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Root Cause Analysis

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Root cause analysis (RCA) is a method of problem solving used for

identifying the root causes of faults or problems. A factor is

considered a root cause if removal thereof from the problem-fault-

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sequence prevents the final undesirable event from recurring; whereas

a causal factor is one that affects an event's outcome, but is not a root

cause. Though removing a causal factor can benefit an outcome, it

does not prevent its recurrence within certainty. Following the

introduction of Kepner-Tregoe Analysis which had limitations in the

highly complex arena of rocket design, development and launch--

RCA arose in the 1950s as a formal study by the National Aeronautics

and Space Administration (NASA) in the United States. New methods

of problem analysis developed by NASA included a high level

assessment practice called MORT (Management Oversight Risk

Tree). MORT differed from RCA by assigning causes to common

classes of cause shortcomings that could be summarized into a short

list. These included work practice, procedures, management, fatigue,

time pressure, along with several others. For example: if an aircraft

accident occurred as a result of adverse weather conditions augmented

by pressure to leave on time; failure to observe weather precautions

could indicate a management or training problem; and lack of

appropriate weather concern might indict work practices. Because

several measures (methods) may effectively address the root causes of

a problem, RCA is an iterative process and a tool of continuous

improvement.

RCA is applied to methodically identify and correct the root causes of

events, rather than to simply address the symptomatic result. Focusing

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correction on root causes has the goal of entirely preventing problem

recurrence. Conversely, RCFA (Root Cause Failure Analysis)

recognizes that complete prevention of recurrence by one corrective

action is not always possible.

RCA is typically used as a reactive method of identifying event(s)

causes, revealing problems and solving them. Analysis is done after

an event has occurred. Insights in RCA make it potentially useful as a

preemptive method. In that event, RCA can be used to forecast or

predict probable events even before they occur. While one follows the

other, RCA is a completely separate process to Incident Management.

Rather than one sharply defined methodology, RCA comprises many

different tools, processes, and philosophies. However, several very-

broadly defined approaches or "schools" can be identified by their

basic approach or field of origin: safety-based, production-based,

process-based, failure-based, and systems-based.

Safety-based RCA arose from the fields of accident analysis and

occupational safety and health.