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Root cause analysis

Creating a learning organisation

There is much an organisation can learn from its past successes and failures. The lessons can help it improve the quality and effectiveness of its processes and systems and optimise its controls.

Organisations benefit from using consistent and systematic approaches to learning the lessons from both successes and failures. This approach is called root cause analysis

The principles of this approach are that:

  1. Organisations learn just as much from successes as failures
  2. We need to define the problem before looking for a solution
  3. It is important to understand the causes before summarising the lessons we have learned
  4. Actions must lead to the organisation improving.

Root cause analysis

Root cause analysis is a key tool in managing risk. While risk assessment can be seen as exercising foresight and planning for the future, good root cause analysis is the application of hindsight and learning from the past. There is much we can learn from past successes and failures that will help to improve the quality and effectiveness of our processes and systems.

Within the risk management process, root cause analysis is part of the step called ‘monitor and review’. In this step the risk register, risks, controls and risk treatment plans are kept up to date. In part this achieved by analysing the causes of critical successes and failures, and then applying those lessons to further treat the associated risks.

A suitable method of root cause analysis is a process:

  • That follows a recognised system
  • That identifies not only direct causes, but also latent and root causes
  • That is transparent, involves relevant stakeholders and is collaborative
  • Where the outcomes are recorded
  • Where the lessons learned are identified and recorded
  • Where actions are agreed that treat the causes and lead to business improvements.

Broadleaf provides an independent service in the conduct of root cause analysis. Whichever tool we decide to use, we always follow the six stage approach shown in the figure below to agree the objectives, define the successes and failures, conduct the analysis and draw out the lessons learned and the actions that must follow.

Six-step process for learning lessons

We normally either use the fishbone (Ishikawa) or cause and effect methods described below. However, we can also conduct analyses using other approaches such as MORT or TapRoot™ or by developing fault trees.

Fishbone analysis

This approach allows multiple possible causes to be associated with a single event. It assists in categorising in an orderly manner the many potential causes of events and in identifying root causes. Thus, for a particular success or failure, a diagram can be constructed to identify and organise possible causes.

We use this form of analysis:

  • Where there appears to be a simple cause and effect relationship
  • To collect data and facts and display them on one diagram
  • To perform a simple analysis of a system and how it is performing
  • To present lessons on an ongoing basis as part of project risk management during project execution
  • As an effective communication device for presenting simple causation information to others.

To be most effective, the analysis requires a trained facilitator, particularly to help the participants group and assimilate similar causes and to move on to the identification of lessons and improvement tasks.

We do not use this method:

  • For complex systems, processes and events with many potential and inter-related causes
  • For successes and failures where very rigorous analysis is justified by the magnitude of the gain or loss involved.

An example of this form of analysis conducted for a client is shown in the figure below.

Fishbone diagram for a success

Cause and effect analysis

We use cause and effect analysis whenever a more rigorous study of events is required than fishbone analysis can provide. Because it is not prescriptive and relies on a methodology and rule set, we find it is widely applicable to all problems, systems and situations.

We use this method:

  • For all types of events, both successes and failures
  • When a complex series of causes is involved
  • When the true root causes are not clear, which is often the case.

We do not use cause and effect analysis where there is a need only to assemble well-known and non-linked causes, when fishbone analysis would be adequate. An example of the kind of diagram assembled during this analysis is shown in the figure below.

The water supply scheme was 2 months late (extract from the cause and effect tree)

Partial cause and effect tree for the water supply system. Note RO means reverse osmosis, a common process for water treatment

Converting lessons learned into improvements

Root cause analysis allows root causes to be identified and lessons to be learned. However, learning lessons cannot be an 'ad hoc' process, and it does not happen by chance. Specific actions are needed to ensure the organisation or project converts those lessons into actions that lead to lasting improvements.

The table below is an extract from an analysis of safety showers on an operating site. It identifies the lessons in specified topic areas, and then documents the agreed actions that will lead to improved outcomes.

Actions from an analysis of safety showers (extract)





Showers may not comply with AS 4775-2007 Emergency eyewash and shower equipment

Check all emergency eyewash and safety showers against the relevant Standard, including signage requirements

Monitoring & response

There is a culture problem leading to some safety reporting being regarded as non-urgent; the identified non compliance may demonstrate other areas of poor reporting practices

Sessions with supervisors have been held over the past four weeks; the safety showers are now being monitored

Provide guidance to chairs of morning meetings on meeting agendas and process

Monitoring & response

The inspection sheet is not adequate to ensure all safety showers are inspected

This is being addressed now

Investigate the use of an electronic guide to make inspections easier and more effective (e.g. with a map, data entry capability, indicators for allowable limits, …)