughly.

References

Attar, N. N. (2022). Ideal order management systems for manufacturing industry. London: Sankalp Publication.

Boryczko, K., Szpak, D., Żywiec, J., & Tchórzewska-Cieślak, B. (2022). The use of a fault tree analysis (FTA) in the operator reliability assessment of the critical infrastructure on the example of water supply system. Energies, 15(12), 4416. https://doi.org/10.3390/en15124416

Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., Biermann, J. S., & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: A review. Patient Safety in Surgery, 10(1). https://doi.org/10.1186/s13037-016-0107-8

Dahlgaard-Park, S. M. (2015). The SAGE encyclopedia of quality and the service economy (Vol. 2). New York: Sage.

Serrat, O. (2017). The five whys technique. Knowledge Solutions, 1(1), 307–310. https://doi.org/10.1007/978-981-10-0983-9_32

Shinde, D. D., Ahirrao, S., & Prasad, R. (2018). Fishbone diagram: Application to identify the root causes of student–staff problems in technical education. Wireless Personal Communications, 100(2), 653–664. https://doi.org/10.1007/s11277-018-5344-y

Singh, G., Patel, R. H., & Boster, J. (2021). Root cause analysis and medical error prevention. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570638/

Vanden, L. N., Lorenzo, D. K., Jackson, L. O., Hanson, W. E., Rooney, J. J., & Walker, D. A. (2014). Root cause analysis handbook. New York: Rothstein Publishing.