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 Root-Cause Analysis (RCA)

The purpose of this article is to provide some practical insight into satisfying the DOD

requirement to determine the cause, not just the symptom, of deficiencies identified by

your internal audit program (IEP! "e find this to be a recurring problem that commonly

results in a finding in the area of internal audits under operations management or maintenance quality assurance! "e hope that by providing some e#amples of $%&

 processes that consistently pass inspection, listing some cause analysis resources, and

 providing one e#ample of an effective $%& tool, 'e 'ill reduce the number of DODfindings associated 'ith this important requirement!

Q&S Requirement Concerning RCA: 

ederal $egister )* %$ +-!. (DOD &ir Transportation /uality and 0afety

$equirements (/10 lists the follo'ing as a required feature of an IEP process2

 An internal quality audit program or other method capable of identifying in-house

deficiencies … has been implemented. Audit results are analyzed in order to determinethe cause, not just the symptom, of any deficiency.

 RCA Processes that Satisfy the Intent of the Q&S:

There are a 'ide range of processes that have satisfied the DOD3s intent for causeanalysis! These processes run the gamut from comple# and e#pensive to simple and free!

These processes come in three basic forms2 - %ommercially purchased programs, * In4

house programs that specifically identify the root cause, and ) In4house programs that

informally identify root cause!

-! %ommercially Purchased Programs2 ormally trained analysts using purchasedsoft'are, spreadsheets, and scientific methods loo5 at facts, identify problems, and findthe most basic or root cause of a deficiency!

*! In4house 0pecific Process (most commonly observed2 &n in4house developedtrac5ing form specifically requires root cause be determined during the resolution

 process! The format obviously varies from company to company, but 'e typically see the

follo'ing information2

4 Discrepancy2 $estatement of deficiency noted during the self inspection4 $oot %ause2 6ost basic cause of the deficiency is identified and documented

4 $esolution Plan2 Plan to fi# or resolve the deficiency is documented

4 ollo'4up Inspection2 $e4evaluation of area to validate effectiveness of the fi#

)! In4house Informal Process2 7ere root cause or the process to find the root cause is

not specifically bro5en out and identified as such 'ith each finding! $ather, the 'rite4upinformally identifies the cause in the resolution plan or corrective action! The root4cause

identification process is usually spelled out in a manual or set of directions! & dra'bac5 

to this process is that it is difficult to determine if root cause identification 'as done,

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failure of personnel to go through the process, and commonly results in a finding for 

inconsistent compliance, and potential for the finding to reoccur!

In the end, the cause analysis process does not need to be complicated, it just needs to

e#ist, be documented in a manner that our evaluators can determine it is being conducted,

and accurately identify the cause of each deficiency!

 RCA Resources:

There are countless articles, boo5s, and programs available to help you design and

implement an $%& process tailored to the operations of your company! The e#amples 'e

are about to provide are just e#amples of root4cause analysis information available! "e

do not endorse either product, nor are 'e able to commit that use of this particular model'ill meet DOD /uality and 0afety $equirements in any particular company! 8y not

using another product as an e#ample, 'e do not intend to imply it 'ould not be as good

as the e#amples 'e use but in fact might be better! "e highly encourage you to conduct

your o'n research to find models that fit your particular operation and company culture!

&! One e#ample is the internet article titled, What is Root Cause Analysis RCA!", byDE%I0IO9 systems, Inc!, at http2::'''!rootcause!com:"hatIs$%&Detail!htm! This

article identified three essential qualities of an effective and reliable $%& process! It also

does a good job of presenting the information 'ithout overstating or overcomplicatingthe subject!

-! The process must ta5e advantage of people3s 5no'ledge 'hile preventing their 

 biases from controlling the direction of the investigation!

*! The process must depict the facts of the case so that the causal relationships are

clear and the causal relevance of those facts can be verified!

& process 'hich ensures that all factors contributing to a problem are identified is an

e#clusive feature of the $E&0O9 system! The $E&0O9 method orders and displays thefacts of the event in a format that ma5es it easy to chec5 for accuracy and completeness

at each step!

)! The process must also help the analyst and management understand 'hat actionsmust be ta5en to implement potential solutions and 'ho in the organi;ation needs to ta5e

those actions!

Once every possible avenue to'ard prevention is identified, the analyst must understand

'hat specific actions need to be ta5en! Is there a policy already on the boo5s that

attempts to address the problem or is a ne' policy needed< If a policy already e#ists,then 'hy 'asn3t it effective, and 'hat steps do 'e need to ta5e to ma5e it effective in the

future< &nd 'ho in our organi;ation needs to ta5e those steps< If the appropriate action

is not ta5en at the appropriate level in the organi;ation, then a sufficient level of control

'ill not be established to insure prevention into the future! These issues are part of the

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 process of identifying preventative measures and must be integrated into the root4cause

analysis system!

The $E&0O9 method teaches the principles governing corrective action and integrates

them into the root4cause analysis process!

8! &nother article titled, Root-Cause Analysis #or $eginners, by =ames =! $ooney and

>ee 9! ?anden 7ouvol and located at http2::'''!asq!org:pub:qualityprogress:past:@A@.:

qp@A@.rooney!pdf  identified the follo'ing qualities as essential for an $%& process2

B $oot4cause analysis helps identify 'hat, ho', and 'hy something happened, thus

 preventing recurrence!

B $oot causes are underlying, are reasonably identifiable, can be controlled bymanagement, and allo' for generation of recommendations!

B The process involves data collection, cause charting, root cause identification,

recommendation generation, and recommendation implementation!

ollo'ing is one e#ample of an $%& flo' chart that is being used effectively at several

approved DOD carriers!

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NO

NO

NO

NO

Did tools exist to prevent failure?

Describe proposed additionaltools.

NO

Did procedure or policy exist to prevent failure?

a. Is an additional procedureor policy necessary?b. If yes, Describe proposedadditional procedure or policy

Did employee claim tohave knowledge of

 procedure or policy?

Describe steps taken tomaintain trained and informedworkforce

 YES

 YES

Had employee receivedformal training / information?

NO

NO

Describe steps taken toprovide OJT and feedback.Had employee received

sufficient OJT and feedbackregarding ob performance?

 YES

Describe steps taken toprovide employeecommunication.

Had employee receivedcommunication regardingprocedure or policy canges?

 YES

Describe steps taken toestablis and maintainemployee proficiency.

Had employee performedfunction correctly in last !"days?

 YES

!as violation doneroutinely?

Describe steps taken toprevent employee#s disregardof procedure or policy

 YES

 YES

!as violation donewith supervisor"sknowledge?

Describe proposed additionalprocedure or policyDescribe steps taken toprovide necessarysupervisory oversigt.

NO

Describe steps taken toprevent employee andsupervisory disregard of

procedure or policy.

 YES

 YES

NODescribe steps taken toevaluate process to identifydeficiency leading to violation

(START)Determine Cause   Describe Solution

Causal Analysis