CSI & Root Cause Analysis

The goal of root cause analysis (RCA) is to find out what really happened, why it happened, and how to prevent it from happening again. Chasing symptoms instead of digging deep to find root cause will almost certainly guarantee that the problem will repeat. Peeling back the onion, layer-by-layer, can be a long and tedious process, but it will be very difficult to attack the heavy-hitters by analyzing the symptoms and not the source.

Although RCA is initially a reactive mechanism, it can become a tool for developing prevention strategies if used properly. Whatever methodology of RCA is used, the system must:

  • Be interdisciplinary team-based
  • Include those most familiar with the situation
  • Dig deep at each level of cause & effect
  • Employ the 5 Whys
  • Be a process that identifies needed system changes
  • Be unbiased

While there may be the occasional Nero Wolfe in a company (or for my younger readers, a Gil Grissom), advanced RCA skills are generally a learned behavior. The first investment should be in advanced problem-solving training for (at a minimum) all management and quality personnel on the tools we have discussed here recently that are part of the Quality Toolbox. I like to make the analogy to one of my favorite television programs, Crime Scene Investigation (the Grissom reference).

CSIRCA

I think a quality professional is like a CSI, and the defect is the crime scene. As illustrated in the adjacent figure, during each episode the point is reiterated that the evidence will lead to the origin of the crime. The same is true with root cause analysis; where you find one you will always find the other if you dig deep enough.

 

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