7 powerful problem solving root cause analysis tools

By using this site you agree to our use of cookies. Please refer to our privacy policy for more information.   Close

7 Powerful Problem-Solving Root Cause Analysis Tools

The first step to solving a problem is to define the problem precisely. It is the heart of problem-solving.

Root cause analysis is the second important element of problem-solving in quality management. The reason is if you don't know what the problem is, you can never solve the exact problem that is hurting the quality.

Manufacturers have a variety of problem-solving tools at hand. However, they need to know when to use which tool in a manner that is appropriate for the situation. In this article, we discuss 7 tools including:

• The Ishikawa Fishbone Diagram (IFD)
• Pareto Chart
• Failure Mode and Effects Analysis (FMEA)
• Scatter Diagram
• Affinity Diagram
• Fault Tree Analysis (FTA)

1. The Ishikawa Fishbone Diagram IFD

The model introduced by Ishikawa (also known as the fishbone diagram) is considered one of the most robust methods for conducting root cause analysis. This model uses the assessment of the 6Ms as a methodology for identifying the true or most probable root cause to determine corrective and preventive actions. The 6Ms include:

• Measurement,
• Mother Nature- i.e., Environment

Related Training: Fishbone Diagramming

2. Pareto Chart

The Pareto Chart is a series of bars whose heights reflect the frequency or impact of problems. On the Chart, bars are arranged in descending order of height from left to right, which means the categories represented by the tall bars on the left are relatively more frequent than those on the right.

Related Training: EFFECTIVE INVESTIGATIONS AND CORRECTIVE ACTIONS (CAPA) Establishing and resolving the root causes of deviations, problems and failures

This model uses the 5 Why by asking why 5 times to find the root cause of the problem. It generally takes five iterations of the questioning process to arrive at the root cause of the problem and that's why this model got its name as 5 Whys. But it is perfectly fine for a facilitator to ask less or more questions depending on the needs.

Related training: Accident/Incident Investigation and Root Cause Analysis

4. Failure Mode and Effects Analysis (FMEA)

FMEA is a technique used to identify process and product problems before they occur. It focuses on how and when a system will fail, not if it will fail. In this model, each failure mode is assessed for:

• Severity (S)
• Occurrence (O)
• Detection (D)

A combination of the three scores produces a risk priority number (RPN). The RPN is then provided a ranking system to prioritize which problem must gain more attention first.

Related Training: Failure Mode Effects Analysis

5. Scatter Diagram

A scatter diagram also known as a scatter plot is a graph in which the values of two variables are plotted along two axes, the pattern of the resulting points revealing any correlation present.

To use scatter plots in root cause analysis, an independent variable or suspected cause is plotted on the x-axis and the dependent variable (the effect) is plotted on the y-axis. If the pattern reflects a clear curve or line, it means they are correlated. If required, more sophisticated correlation analyses can be continued.

Related Training: Excel Charting Basics - Produce Professional-Looking Excel Charts

6. Affinity Diagram

Also known as KJ Diagram, this model is used to represent the structure of big and complex factors that impact a problem or a situation. It divides these factors into small classifications according to their similarity to assist in identifying the major causes of the problem.

7. Fault Tree Analysis (FTA)

The Fault Tree Analysis uses Boolean logic to arrive at the cause of a problem. It begins with a defined problem and works backward to identify what factors contributed to the problem using a graphical representation called the Fault Tree. It takes a top-down approach starting with the problem and evaluating the factors that caused the problem.

Finding the root cause isn't an easy because there is not always one root cause. You may have to repeat your experiment several times to arrive at it to eliminate the encountered problem. Using a scientific approach to solving problem works. So, its important to learn the several problem-solving tools and techniques at your fingertips so you can use the ones appropriate for different situations.

ComplianceOnline Trainings on Root Cause Analysis

P&PC, SPC/6Sigma, Failure Investigation, Root Cause Analysis, PDCA, DMAIC, A3 This webinar will define what are the US FDA's expectation for Production and Process Control / Product Realization, the use of statistical tehniques, 6 sigma, SPC, for establishing, controlling , and verifying the acceptability of process capability and product characteristics, product acceptance or validation and other studies. Non-conformance, OOS, deviations Failure Investigations, and Root Cause Analysis, PDCA, DMAIC, and similar project drivers to improvement, A# and similar dash boards.

Accident/Incident Investigation and Root Cause Analysis If a major workplace injury or illness occurred, what would you do? How would you properly investigate it? What could be done to prevent it from happening again? A properly executed accident/incident investigation drives to the root causes of the workplace accident to prevent a repeat occurrence. A good accident/incident investigation process includes identifying the investigation team, establishing/reviewing written procedures, identifying root causes and tracking of all safety hazards found to completion.

Root Cause Analysis - The Heart of Corrective Action This presentation will explain the importance of root cause analysis and how it fits into an effective corrective and preventive action system. It will cover where else in your quality management system root cause analysis can be used and will give examples of some of the techniques for doing an effective root cause analysis. Attendees will learn how root cause analysis can be used in process control.

Addressing Non-Conformances using Root Cause Analysis (RCA) RCA assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, you can discover where the issue started and how it grew into the problem you're now facing.

Introduction to Root Cause Investigation for CAPA If you have reoccurring problems showing up in your quality systems, your CAPA system is not effective and you have not performed an in-depth root cause analysis to be able to detect through proper problem solving tools and quality data sources, the true root cause of your problem. Unless you can get to the true root cause of a failure, nonconformity, defect or other undesirable situation, your CAPA system will not be successful.

Root Cause Analysis and CAPA Controls for a Compliant Quality System In this CAPA webinar, learn various regulations governing Corrective and Preventive Actions (CAPA) and how organization should collect information, analyze information, identify, investigate product and quality problems, and take appropriate and effective corrective and/or preventive action to prevent their recurrence.

Root Cause Analysis for CAPA Management (Shutting Down the Alligator Farm) Emphasis will be placed on realizing system interactions and cultural environment that often lies at the root of the problem and prevents true root cause analysis. This webinar will benefit any organization that wants to improve the effectiveness of their CAPA and failure investigation processes.

Root Cause Analysis for Corrective and Preventive Action (CAPA) The Quality Systems Regulation (21 CFR 820) and the Quality Management Standard for Medical Devices (ISO 13485:2003), require medical device companies to establish and maintain procedures for implementing corrective and preventive action (CAPA) as an integral part of the quality system.

Strategies for an Effective Root Cause Analysis and CAPA Program This webinar will provide valuable assistance to all regulated companies, a CAPA program is a requirement across the Medical Device, Diagnostic, Pharmaceutical, and Biologics fields. This session will discuss the importance, requirements, and elements of a root cause-based CAPA program, as well as detailing the most effective ways to determine root cause and describing the uses of CAPA data.

Legal Disclaimer

This piece of content and any of its enclosures, attachments or appendices, references are created to provide solely for information purpose. ComplianceOnline has made all effort to provide accurate information concerning the subject matter covered. This content is created from interpretation, and understanding of relevant and applicable information and it is not all inclusive. It can be best used in conjunction with your professional judgment and discretion.

However, this piece of content and any other ancillary items disseminated in connection with same are not necessarily prepared by a person licensed to practice law in a particular jurisdiction. This piece of content is not a substitute for the advice of an attorney. If you require legal or other expert advice, you should seek the services of a competent attorney or other professional.

ComplianceOnline necessarily is not, cannot and will not be liable for any claims, damages, or regulatory legal proceedings initiated as a consequence of you using whole or any part of the content present in this document. If any action, claim for damages, or regulatory proceedings is commenced against ComplianceOnline as a consequence of your use of this document, then and in that event, you agree to indemnify ComplianceOnline for such claims, and for any attorney's fees expended by ComplianceOnline in connection with defense of same.

Filter by Keywords

6 Powerful Problem-Solving Root Cause Analysis Tools

Engineering Team

February 13, 2024

When solving problems, you either take a proactive approach or a reactive one. Proactive: address the underlying causes of the issue to avoid future challenges. Reactive: respond to issues as they come.

For many project managers, getting at the root cause of an issue before it derails an entire project is key. You’ll save time, money, and valuable resources where they matter most. Plus, you develop insights to build better processes for smoother workflows. 

To nail down what’s at the heart of an issue, you need root cause analysis. 👀

In this article, we’ll share ten of the best root cause analysis tools and techniques. We’ll dive into what root cause analysis is and how to choose the right tools for your business. 

How to choose the right root cause analysis tool for a specific problem 

2. intelex root cause analysis software, 3. apache skywalking, 4. taproot®, 5. appdynamics from cisco, 6. sologic root cause analysis software, pareto chart, fishbone diagram, scatter plot diagram.

What Is Root Cause Analysis? 

Root cause analysis is the process of examining the source of an issue using various techniques and tools. It’s ideal for solving complex problems and helps teams create and prioritize solutions for better quality control and seamless processes.

There are several steps in the process, including: 

• Describing the existing issue
• Analyzing metrics and collecting data
• Identifying potential causes
• Brainstorming solutions
• Taking corrective action
• Observing changes and performance

Root cause analysis is a key component of quality management because its goal is to get to the heart of an issue and what’s causing it. That way, you prevent similar problems from arising and causing havoc on a project.

The benefit of root cause analysis is that it allows you to examine potential issues at their core. Plus, it’s designed to assess the issue as well as the solutions as you implement them.

As you gather valuable data on the problems your business faces and the effectiveness of the solutions you try out, you learn how to improve processes every step of the way. The result is a more efficient and successful business that’s able to adapt to whatever comes next. 🤩

You’ll find plenty of tools and methods designed to make root cause analysis easier and streamline the overall process. Luckily, there are also a number of free options in addition to paid analytics tools on the market to gather insights into the cause of the problem.

Of course, not all tools are equally effective. Some are meant to help brainstorm ideas for solutions. Others are designed to dive into metrics to track issues and nail down what’s behind them. And some are complete process software tools designed to integrate into your daily work. 🛠️

Want effective root cause analysis? Here’s what to look for in different tools and techniques:

• Integrations : RCA is best when done collaboratively. Look for tools that let you work with team members to break down problems
• Data tools : You can’t figure out what’s wrong without diving into metrics. Choose a tool that lets you collect data to inform the process
• Specific actions : It’s not enough to know what’s causing a problem. You need a tool that lets you take specific actions, like instantly assigning remedial tasks

6 Best Root Cause Analysis Tools in 2024

Ready to figure out what’s at the root of your problem? With these six best root cause analysis tools and techniques, you’ll have what you need to break down an issue. From integrated software tools to free methods, there’s something for everyone. 💪

ClickUp is an all-in-one project management software designed to centralize your work across apps into one collaborative platform. With a rich set of dynamic features to streamline any workflow, teams rely on ClickUp to drive productivity, reduce downtime, and make processes more efficient. 

One of the first steps in root cause analysis is to describe the problem. With ClickUp Whiteboards , teams can take a visual approach to this step. With live cursors, actionable tasks, embedding, and more, teams can work collaboratively to identify the root cause and present metrics that support their ideas. 

The next step is to collect data. Use metrics to truly see what’s driving the issue. With ClickUp Forms , you can survey customers and employees to find out what problems are present and what may be causing them. These Forms are completely customizable, letting you collect the specific data you need. Plus, they’re easy to share, allowing you to cast a wide net to gather as much information as possible.

Once you’re in the analysis stage, ClickUp’s Table view will be your best friend. Create spreadsheets in seconds and design visual databases of information. Use these views to analyze your data and lay the groundwork for next steps to correct the problem. 🤩

ClickUp best features

• ClickUp AI features hundreds of tools for various use cases, identifying issues and brainstorming solutions
• Use Docs from ClickUp to easily document your RCA process and keep track of important insights and potential next steps
• More than 1,000 templates, including ClickUp’s Root Cause Analysis Template , make it easy to do your work faster and more efficiently

ClickUp limitations

• Right now, ClickUp AI writing tools are only available on desktop, but mobile rollout is on the way
• The sheer number of features requires some time to learn, but once you do, you’ll be able to create more powerful processes

ClickUp pricing

• Free Forever
• Unlimited : $7/month per user
• Business : $12/month per user
• Enterprise : Contact for pricing
• ClickUp AI is available on all paid plans for $5 per Workspace member per month

ClickUp ratings and reviews

• G2 : 4.7/5 (2,000+ reviews)
• Capterra : 4.7/5 (2,000+ reviews)

The Root Cause Analysis Software from Intelex is a SaaS tool designed to help companies create better environment, health, safety, and quality (EHSC) procedures. It uses various methodologies to get to the root cause of the problem.

Start by recording incident data in the tool where everyone on the team can access and analyze the information. Next, use methodology tools like Ishikawa diagrams and failure mode and effects analysis (FMEA) to identify trends.

Intelex best features

• Integrated RCA techniques, including 5 whys, checklists, and gap analysis, make it easy to assess problems in one space
• Workflow tools feature integrations to identify the root causes of problems outside your organization when they occur
• Custom dashboards and reporting make sharing insights with various team members easier than ever

Intelex limitations

• Some users felt the tool was rigid and that data collection features could be more insightful
• The user interface isn’t the most friendly, particularly for beginners

Intelex pricing

• Free: seven-day trial
• Custom : Contact for pricing

Intelex ratings and reviews

• G2 : 4/5 (10+ reviews)
• Capterra : N/A

Apache Skywalking is an application performance management (APM) tool designed to identify issues in software tools. Specifically made for microservices, cloud, and Kubernetes applications, this tool is useful for software engineers in charge of tech teams. 👨🏽‍💻

Apache Skywalking best features

• Profile codes on runtime using the built-in root causes analysis features that identify the exact point where issues develop
• Performance optimization tools let you create continuous improvement processes to better meet customer needs
• In-depth metrics get to the heart of the problem, so your team can brainstorm solutions

Apache Skywalking limitations

• The complex interface may be intimidating, particularly for entry-level team members
• Some found the tool was better suited for smaller-scale projects 

Apache Skywalking pricing

• Free (open source tool)

Apache Skywalking ratings and reviews

Bonus: Check out The Best Open-Source Project Management Tools in 2024

TapRooT® is a software tool designed to identify and fix problems caused by both equipment and humans. Use this tool to collect evidence of the issue, identify the cause and effect of various actors, and develop fixes.

TapRooT® best features

• Processes are differentiated based on whether it’s a simple incident or a major accident, so you react accordingly
• The Corrective Action Helper® Guide/Module leads you through potential solutions and makes implementation faster
• Charts and graphs organize data so it’s easier to identify trends

TapRooT® limitations

• Some users found the pricing to be high
• The tool is extremely in-depth, making it a better choice for big businesses 

TapRooT® pricing

• Contact for pricing

TapRooT® ratings and reviews

AppDynamics is a tech tool from Cisco that’s designed to identify the root causes of issues across your business. Use it to break down problems in software, applications, user experience, and overall business health. The tool lets you gain visibility, gather data, and automate solutions. 📚

AppDynamics best features

• Extensive supported technologies, including Apache, Python, and Docker
• Monitoring and migration tools make implementing solutions faster
• Application flow maps let you pinpoint the exact moment issues arise

AppDynamics limitations

• A steep learning curve means you have to allocate resources to get the team up to speed
• Complicated licensing and limited data security features

AppDynamics pricing

• Infrastructure Monitoring Edition : $6/month/CPU Core
• Premium Edition : $60/month/CPU Core
• Enterprise Edition : $90/month/CPU Core
• Enterprise Edition for SAP® Solutions : $167/month/CPU Core
• Real User Monitoring : $0.06/month per 1,000 tokens

AppDynamics ratings and reviews

• G2 : 4.3/5 (300+ reviews)
• Capterra : 4.5/5 (30+ reviews)

Causelink® is Sologic’s RCA tool. It uses techniques like 5 whys, fishbone diagrams, and incident timelines to pinpoint the root cause of a problem. Use it as an individual, team, or enterprise tool based on the size of your business.

Sologic best features

• Virtual RCA training features make it easy to provide professional development opportunities for all team members 
• Multiple built-in techniques let you analyze data in ways that make the most sense for your business
• The built-in five-step method takes the guesswork out of RCA

Sologic limitations

• Since the tool features built-in methodologies, there isn’t as much customization as with other tools
• Pricing can be expensive, making it harder for small businesses to use

Sologic pricing

• Causelink® Individual : $384/year
• Causelink® Team : Contact for pricing
• Causelink® Enterprise : Contact for pricing

Sologic ratings and reviews

• G2 : 4/5 (1+ reviews)

Root Cause Analysis Techniques

A major benefit to using root cause analysis tools is that they’re designed to help teams integrate proven techniques into their daily processes. There are a ton of ways to get to the root of a problem, especially when you consider the range of issues teams face across industries.

If you’re searching for a new strategy or wondering what root cause analysis technique will best fit your team’s needs, start here with a few of our favorite examples:

Also called Pareto analysis, this RCA tool is a simple bar chart that ranks data based on frequency. It’s useful for identifying problems that cause the most downtime and highlighting where you should focus your efforts. The main purpose of a Pareto Chart is to separate minor problems from major ones. Teams turn to Pareto charts and analysis to:

• Simplify the problem-solving process 
• Look for a singular cause to hone in on the root issue
• Highlight the most commonly felt problems

The 5 Whys method is an investigative tool that’s much like a child repeatedly asking, “Why?” 🤔

That might be frustrating in other areas of life, but it’s great for root cause analysis because it pushes you to consider what’s behind a problem.

This tool isn’t meant for quantitative analysis; it’s more for a qualitative approach to finding out what’s behind an issue. It’s a mental exercise that limits your focus on one potential issue and encourages you to identify multiple contributors to that problem. The idea is to ask why-type questions about the problem to understand what’s wrong and why it may not be working.

This root cause analysis method is named for the shape of the diagram. It’s a process that breaks down problems into subcategories like machine, method, and materials. 🐟

Use fishbone diagram templates when you have no idea what’s behind the issue and need to do a big brainstorm. This strategy can be used for both simple and complex problems by breaking down each subcategory further and further until you nail down the root cause.

A scatter diagram helps you analyze the correlation of two sets of data. An independent variable (or potential cause) is plotted on the x-axis, while a dependent variable (the observed effect) is plotted on the y-axis. If the dots are grouped to create a line, this means there is a relationship between the two.

By clearly identifying the cause and effect based on data, you can implement solutions quickly and efficiently—even when using data points that may initially seem unrelated to each other.

Identify and Solve Problems With ClickUp

With these root cause analysis tools and methods, finding the problem and creating solutions is easier than ever. Choose one tool or mix and match a few depending on your business needs.

Sign up for ClickUp today to start gathering metrics, identifying problems, and creating solutions in your processes. With AI insights, Whiteboards, and Forms, quickly brainstorm ideas on what’s behind the issue and work collaboratively with your team. 

Once you identify the problem, ClickUp makes it easy to instantly assign tasks and create a schedule for implementing solutions. 🏆

Questions? Comments? Visit our Help Center for support.

Receive the latest WriteClick Newsletter updates.

Thanks for subscribing to our blog!

Please enter a valid email

• Free training & 24-hour support
• Serious about security & privacy
• 99.99% uptime the last 12 months

Root Cause Analysis Guide for Efficient Business Problem-Solving

Updated on: 5 January 2023

Sometimes things go wrong. Well-planned projects fail, processes break down and employees lose their productivity.

To understand what happened, you need to get to the bottom of things.

Many organizations use the root cause analysis when a problem or something unplanned happens that will interrupt their business processes. It helps dig deeper and find effective solutions.

In this post, we will look at what is root cause analysis, the root cause analysis steps, and root cause analysis tools.  

What is Root Cause Analysis

Root cause analysis is a method that helps understand the primary cause of a problem or why a problem occurred in the first place.

It helps you to dig into the underlying causes of the situation, thus allowing you to find appropriate solutions for it.

There are several root cause analysis tools and techniques that can be used in the investigation of a problem. But before we get to that, let’s understand how to conduct a root cause analysis first.

Root Cause Analysis Steps

A root cause analysis may take several hours of your time.

It would be easier for you if you involve a team of relevant people; for example, if you are investigating bottlenecks in a process, it would help to have the process owner and other experts for the analysis.

Follow the steps below to conduct a successful root cause analysis.

Step 1: Define the problem

Define the problem your organization is facing and gather data and evidence relevant to it and necessary to understand the current situation.

Create a problem statement which should include information about the problem like the actual impact, potential impact, the focal point, etc. However keep the statement concise.

Step 2: Determine the factors that caused the problem.

Gather a team of people directly involved in the execution of the process and corrective actions, and experts whose input can help find solutions faster.

Together with the team, brainstorm the possible factors for the problem by asking ‘why?’. You can use a 5 whys diagram or a fishbone diagram here.

Step 3: Identify the root cause.

Dig deeper by continuing to ask why after the first layer of causal factors. Keep at it until finally you have discovered the fundamental cause for the problem at hand.

Step 4: Decide the corrective actions

Decide the corrective actions you need to take to eliminate the problem and prevent it from recurring. Make sure that you clearly communicate them to the people who will be involved.

Step 5: Review and evaluate

Review and evaluate the impact of the corrective actions. Make improvements as necessary.

Root Cause Analysis Tools

Many root cause analysis tools are out there. Following we have listed some that are widely used and more effective in problem-solving.

5 Whys Analysis

To carry out a 5 whys analysis, you need to gather a team of people who are affected by the problem.

As the name suggests, in the 5 whys analysis the question ‘why?’ is asked five times in the course of finding the root cause of a problem.

You can use a 5 whys template like the one below to facilitate the brainstorming session.

Once you have asked ‘why’ five times and figured out the root cause, come up with improvement measure you need to apply. Assign everyone the corrective actions that need to be taken.

Cause and Effect Analysis

Once you have identified the problem, you can use the cause and effect analysis to explore the causes of a problem and its effects.

For the analysis, you can use a cause and effect diagram, which is also known as a fishbone diagram or the Ishikawa diagram.

Just as it helps explore the factors that are preventing an outcome, it can also be used to identify the factors needed to generate the desired outcome.

Here’s how to use the cause and effect analysis to solve business problems . You can also refer to our guide on fishbone diagrams to learn how to use the tool in more detail.  

Pareto Chart

Pareto chart is a combination of a bar chart and a line graph. While the length of the bars represent the frequency or cost of faults, they are arranged in such a way that highlights the most frequent to least frequent. The chart helps prioritize your issues based on the cumulative effect they have on a system.

The Pareto chart is based on the theory that 80% of the total problems that occur are caused by 20% of problem causes. This means if you have solutions to your major problems, you can also solve a majority of your other smaller problems.

Learn how to create a Pareto chart step-by-step here .  

Scatter Diagram

Scatter diagrams or scatter plot diagrams can be used to visualize the relationship between two variables. Once you have created a cause and effect diagram and identified potential causes to your problem, you can use the scatter diagram to determine which causes are responsible for the variation.

While the independent variable is plotted along the horizontal axis, the vertical axis is for the dependent axis. Learn more here .

Fault Tree Analysis

Fault tree analysis is a deductive analysis to that visually represent the failure path. You can use the fault tree analysis to determine the possible causes of a problem or an event. The fault tree starts with the event at the top and the possible causes are placed below.

Anymore Root Cause Analysis Tools?

What other root cause analysis tools do you use? Have you got any more tips on accelerating the root cause analysis steps we have discussed above? Do share them with us in the comments below.

Join over thousands of organizations that use Creately to brainstorm, plan, analyze, and execute their projects successfully.

More Related Articles

Leave a comment Cancel reply

Please enter an answer in digits: 2 × one =

Download our all-new eBook for tips on 50 powerful Business Diagrams for Strategic Planning.

Advisory boards aren’t only for executives. Join the LogRocket Content Advisory Board today →

• Product Management
• Solve User-Reported Issues
• Find Issues Faster
• Optimize Conversion and Adoption

Better problem solving with root cause analysis (with template)

If you walk into your kitchen to find your favorite vase smashed on the floor, it might be safe to assume that the grinning cat nearby was the root cause of this problem. If only it was this simple in business and we could just say “the cat did it.” Product problems are often much more complex and connected to a variety of root causes.

If you think of a weed, the surface is only the problem you can immediately see. However, if you cut the weed from the ground level, it’s likely to grow back from the root. This is just like fixing product problems with a band-aid with little to no investigation of a root cause — it’s likely to return.

These types of problems need a more thorough root cause analysis (RCA) to determine how, and why the problem happened, and how to prevent it in the future.

What is root cause analysis?

Root cause analysis is a tool you can utilize when determining the true cause of a problem. You might have assumptions about what the cause of a problem might be or experience biases towards one as the main cause.

Performing a root cause analysis can help you determine what the underlying causes of a problem are to help address a more impactful and valuable solution:

What are the 4 steps in a root cause analysis?

When you’re trying to uncover the roots of a problem, it can be daunting to figure out where to start. The process to conduct a root cause analysis can be broken down into a few easy steps:

• Define the problem
• Identify and map the problem causes
• Identify the evidence that supports your causes
• Create a root cause analysis report and set up your action plan

1. Define the problem

A clear definition of the problem is the first step. Sometimes problems are easy to identify, like a broken link. More often, problems can be abstract and need clarification, like a decrease in overall purchases through a site or an increase in bugs reported.

Here are some more examples of problems:

• A 20 percent drop in customer purchases placed from the shopping cart page from the previous week
• 60 percent of customers on hold end up dropping their call and, as a result, the company has experienced a decrease in NPS scores
• A 40 percent increase of customer reported issues with using the folders feature in a CRM
• A 15 percent decrease in user engagement with a core feature on a social media site

It’s also critical to understand how to define a problem:

2. Identify and map the problem causes

Using tools like a fishbone analysis and the Five Whys framework can help you put together causes and start to categorize themes of the problem. When going through a Five Whys diagram, try to come up with a few alternate pathways and you might notice overlapping areas.

Each example of a Five Whys diagram is accurate, but only looking at one cause can prevent you from understanding the fuller picture. For example, there was more than one reason why the Fyre Festival failed and it’s important to identify overlapping themes to avoid leaning on only one cause:

In a product example, there might be numerous reasons why session times have decreased, or user reported bugs are up.

After evaluating the size, impact, general cause themes, and urgency of the problem, you’ll have a better understanding of how much effort will be needed for the analysis. The larger the problem on the surface, the more underlying causes you might find. Even simple problems can sometimes have numerous causes to consider and you need to determine how in-depth you need to dig to “unroot” the causes.

It’s also critical to check all your bases. Once you have evaluated and categorized the different potential causes to a problem, use the following as a checklist to ensure you’re covering all areas of where and how this problem happened. Be sure to identify any changes or recent events that might have occurred that could have impacted the problem.

Over 200k developers and product managers use LogRocket to create better digital experiences

• Demographics : is the problem happening to one specific demographic? Only happening to iPhone users? Users in a specific location?
• Time specific : when did the problem happen? Is it continuing to happen? Did the problem only occur during a specific time? You might discover that the problem is related to a time-specific cause, like a release or outage
• User journey : did anything change within the user journey? Map the workflow to determine if any new developments have occurred
• External factors : is this an issue with a third party integration? Did a competitor launch a successful new feature that might be taking business from you? Some of these external factors could be out of your control, but important to recognize
• Internal factors : how many feature releases happened during this time frame? Was there any product downtime or maintenance at that time?

3. Identify the evidence that supports your causes

Collecting evidence is a key part of a root cause analysis. Without evidence, your problem causes are based on assumptions and potentially harmful biases.

Start evaluating any data you might have available. Using session replay tools like LogRocket can help you collect evidence of the problem. Here are a couple of examples of the type of data that can be used to collect evidence:

• User count — number of users impacted by the problem
• Usage — daily, weekly, or monthly active users and a decrease or increase in session time
• Decrease or increase in events — for example, a decrease in users selecting the Add to cart button from a page or an increase in error pages
• Error tracking and user frustration — tools like LogRocket can help track where things are going wrong in your product and surface critical issues
• Qualitative evidence — run user interviews or user-submitted feedback with tools like Loom. Are multiple users running into the same roadblock? Are you seeing the same complaint from multiple users in feedback tickets?

4. Create a root cause analysis report and set up your action plan

Collect your evidence and root cause evaluation into an RCA template. Once you have your causes identified and your discovery efforts into one root cause analysis report, you can start creating a plan to address the problem and prevent it from happening in the future.

Collaborate with a team to brainstorm solutions and discuss which options might address multiple causes. Evaluate if you need both a short-term and long-term solution, depending on the level of effort and urgency required. As part of your analysis report, discuss how you can avoid this problem again in the future and any other risk mitigation plans.

Root cause analysis template

You can use this root cause analysis template on Google Sheets to organization your investigation, collect your evidence, and share with your team to determine next step solutions:

Root cause analysis example

Below is an RCA for Company B, a tax preparation product that experienced an increase in dropped customer calls.

Company B experienced an increase of 60 percent of customers on hold that ended up dropping their call. They also experienced an increase in NPS dissatisfaction and have concerns about losing customers.

After going through a root cause analysis, they discovered an 80 percent increase in user calls during tax season. This increase of call volume indicated much longer wait times to speak to a live agent.

After investigating some of the customer call reasons, they discovered that numerous customers had simple questions that could be answered quickly without too much support.

More great articles from LogRocket:

• How to implement issue management to improve your product
• 8 ways to reduce cycle time and build a better product
• What is a PERT chart and how to make one
• Discover how to use behavioral analytics to create a great product experience
• Explore six tried and true product management frameworks you should know
• Advisory boards aren’t just for executives. Join LogRocket’s Content Advisory Board. You’ll help inform the type of content we create and get access to exclusive meetups, social accreditation, and swag.

Company B gathered call logs that confirmed their suspicions. They brought the logs together that demonstrated the simplicity of repeated questions and gathered records of customers that dropped off after a certain amount of time on the phone.

Company B implemented a conversational AI chatbot that could answer generic questions and direct more complex questions to a live agent. Further, they implemented tooltips throughout the tax process flow to help users that appeared to be stuck.

Through the RCA process, you might discover that some parts of the user’s experience are confusing and create a plan to address minor UI challenges.

These solutions helped Company B improve their accessibility and scalability needs during an increase in call volume, without having to add more employee support. Going forward, Company B can plan to monitor call times and continuously evaluate customer service topics to determine where users might need further support and guidance in the future:

Common mistakes to avoid

There are a number of easy-to-fall-into traps when performing root cause analysis, including:

• Don’t rely on assumptions when determining root causes. Use evidence to support to disprove a cause
• Don’t limit your investigation. Go beyond one Five Why framework and be sure to exhaust all possibilities to avoid leaning on the first cause
• Don’t rely on the first idea — come up with multiple solutions to solve a problem
• Don’t work alone. Collaborating with a team will help you come up with a variety of potential solutions or new opportunities
• Don’t think this is a one-time thing. Prepare for the future and discuss risk management and mitigation if you expect this problem to happen again, especially with issues that might be related to factors out of your control. What’s the worst that can happen, and what can we do about it to make sure the problem is addressed quickly with minimal interruption?

Final thoughts

A root cause analysis can be a great tool to help you uncover the true causes of a problem and reduce any reliance on assumptions or biases. With the right investigation and evidence collection, you can learn more about how and why a problem happened and identify causes below the surface.

RCA can ensure your solutions address the root problem and help you better plan for the future.

Featured image source: IconScout

LogRocket generates product insights that lead to meaningful action

Get your teams on the same page — try LogRocket today.

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Reddit (Opens in new window)
• Click to share on LinkedIn (Opens in new window)
• Click to share on Facebook (Opens in new window)
• #product strategy

Stop guessing about your digital experience with LogRocket

Recent posts:.

Leader Spotlight: Improving product development through documentation, with Mark Francis

Mark Francis discusses the importance of stakeholders across all business groups embracing the need for documentation and transparency.

A guide to crafting your brand strategy

Brand strategy is one of the most underestimated forces that shapes the trajectory of your products and services.

Leader Spotlight: Helping turn Apple’s business around, with Steve Chazin

Steve Chazin, VP of Products at Alarm.com, shares how he was re-hired by Steve Jobs to help turn Apple around.

Leader Spotlight: Building a comprehensive migration plan, with Deepika Manglani

Deepika Manglani discusses major transitions she’s worked on at Tribune Publishing, including a divestiture and application migration plan.

Leave a Reply Cancel reply

tableau.com is not available in your region.

• Business Essentials
• Leadership & Management
• Credential of Leadership, Impact, and Management in Business (CLIMB)
• Entrepreneurship & Innovation
• *New* Digital Transformation
• Finance & Accounting
• Business in Society
• For Organizations
• Support Portal
• Media Coverage
• Founding Donors
• Leadership Team

• Harvard Business School →
• HBS Online →
• Business Insights →

Business Insights

Harvard Business School Online's Business Insights Blog provides the career insights you need to achieve your goals and gain confidence in your business skills.

• Career Development
• Communication
• Decision-Making
• Earning Your MBA
• Negotiation
• News & Events
• Productivity
• Staff Spotlight
• Student Profiles
• Work-Life Balance
• Alternative Investments
• Business Analytics
• Business Strategy
• Business and Climate Change
• Design Thinking and Innovation
• Digital Marketing Strategy
• Disruptive Strategy
• Economics for Managers
• Entrepreneurship Essentials
• Financial Accounting
• Global Business
• Launching Tech Ventures
• Leadership Principles
• Leadership, Ethics, and Corporate Accountability
• Leading with Finance
• Management Essentials
• Negotiation Mastery
• Organizational Leadership
• Power and Influence for Positive Impact
• Strategy Execution
• Sustainable Business Strategy
• Sustainable Investing
• Winning with Digital Platforms

Root Cause Analysis: What It Is & How to Perform One

• 07 Mar 2023

The problems that affect a company’s success don’t always result from not understanding how to solve them. In many cases, their root causes aren’t easily identified. That’s why root cause analysis is vital to organizational leadership .

According to research described in the Harvard Business Review , 85 percent of executives believe their organizations are bad at diagnosing problems, and 87 percent think that flaw carries significant costs. As a result, more businesses seek organizational leaders who avoid costly mistakes.

If you’re a leader who wants to problem-solve effectively, here’s an overview of root cause analysis and why it’s important in organizational leadership.

Access your free e-book today.

What Is Root Cause Analysis?

According to the online course Organizational Leadership —taught by Harvard Business School professors Joshua Margolis and Anthony Mayo— root cause analysis is the process of articulating problems’ causes to suggest specific solutions.

“Leaders must perform as beacons,” Margolis says in the course. “Namely, scanning and analyzing the landscape around the organization and identifying current and emerging trends, pressures, threats, and opportunities.”

By working with others to understand a problem’s root cause, you can generate a solution. If you’re interested in performing a root cause analysis for your organization, here are eight steps you must take.

8 Essential Steps of an Organizational Root Cause Analysis

1. identify performance or opportunity gaps.

The first step in a root cause analysis is identifying the most important performance or opportunity gaps facing your team, department, or organization. Performance gaps are the ways in which your organization falls short or fails to deliver on its capabilities; opportunity gaps reflect something new or innovative it can do to create value.

Finding those gaps requires leveraging the “leader as beacon” form of leadership.

“Leaders are called upon to illuminate what's going on outside and around the organization,” Margolis says in Organizational Leadership , “identifying both challenges and opportunities and how they inform the organization's future direction.”

Without those insights, you can’t reap the benefits an effective root cause analysis can produce because external forces—including industry trends, competitors, and the economy—can affect your company’s long-term success.

2. Create an Organizational Challenge Statement

The next step is writing an organizational challenge statement explaining what the gap is and why it’s important. The statement should be three to four sentences and encapsulate the challenge’s essence.

It’s crucial to explain where your organization falls short, what problems that poses, and why it matters. Describe the gap and why you must urgently address it.

A critical responsibility is deciding which gap requires the most attention, then focusing your analysis on it. Concentrating on too many problems at once can dilute positive results.

To prioritize issues, consider which are the most time-sensitive and mission-critical, followed by which can make stakeholders happy.

3. Analyze Findings with Colleagues

It's essential to work with colleagues to gain different perspectives on a problem and its root causes. This involves understanding the problem, gathering information, and developing a comprehensive analysis.

While this can be challenging when you’re a new organizational leader, using the double helix of leadership —the coevolutionary process of executing organizational leadership's responsibilities while developing the capabilities to perform them—can help foster collaboration.

Research shows diverse ideas improve high-level decision-making, which is why you should connect with colleagues with different opinions and expertise to enhance your root cause analysis’s outcome.

4. Formulate Value-Creating Activities

Next, determine what your company must do to address your organizational challenge statement. Establish three to five value-creating activities for your team, department, or organization to close the performance or opportunity gap you’ve identified.

This requires communicating organizational direction —a clear and compelling path forward that ensures stakeholders know and work toward the same goal.

“Setting direction is typically a reciprocal process,” Margolis says in Organizational Leadership . “You don't sit down and decide your direction, nor do you input your analysis of the external context into a formula and solve for a direction. Rather, setting direction is a back-and-forth process; you move between the value you'd like to create for customers, employees, investors, and your grasp of the context.”

5. Identify Necessary Behavior Changes

Once you’ve outlined activities that can provide value to your company, identify the behavior changes needed to address your organizational challenge statement.

“Your detective work throughout your root cause analysis exposes uncomfortable realities about employee competencies, organizational inefficiencies, departmental infighting, and unclear direction from leadership at multiple levels of the company,” Mayo says in Organizational Leadership .

Factors that can affect your company’s long-term success include:

• Ineffective communication skills
• Resistance to change
• Problematic workplace stereotypes

Not all root cause analyses reveal behaviors that must be eliminated. Sometimes you can identify behaviors to enhance or foster internally, such as:

• Collaboration
• Innovative thinking
• Creative problem-solving

6. Implement Behavior Changes

Although behaviors might be easy to pinpoint, putting them into practice can be challenging.

To ensure you implement the right changes, gauge whether they’ll have a positive or negative impact. According to Organizational Leadership , you should consider the following factors:

• Motivation: Do the people at your organization have a personal desire for and commitment to change?
• Competence: Do they have the skills and know-how to implement change effectively?
• Coordination: Are they willing to work collaboratively to enact change?

Based on your answers, decide what behavior changes are plausible for your root cause analysis.

7. Map Root Causes

The next step in your analysis is mapping the root causes you’ve identified to the components of organizational alignment. Doing so helps you determine which components to adjust or change to implement employee behavior changes successfully.

Three root cause categories unrelated to behavior changes are:

• Systems and structures: The formal organization component, including talent management, product development, and budget and accountability systems
• People: Individuals’ profiles and the workforce’s overall composition, including employees’ skills, experience, values, and attitudes
• Culture: The informal, intangible part of your organization, including the norms, values, attitudes, beliefs, preferences, common practices, and habits of its employees

8. Create an Action Plan

Using your findings from the previous steps, create an action plan for addressing your organizational problem’s root cause and consider your role in it.

To make the action plan achievable, ensure you:

• Identify the problem’s root cause
• Create measurable results
• Ensure clear communication among your team

“One useful way to assess your potential impact on the challenge is to understand your locus of control,” Mayo says in Organizational Leadership , “or the extent to which you can personally drive the needed change or improvement.”

The best way to illustrate your control is by using three concentric circles: the innermost circle being full control of resources, the middle circle representing your ability to influence but not control, and the outermost circle alluding to shifts outside both your influence and control.

Consider these circles when implementing your action plan to ensure your goals don’t overreach.

The Importance of Root Cause Analysis in Organizational Leadership

Root cause analysis is a critical organizational leadership skill for effectively addressing problems and driving change. It helps you understand shifting conditions around your company and confirm that your efforts are relevant and sustainable.

As a leader, you must not only effect change but understand why it’s needed. Taking an online course, such as Organizational Leadership , can enable you to gain that knowledge.

Using root cause analysis, you can identify the issues behind your organization’s problems, develop a plan to address them, and make impactful changes.

Are you preparing to transition to a new leadership role? Enroll in our online certificate course Organizational Leadership —one of our leadership and management courses —and learn how to perform an effective root cause analysis to ensure your company’s long-term success. To learn more about what it takes to be an effective leader, download our free leadership e-book .

About the Author

Root Cause Analysis (RCA) Methods for Effective Problem Solving

By Status.net Editorial Team on May 8, 2023 — 7 minutes to read

Imagine facing a problem in your organization that keeps recurring despite your best efforts to solve it. You might be addressing the symptoms, but not the underlying cause. This is where root cause analysis (RCA) comes into play. RCA is a systematic approach to identifying the root cause of problems or events, understanding how to fix or compensate for them, and applying the knowledge gained to prevent future issues or replicate successes. In this comprehensive guide to root cause analysis, you’ll learn various methods and techniques for conducting an RCA. You’ll understand how to gather and manage evidence, investigate the people, processes, and systems involved, and determine the key factors leading to the problem or event.

Whether you’re a project manager, a team leader, or simply someone looking to improve your problem-solving skills, this guide will help you grasp the fundamentals of RCA and apply them effectively in your work. As you delve deeper into the world of Root Cause Analysis, you’ll discover how it can turn challenges into opportunities for growth and pave the way for a more efficient and successful future.

Related: 3 Root Cause Analysis Templates (and Examples)

5 Whys: How to Uncover Root Causes [Examples]

Root Cause Analysis Fundamentals

Root Cause Analysis (RCA) is a systematic approach to identify the underlying cause of a problem. By focusing on the root cause, you can effectively address the issue and prevent recurrence. Generally, RCA is used to investigate incidents, eliminate defects, and enhance systems or processes.

RCA aims to achieve the following objectives:

• Determine the root cause of a problem or issue, not just its symptoms.
• Identify and implement solutions that address the root cause and prevent its recurrence.
• Improve understanding of the systems, processes, or components involved to avoid similar issues in the future.
• Foster a proactive and continuous improvement mindset within your organization.

When conducting RCA, maintain an open mind and avoid making assumptions. Utilize critical thinking and involve team members from various disciplines to achieve a comprehensive understanding of the problem.

The RCA Process

Problem identification.

To effectively utilize Root Cause Analysis (RCA), first identify the problem at hand. Determine the specific issue, incident, or failure that needs to be investigated. Clearly define the problem and its impact on your organization’s operations in order to establish a focused and valuable analysis.

Data Collection

Gather relevant data about the problem, including when and where it occurred, who was involved, what processes and systems were affected, and any other important context. Be thorough and systematic in your data collection, and make use of any available documentation, interviews, or observations to build a comprehensive understanding.

Cause Identification

Analyze the collected data to pinpoint potential causes of the problem. This could start with brainstorming and then using tools such as cause-and-effect diagrams or the “5 Whys” technique to delve deeper into the issue. Determine the causes that are most likely to have contributed to the problem and classify them as either root causes or contributing factors.

Solution Implementation

Once you have identified the root cause(s) of the problem, develop and execute an action plan to address the issue. Design solutions that specifically target the root cause(s) to eliminate them from your processes, rather than simply addressing the symptoms of the problem. Implement the appropriate changes to your processes or systems and ensure that all stakeholders are aware of these changes.

Follow-up and Monitoring

After implementing the solutions, monitor the results to ensure they are effective in addressing the root cause(s) and preventing the problem from reoccurring. Collect and analyze data regularly to evaluate the impact of the implemented solutions on your organization’s performance. Adjust and refine the solutions if necessary, and maintain ongoing vigilance in order to identify any future problems that may arise from the same root cause(s).

RCA Techniques

The 5 Whys technique is a straightforward method for identifying the root cause of a problem. To employ this approach, you simply ask “why” five times, with each question delving deeper into the issue. The process helps trace the problem to its origin by examining each level of cause and effect. Here’s an example:

• Why did the machine stop working?
• Why did the fuse blow?
• Why did the motor overheat?
• Why was there insufficient lubrication on the motor?
• Why was the lubrication schedule not followed?

In this case, the root cause is the failure to adhere to the lubrication schedule.

Learn more: 5 Whys: How to Uncover Root Causes [Examples]

Fishbone Diagram

The Fishbone Diagram, also known as the Ishikawa Diagram or cause-and-effect diagram, is a visual tool that helps you organize and sort potential root causes. To create a Fishbone Diagram:

• Write down the problem statement at the head of the fishbone structure.
• Identify major categories of causes, such as people, process, equipment, and environment. Draw lines connecting them to the problem statement.
• Assign specific causes under each category and draw smaller lines connecting them to the respective major categories.
• Analyze the diagram to find trends, patterns, or potential areas of focus.

By organizing information in this way, you can better assess the causes and identify the root cause of the problem.

Learn more: Fishbone Diagram (Components, Factors, Examples) and Ishikawa Diagram: Examples and Applications

Failure Modes and Effects Analysis (FMEA) is a systematic approach to identify potential failures and evaluate the consequences. FMEA processes typically involve these steps:

• Identify potential failure modes, which are the ways something could go wrong.
• Determine the potential effects of each failure mode, and how it could impact the overall system or process.
• Assign a risk priority number (RPN) to each failure mode, considering factors such as likelihood, severity, and detectability.
• Develop actions and strategies to mitigate high-risk failure modes.

By using FMEA, you can proactively address possible issues before they escalate, and maintain a more reliable process or system.

Barrier Analysis

Barrier Analysis focuses on preventing problems by examining the barriers in place to control risks. The objective is to identify vulnerabilities in these barriers and develop strategies for improvement. The steps of Barrier Analysis include:

• Identify hazards and risks associated with your system or process.
• Define the barriers in place that protect against these hazards.
• Evaluate the effectiveness, strength, and reliability of each barrier.
• Identify gaps or weaknesses in the barriers.
• Develop and implement improvements to strengthen the barriers.

This method provides a clear understanding of how existing safety measures perform and how they can be improved to better protect against potential issues.

See also: 3 Root Cause Analysis Templates (and Examples)

What is Poka-Yoke? [Examples, Principles, Methods]

Benefits of Root Cause Analysis

Quality improvement.

Root cause analysis can significantly enhance the quality of your products or services. By systematically identifying the root causes of issues and implementing corrective actions, you’ll prevent recurring problems and reduce the number of defects. In turn, this will help you maintain customer satisfaction, reduce costs associated with rework or returns, and improve your reputation in the market.

Risk Reduction

Reducing risk is another advantage of root cause analysis. When you identify the underlying causes of problems, you can take necessary measures to eliminate or mitigate those risks. This proactive approach can protect your business from potential losses or disruptions, such as regulatory penalties, customer dissatisfaction, or harm to employees or the environment. By addressing the sources of risk, you can maintain a safer and more profitable business.

Process Optimization

Root cause analysis supports continuous improvement by highlighting inefficiencies and areas for optimization in your operations. By examining your processes beyond the symptoms of a specific issue, you can uncover opportunities to streamline workflows, reduce waste or downtime, and better utilize resources. Implementing these improvements not only resolves the immediate problem but also enhances overall productivity and efficiency in your organization.

To attain the benefits of root cause analysis, apply it consistently and rigorously. Ensure that you involve relevant stakeholders, gather necessary data, and employ a systematic approach to identifying and addressing root causes.

Challenges of Root Cause Analysis

Common pitfalls.

When conducting Root Cause Analysis (RCA), you might face common pitfalls that can reduce the effectiveness of your investigation. Some of these pitfalls include:

• Rushing the process : It is important to allocate appropriate time and resources to conduct a thorough RCA.
• Overlooking small details : Make sure to pay attention to all possible contributing factors when investigating a problem. Small details can often hold the key to the root cause.
• Focusing on blame : RCA should focus on identifying systemic issues and providing solutions rather than blaming individuals or departments.

Addressing Human Factors

Human factors play a critical role in many problems. When conducting RCA, it is crucial to consider the human factors that may have contributed to the issue. Here are some tips to help you address human factors in your RCA:

• Consider psychological factors : Assess the mental state of the people involved in the incident, including their level of stress, fatigue, and emotions.
• Evaluate communication and collaboration : Analyze how effectively teams were communicating and working together at the time of the incident.
• Assess training and competency : Determine if the people involved had the appropriate training and knowledge to handle the situation.

Keep a neutral and non-blaming tone while assessing human factors. The aim is to uncover systemic issues that can be improved upon.

Fishbone Diagram (Components, Factors, Examples)

Ishikawa Diagram: Examples and Applications

• Advantages of SWOT Analysis (6 Benefits and 4 Limitations)
• Top Problem Solving Skills for Today's Job Market
• What is Problem Solving? (Steps, Techniques, Examples)

• Quality Management

6 Best Root Cause Analysis Tools for Problem-Solving

Root Cause Analysis is a disciplined approach to analyze data. It not only identifies the symptoms but also the underlying cause of the problem. RCA does not provide a temporary fix for the problem but acts like a band-aid for that. This reduces wastage in terms of time and resources. As we can gather from its name, it pinpoints the root cause of the problem. After getting a hold of the root cause, we can move forward to resolve the issues. In other words, we can say that RCA is a valuable tool for those organizations that are looking forward to improving their output. This analysis results in saving time, money, and valuable resources. Now that we get a hold of what Root Cause Analysis means, let us move forward to its tools. 

• A manufacturing company uses RCA to identify the root cause of a quality defect in their output. 
• Hospitals uses RCA for medical errors
• Software companies use RCA for debugging. 

Jump ahead to

Root Cause Analysis Tools

Root Cause Analysis tools help in ensuring Quality Management. Whichever domain you choose to work in, quality is the priority for everyone, everywhere. To ensure and support quality management, root cause analysis tools come into action. They identify a problem and find the root cause of the issue we’re dealing with. Their sole purpose is not only to identify the problem but also to provide measures to deal with it.

There are several tools, but here we are going to learn Six Sigma Root Cause Analysis tools. Let’s dive right in:

Pareto Charts

Quality Management professionals use Pareto charts, also known as Pareto diagrams, as tools. They are a combination of bar graphs and line graphs. These charts detect the potential issue or problem and carry out the probable solutions for the same to ensure quality. In these charts, the bars present themselves in descending order. The purpose of using this Root Cause Analysis Tool is that it collects the data and represents it in the form of charts for people to understand it.

These charts work on Pareto Principles of Root Cause Analysis. This principle states that 20% of the causes determine 80% of the results. Professionals should also focus on the fact that this principle does not always work. So, they should not only rely on this principle.

In this modern era, these Pareto charts and/or diagrams determine the most critical and complex issues across different departments. This analysis avoids wasting the project’s or organization’s most scarce resource by identifying and addressing the critical issues that require our immediate attention or focus. 

Failure Mode And Effect Analysis (FMEA)

Failure Mode and Effect Analysis (FMEA) is a step-by-step process for collecting information. The project or design team carries out knowledge of potential failures and their possible effects based on the provided information. It is a two-way process; the first is failure mode. It is a risk-measuring tool that scales from 1 to 10. If the risk scale is at 1, then the risk is low, while 10 shows a very high risk. 

In Failure Mode, we determine all the possible ways that may cause a failure or breakdown in a project. It affects the customer, as it includes all the errors. For example, for some reason, your water tap is not working. In that case, you would carry out all the potential reasons for that, like the pipes are not working or there is something wrong with the tap, etc., which are the potential causes of failure. 

In Effect Analysis, we involve all the consequences of the failure. We perform this analysis to ensure that we detect all failures or breakdowns. By examining how frequently those failures occur and determining which failures should be prioritized first, it is done. This is to ensure that the failures or breakdowns that need our immediate attention are being attended to.

By proactively analyzing the failures before their occurrence, we may use this root cause analysis tool to identify possible issues before they arise. We might save a lot of time and money by identifying these mistakes early on and assessing how they might affect other people. This analytical tool minimizes the impact of the issue by analyzing and pointing it out. 

5 Whys 

The 5 whys technique is a traditional tool for RCA. It was first introduced in the 1930s. Then in the 1970s, it reached its peak of popularity. So, what is this 5 Whys method?

Its technique is true to its philosophy and its traditions, people consider it the most effective problem-solving method. This technique is as simple as writing the alphabet; whenever a problem occurs, your instant response to that should be Why? five times. Then the answer or the cause becomes apparent; we just need to work on that cause. However, this technique is not suitable for a complex or critical situation as it focuses solely on a single problem. If we keep on going with this technique in a complex situation, all the other problems that require our attention would be left out. 

5 Whys technique stands out as one of the most accessible among other analytical techniques as it doesn’t require extensive critical thinking in forming the solutions. Simply asking WHY to each of the issues being stated towards us. The answers to all those WHYS would ultimately lead us toward the root cause. With this, we could state that the 5 Whys analysis systematically peels back the layers of analysis.  

Ishikawa Fishbone Diagram  

This RCA tool is used by individuals to solve critical and complex problems. For the problems for which we are not able to identify the root cause, we need brainstorming process to be introduced. First, we identify a problem and then we carry out all potential causes for that problem. Breaking those potential causes into subcategories one after another causes them to link back to the main problem to investigate the root cause of the problem. Investigators continue the investigation till they find the exact cause.

This Fishbone diagram’s visual map reveals the relationship between the potential cause and the problem which makes it easier to trace it back to its origin. This comprehensive overview of the project or the business information gives clarity for project managers to streamline the analysis of the problem. 

Fault Tree Analysis

This analysis is also known as Event Tree Analysis. This method identifies  possible causes of failure in a project. In this analysis, we graphically illustrate and diagrammatically show the different potential causes of the failure. It makes the identification of the cause easy. With the diagram, we can identify the problem and the cause of its occurrence. 

This analysis works on three major steps:

• Creation of FTA.
• identifying all the contributing factors. 
• Evaluation of failures and their contributing factors. 

Scatter Diagram

A scatter diagram is also known as a scatter plot. We take two sets of data and then we show the visual representation of their relationship. In simple words, it is a quantitative method that tests the correlation between two sets of data. In this analysis tool, we plot the root cause of the problem on the x-axis and the dependent effect on the y-axis to determine the suspected cause. If the patterns intersect each other in this diagram, forming a clear line or curve, we can determine that they correlate to each other.

This diagram highlights the patterns and trends in the data between variables and demonstrates how these affect each other. This helps us state that different factors which are not related to each other can still affect the project. As we can gather from its name, it focuses on two potential variables by illuminating a clear relationship between them and by providing valuable insight for root cause analysis. 

All these six tools work as detectives in figuring out the root cause of the failure of a project. They offer techniques that are unique in their own way. A single tool or technique in Root Cause Analytic Tools can sometimes not work alone, but a blend of them could surely lead us towards the solution of the failure. These RCA Tools not only identify the root cause of the failure but also suggest measures for its prevention. We should tailor our approach to every step. To gain command over these root cause analysis tools a professionals can take up RCA Through Six Sigma Training program .

Related Articles

Quality Control Inspector – Roles and Responsibilities 

Six Sigma Root Cause Analysis For Your Business

Quality Management in the Era of Smart Logistics

Trends in Quality Management 2024

• Get Your Maintenance and Reliability Training from Experts

List of Essential Root Cause Analysis Tools to Use In the RCA Process

Useful root cause analysis tools to use in each phase of the rca process, rca is used to investigate and address unwanted problems, troubles, and failures, be they within a procedure; from a business or operational process; or in a physical asset..

Root Cause Analysis (RCA) is a problem-solving methodology that steps you through the RCA process. Each RCA process phase has a range of root cause analysis tools that you can use. The RCA process starts at the problem event then moves through evidence collection, investigation, analysis, developing corrective actions to address the problem or a failure, and concludes with the RCA Report.

Figure 1 is a slide from our online root cause analysis training course by tutored distance learning . It shows the basic RCA process and the root cause analysis tools you can use in each step. There are more advanced, highly technical RCA tools too, but the ones bullet pointed in Figure 1 are the foundational tools that can be applied in every RCA.

Figure 1 – A Range of Basic Root Cause Analysis Tools to Use in Each Phase of the RCA Process

Evidence Collection Phase Root Cause Analysis Tools

At the beginning of an RCA, you want to understand what happened before and during the failure event. You seek information and data from all possible sources about the history leading up to the incident. There are several RCA tools to use, like:

• Protect Equipment/Location
• Documents, Records, Diagrams
• Creative Disassembly of Parts
• Scatter Diagrams
• Control Charts, Run Charts
• Expert Investigation

  The Evidence Collection RCA tools aim to garner all that is known about the situational circumstances, including personal experiences, the engineering and technical details, the relevant body-of-knowledge, and what is recorded in the organization’s systems.

Investigation Phase Root Cause Analysis Tools

Once evidence is collected, it is necessary to find the truth amongst the noise. The event history is investigated with root cause analysis tools like those noted below.

• Process Mapping Flowchart
• Fishbone Diagram
• Cause and Effect Map
• Timeline Plots
• Distribution Histograms
• Pareto Charts
• Failure Mode Effects Analysis (FMEA)

  These RCA tools interrogate the event data, records, and information. They force you to look for the factual details of the incident. They allow you to identify relevant and missing aspects to explain what occurred.

Analysis Phase Root Cause Analysis Tools

Now that we have the full, accurate history, we need RCA tools to help understand the sequence of cause-effect events associated with the incident. Common tools often used include:

• Brainstorming
• Brain Writing
• Is-Is Not Table
• Why Tree (Fault Tree Analysis)
• 5-Why Table (to test the Why Tree)

  At this point in the root cause analysis process, it is time to confirm the truth and provide sure proof. The analysis phase tools review the sequence of operations, actions, decisions, and misunderstandings that led to the failure event.

Corrective Action Choice Phase Root Cause Analysis Tools

Finally, a viable, practical, and affordable solution needs to be found to put into the RCA Report. The following RCA tools can be used to help find an effective solution to address the factors that caused the problem.

• Evaluation Table
• Affinity Diagrams
• Relationship Digraph

  The recommendation chosen for the RCA Report must stop the event from happening again at a cost the organization can pay for to implement. Proposed solutions must be sure to address as many factors related to the causes of the event as possible. These choice-making tools give you a means to confirm that what is recommended does focus on addressing the incident’s causes at an affordable price.

Once the Root Cause Analysis Report is passed to Management the RCA is finished. The decision to make recommended changes is the responsibility of Management. When the go-ahead is given the required work is an improvement project and project management methodology is applied.

There is a great deal to know if you want to do Root Cause Analysis to top class performance. You are welcome to see if the Root Cause Analysis course by distance learning is of value in your training.

You can also get the 2-day Advanced Root Cause Analysis training course PPT presentation materials from our online shop to review and find new knowledge and solutions to use in your operation.

• Mission and Values
• Privacy Policy
• License Our Courses

Quick Links

• Example Training
• Example Tutorials
• Example Articles
• Online Store

Help & Support

• Subscribe for Training News

Lifetime Reliability Solutions | World Class Reliability – All rights reserved.

5 Root Cause Analysis Tools for More Effective Problem-Solving

Next to defining a problem accurately, root cause analysis is one of the most important elements of problem-solving in quality management. That’s because if you’re not aiming at the right target, you’ll never be able to eliminate the real problem that’s hurting quality.

So which type of root cause analysis tool is the best one to use? Manufacturers have a range of methods at their fingertips, each of which is appropriate for different situations. Below we discuss five common root cause analysis tools, including:

• Pareto Chart
• Fishbone Diagram
• Scatter Diagram
• Failure Mode and Effects Analysis (FMEA)

Download our free Root Cause Analysis 101 Guidebook Read 14 quality metrics every executive should know

1. Pareto Chart

A Pareto chart is a histogram or bar chart combined with a line graph that groups the frequency or cost of different problems to show their relative significance. The bars show frequency in descending order, while the line shows cumulative percentage or total as you move from left to right.

The Pareto chart example above is a report from layered process audit software that groups together the top seven categories of failed audit questions for a given facility. Layered process audits (LPAs) allow you to check high-risk processes daily to verify conformance to standards. LPAs identify process variations that cause defects, making Pareto charts a powerful reporting tool for analyzing LPA findings.

Pareto charts are one of the seven basic tools of quality described by quality pioneer Joseph Juran. Pareto charts are based on Pareto’s law, also called the 80/20 rule, which says that 20% of inputs drive 80% of results.

Learn how to create Pareto charts in this post or download the Pareto Chart Tip Sheet and Sample Excel File

The 5 Whys is a method that uses a series of questions to drill down into successive layers of a problem. The basic idea is that each time you ask why, the answer becomes the basis of the next why. It’s a simple tool useful for problems where you don’t need advanced statistics, so you don’t necessarily want to use it for complex problems.

One application of this technique is to more deeply analyze the results of a Pareto analysis. Here’s an example of how to use the 5 Whys:

Problem: Final assembly time exceeds target

• Why is downtime in final assembly higher than our goal? According to the Pareto chart, the biggest factor is operators needing to constantly adjust Machine A
• Why do operators need to constantly adjust Machine A? Because it keeps having alignment problems
• Why does Machine A keep having alignment problems? Because the seals are worn
• Why are Machine A’s seals worn? Because they aren’t being replaced as part of our preventive maintenance program
• Why aren’t they being replaced as part of our preventive maintenance program? Because seal replacement wasn’t captured in the needs assessment

Of course, it may take asking why more than five times to solve the problem—the point is to peel away surface-level issues to get to the root cause.

Learn more about the 5 Whys method in this blog post or download our free 5 Whys worksheet

3. Fishbone Diagram

A fishbone diagram sorts possible causes into various categories that branch off from the original problem. Also called a cause-and-effect or Ishakawa diagram, a fishbone diagram may have multiple sub-causes branching off of each identified category.

Learn more about how to use a fishbone diagram in this blog post and download our free set of fishbone diagram templates

4. Scatter Plot Diagram

A scatter plot or scatter diagram uses pairs of data points to help uncover relationships between variables. A scatter plot is a quantitative method for determining whether two variables are correlated, such as testing potential causes identified in your fishbone diagram.

Making a scatter diagram is as simple as plotting your independent variable (or suspected cause) on the x-axis, and your dependent variable (the effect) on the y-axis. If the pattern shows a clear line or curve, you know the variables are correlated and you can proceed to regression or correlation analysis.

Download a free tip sheet to start creating your own scatter diagrams today!

5. Failure Mode and Effects Analysis (FMEA)

Failure mode and effects analysis (FMEA) is a method used during product or process design to explore potential defects or failures. An FMEA chart outlines:

• Potential failures, consequences and causes
• Current controls to prevent each type of failure
• Severity (S), occurrence (O) and detection (D) ratings that allow you to calculate a risk priority number (RPN) for determining further action

When applied to process analysis, this method is called process failure mode and effects analysis (PFMEA). Many manufacturers use PFMEA findings to inform questions for process audits , using this problem-solving tool to reduce risk at the source.

No matter which tool you use, root cause analysis is just the beginning of the problem-solving process. Once you know the cause, the next step is implementing a solution and conducting regular checks to ensure you’re holding the gain and achieving sustainable continuous improvement.

Download our free Root Cause Analysis 101 Guidebook

Related articles

Root Cause Problem Solving - Methods and Tools PD530931

Topics: Management and Organization Management and Organization , Failure analysis , Analysis methodologies

How do you solve a problem? Do you find yourself using quick and easy solutions or a structured methodology? Too often, organizations tend to seek quick solutions to a problem without adequately addressing its underlying cause. These decisions often result in solutions that don't work or aren't sustainable, often wasting time, effort, and money. To combat these issues and adopt a fresh approach, teams can use the methods and tools of root cause problem solving. By first viewing a problem as an opportunity for improvement, the team can then identify the problem's root cause or causes, and implement solutions to prevent the problem's reoccurrence.

This six module course introduces the Root Cause Problem Solving approach. It explains how using Root Cause analysis can help improve operational and financial performance by identifying root causes and implementing solutions to significant or recurring problems. This methodology is used by many major automotive manufacturers to improve quality and customer satisfaction, reduce operation costs, and provide greater employee knowledge of work processes.

Participants will become familiar with the eight steps of the Root Cause Problem Solving approach, learning the key actions completed in each step and interacting with examples and scenarios that demonstrate how each step functions to solve problems and keep them from reoccurring in an organization. Participants will also be supplied with tools that assist with the completion of each step that they can use in their own problem-solving efforts on-the-job.

By participating in this eLearning course, you'll be able to:

• Explain why root cause analysis using the 8-step problem solving methodology is more effective than non-structured problem solving efforts
• Define the difference between a problem, symptom, cause, and root cause
• Use tools and techniques to solve problems
• Evaluate the effectiveness of problems solving efforts
• Describe the role of problem solving in continuous improvement

Materials Provided

• 90 days of online single-user access (from date of purchase) to the six hour presentation
• Integrated knowledge checks to reinforce key concepts
• Follow-up to your content questions
• 1.0 CEUs*/Certificate of Achievement (upon completion of all course content and a score of 70% or higher on the learning assessment)

*SAE International is authorized by IACET to offer CEUs for this course.

Is this On Demand Course for You?

This course is applicable to those directly working in or responsible for performance improvement of any definable, repetitive process (e.g., manufacturing, design, logistics, purchasing, sales, or distribution), including: manufacturing managers, supervisors, and team leaders; manufacturing engineers; design engineers; quality engineers and technicians; technical managers; project team leaders; problem solving and quality improvement facilitators; anyone whose role includes problem solving: supervisors and lead personnel.

Testimonial

"Thank you for introducing me to the SAE Root Cause Problem Solving course. Quality has been my vocation for 11 years and this course opened my eyes to so many things I have been missing. It should be required for anyone in the quality business." Chuck Hartshorn Quality Manager

For More Details

Email [email protected] , or call 1-877-606-7323 (U.S. and Canada) or 724-776-4970 (outside US and Canada).

• Windows 7, 8, 10 (other operating systems and mobile platforms are not supported but may work)
• Internet Explorer 11, Mozilla Firefox 37, Google Chrome 42 (other browsers are not supported but may work)
• Broadband-1Mbps minimum

How it works

For Business

Join Mind Tools

Article • 11 min read

Getting to the Root of a Problem Quickly

By the Mind Tools Content Team

5 Whys Root-Cause Analysis

Have you ever had a problem that refused to go away? No matter what you did, sooner or later it would return, perhaps in another form.

Stubborn or recurrent problems are often symptoms of deeper issues. "Quick fixes" may seem convenient, but they often solve only the surface issues and waste resources that could otherwise be used to tackle the real cause.

In this article and in the video, below, we look at the 5 Whys technique (sometimes known as 5Y). This is a simple but powerful tool for cutting quickly through the outward symptoms of a problem to reveal its underlying causes – so that you can deal with it once and for all.

Origins of the 5 Whys Technique

Sakichi Toyoda, the Japanese industrialist, inventor, and founder of Toyota Industries, developed the 5 Whys technique in the 1930s. It became popular in the 1970s, and Toyota still uses it to solve problems today.

Toyota has a "go and see" philosophy. This means that its decision making is based on an in-depth understanding of what's actually happening on the shop floor , rather than on what someone in a boardroom thinks might be happening.

The 5 Whys technique is true to this tradition, and it is most effective when the answers come from people who have hands-on experience of the process or problem in question.

The method is remarkably simple: when a problem occurs, you drill down to its root cause by asking "Why?" five times. Then, when a counter-measure becomes apparent, you follow it through to prevent the issue from recurring.

The 5 Whys uses "counter-measures," rather than "solutions." A counter-measure is an action or set of actions that seeks to prevent the problem from arising again, while a solution may just seek to deal with the symptom. As such, counter-measures are more robust, and will more likely prevent the problem from recurring.

When to Use a 5 Whys Analysis

You can use 5 Whys for troubleshooting, quality improvement, and problem solving, but it is most effective when used to resolve simple or moderately difficult problems.

It may not be suitable if you need to tackle a complex or critical problem. This is because 5 Whys can lead you to pursue a single track, or a limited number of tracks, of inquiry when, in fact, there could be multiple causes. In cases like these, a wider-ranging method such as Cause and Effect Analysis or Failure Mode and Effects Analysis may b e more effective.

This simple 5 Whys technique, however, can often direct you quickly to the root cause of a problem. So, whenever a system or process isn't working properly, give it a try before you embark on a more in-depth approach – and certainly before you attempt to develop a solution.

The tool's simplicity gives it great flexibility, too, and 5 Whys combines well with other methods and techniques, such as Root Cause Analysis . It is often associated with Lean Manufacturing , where it is used to identify and eliminate wasteful practices. It is also used in the analysis phase of the Six Sigma quality improvement methodology.

How to Use the 5 Whys

The model follows a very simple seven-step process: [1]

1. Assemble a Team

Gather together people who are familiar with the specifics of the problem, and with the process that you're trying to fix. Include someone to act as a facilitator , who can keep the team focused on identifying effective counter-measures.

2. Define the Problem

If you can, observe the problem in action. Discuss it with your team and write a brief, clear problem statement that you all agree on. For example, "Team A isn't meeting its response time targets" or "Software release B resulted in too many rollback failures."

Then, write your statement on a whiteboard or sticky note, leaving enough space around it to add your answers to the repeated question, "Why?"

3. Ask the First "Why?"

Ask your team why the problem is occurring. (For example, "Why isn't Team A meeting its response time targets?")

Asking "Why?" sounds simple, but answering it requires serious thought. Search for answers that are grounded in fact: they must be accounts of things that have actually happened, not guesses at what might have happened.

This prevents 5 Whys from becoming just a process of deductive reasoning, which can generate a large number of possible causes and, sometimes, create more confusion as you chase down hypothetical problems.

Your team members may come up with one obvious reason why, or several plausible ones. Record their answers as succinct phrases, rather than as single words or lengthy statements, and write them below (or beside) your problem statement. For example, saying "volume of calls is too high" is better than a vague "overloaded."

4. Ask "Why?" Four More Times

For each of the answers that you generated in Step 3, ask four further "whys" in succession. Each time, frame the question in response to the answer you've just recorded.

What Is a 5 Whys Template?

The diagram, below, shows an example of 5 Whys in action, following a single lane of inquiry.

Figure 1: 5 Whys Example (Single Lane)

The 5 Whys method also allows you to follow multiple lanes of inquiry. An example of this is shown in Figure 2, below.

In our example, asking "Why was the delivery late?" produces a second answer (Reason 2). Asking "Why?" for that answer reveals a single reason (Reason 1), which you can address with a counter-measure.

Similarly, asking "Why did the job take longer than expected?" has a second answer (Reason 2), and asking "Why?" at this point reveals a single reason (Reason 1). Another "Why?" here identifies two possibilities (Reasons 1 and 2) before a possible counter-measure becomes evident.

There is also a second reason for "Why we ran out of printer ink" (Reason 2), and a single answer for the next "Why?" (Reason 1), which can then be addressed with a counter-measure.

Figure 2: 5 Whys Example (Multiple Lanes)

Step 5. Know When to Stop

You'll know that you've revealed the root cause of the problem when asking "why" produces no more useful responses, and you can go no further. An appropriate counter-measure or process change should then become evident. (As we said earlier, if you're not sure that you've uncovered the real root cause, consider using a more in-depth problem-solving technique like Cause and Effect Analysis , Root-Cause Analysis , or FMEA .)

If you identified more than one reason in Step 3, repeat this process for each of the different branches of your analysis until you reach a root cause for each one.

6. Address the Root Cause(s)

Now that you've identified at least one root cause, you need to discuss and agree on the counter-measures that will prevent the problem from recurring.

7. Monitor Your Measures

Keep a close watch on how effectively your counter-measures eliminate or minimize the initial problem. You may need to amend them, or replace them entirely. If this happens, it's a good idea to repeat the 5 Whys process to ensure that you've identified the correct root cause.

Appreciation

A similar question-based approach known as "appreciation" can help you to uncover factors in a situation that you might otherwise miss.

It was originally developed by the military to assist commanders in gaining a comprehensive understanding of any fact, problem or situation. But you can also apply it in the workplace.

Starting with a fact, you first ask the question, "So what?" – in other words, what are the implications of that fact? Why is this fact important?

You then continue asking that question until you've drawn all possible conclusions from it.

The major difference between this and the 5 Whys technique is that appreciation is often used to get the most information out of a simple fact or statement, while 5 Whys is designed to drill down to the root of a problem.

Tips for Using the 5 Whys Technique

• Try to move quickly from one question to the next. That way, you'll have the full picture before you jump to any conclusions.
• The "5" in 5 Whys is really just a " rule of thumb ." In some cases, you may need to ask "Why?" a few more times before you get to the root of the problem. In other cases, you may reach this point before you ask your fifth "Why?" If you do, make sure that you haven't stopped too soon, and that you're not simply accepting "knee-jerk" responses.
• Know when to stop! The important point is to stop asking "Why?" when you stop producing useful responses.

Frequently Asked Questions About 5 Whys

1. what is the 5 whys technique.

The 5 Whys Technique is a problem-solving method involving repeatedly asking "why?" It's a way of quickly getting to the root cause of a situation.

2. Who Invented 5 Whys?

The 5 Whys technique was invented in the 1930s by Sakichi Toyoda, the Japanese industrialist, inventor, and founder of Toyota Industries.

5 Whys Infographic

See our infographic on the 5 Whys and use it to get to the root of your problems!

Bear in mind that appreciation can restrict you to one line of thinking. For instance, once you've answered your first "So what?" question, you might follow a single line of inquiry to its conclusion. To avoid this, repeat the appreciation process several times over to make sure that you've covered all bases.

The 5 Whys strategy is a simple, effective tool for uncovering the root of a problem. You can use it in troubleshooting, problem-solving, and quality-improvement initiatives.

Start with a problem and ask why it is occurring. Make sure that your answer is grounded in fact, and then ask the question again. Continue the process until you reach the root cause of the problem, and you can identify a counter-measure that will prevent it from recurring.

Bear in mind that this questioning process is best suited to simple or moderately difficult problems. Complex problems may benefit from a more detailed approach, although using 5 Whys will still give you useful insights.

[1] Pojasek, R. (2000). 'Asking "Why?" Five Times,' Environmental Quality Management , Volume 10, Issue 1, 79–84. Available here . [Accessed July 1, 2022.]

You've accessed 1 of your 2 free resources.

Get unlimited access

Discover more content

Using root cause analysis.

Find the Root of Your Problems

Root Cause Analysis

Tracing a Problem to Its Origins

Add comment

Comments (0)

Be the first to comment!

Team Management

Learn the key aspects of managing a team, from building and developing your team, to working with different types of teams, and troubleshooting common problems.

Sign-up to our newsletter

Subscribing to the Mind Tools newsletter will keep you up-to-date with our latest updates and newest resources.

Subscribe now

Business Skills

Personal Development

Leadership and Management

Member Extras

Most Popular

Newest Releases

SWOT Analysis

SMART Goals

Mind Tools Store

About Mind Tools Content

Discover something new today

How to stop procrastinating.

Overcoming the Habit of Delaying Important Tasks

What Is Time Management?

Working Smarter to Enhance Productivity

How Emotionally Intelligent Are You?

Boosting Your People Skills

Self-Assessment

What's Your Leadership Style?

Learn About the Strengths and Weaknesses of the Way You Like to Lead

Recommended for you

Essential negotiation skills.

Reaching an Agreement That Works for You

Business Operations and Process Management

Strategy Tools

Customer Service

Business Ethics and Values

Handling Information and Data

Project Management

Knowledge Management

Self-Development and Goal Setting

Time Management

Presentation Skills

Learning Skills

Career Skills

Communication Skills

Negotiation, Persuasion and Influence

Working With Others

Difficult Conversations

Creativity Tools

Self-Management

Work-Life Balance

Stress Management and Wellbeing

Coaching and Mentoring

Change Management

Managing Conflict

Delegation and Empowerment

Performance Management

Leadership Skills

Developing Your Team

Talent Management

Problem Solving

Decision Making

Member Podcast

• Join Mind Tools

Root Cause Analysis

Tracing a problem to its origins.

In medicine, it's easy to understand the difference between treating the symptoms and curing the condition. A broken wrist, for example, really hurts! But painkillers will only take away the symptoms; you'll need a different treatment to help your bones heal properly.

But what do you do when you have a problem at work? Do you jump straight in and treat the symptoms, or do you stop to consider whether there's actually a deeper problem that needs your attention? If you only fix the symptoms – what you see on the surface – the problem will almost certainly return, and need fixing over and over again.

However, if you look deeper to figure out what's causing the problem, you can fix the underlying systems and processes so that it goes away for good.

What Is Root Cause Analysis?

Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why the problem occurred in the first place. It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

• Determine what happened.
• Determine why it happened.
• Figure out what to do to reduce the likelihood that it will happen again.

RCA assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, you can discover where the problem started and how it grew into the symptom you're now facing.

You'll usually find three basic types of cause:

• Physical causes – Tangible, material items failed in some way (for example, a car's brakes stopped working).
• Human causes – People did something wrong, or did not do something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing).
• Organizational causes – A system, process, or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid).

RCA looks at all three types of causes. It involves investigating the patterns of negative effects, finding hidden flaws in the system, and discovering specific actions that contributed to the problem. This often means that RCA reveals more than one root cause.

You can apply RCA to almost any situation. Determining how far to go in your investigation requires good judgment and common sense. Theoretically, you could continue to trace the root causes back to the Stone Age, but the effort would serve no useful purpose. Be careful to understand when you've found a significant cause that can, in fact, be changed.

To learn more about Root Cause Analysis, watch this video   .

The Root Cause Analysis Process

RCA has five identifiable steps.

Step One: Define the Problem

• What do you see happening?
• What are the specific symptoms?

Step Two: Collect Data

• What proof do you have that the problem exists?
• How long has the problem existed?
• What is the impact of the problem?

You need to analyze a situation fully before you can move on to look at factors that contributed to the problem. To maximize the effectiveness of your RCA, get together everyone – experts and front line staff – who understands the situation. People who are most familiar with the problem can help lead you to a better understanding of the issues.

Finding This Article Useful?

You can learn another 44 problem-solving skills, like this, by joining the Mind Tools Club.

Subscribe to Our Newsletter

Receive new career skills every week, plus get our latest offers and a free downloadable Personal Development Plan workbook.

A helpful tool at this stage is CATWOE   . With this process, you look at the same situation from different perspectives: the Customers, the people (Actors) who implement the solutions, the Transformation process that's affected, the World view, the process Owner, and Environmental constraints.

Step Three: Identify Possible Causal Factors

• What sequence of events leads to the problem?
• What conditions allow the problem to occur?
• What other problems surround the occurrence of the central problem?

During this stage, identify as many causal factors as possible. Too often, people identify one or two factors and then stop, but that's not sufficient. With RCA, you don't want to simply treat the most obvious causes – you want to dig deeper.

Use these tools to help identify causal factors:

• Appreciation   – Use the facts and ask "So what?" to determine all the possible consequences of a fact.
• 5 Whys   – Ask "Why?" until you get to the root of the problem.
• Drill Down   – Break down a problem into small, detailed parts to better understand the big picture.
• Cause and Effect Diagrams   – Create a chart of all of the possible causal factors, to see where the trouble may have begun.

Step Four: Identify the Root Cause(s)

• Why does the causal factor exist?
• What is the real reason the problem occurred?

Use the same tools you used to identify the causal factors (in Step Three) to look at the roots of each factor. These tools are designed to encourage you to dig deeper at each level of cause and effect.

Step Five: Recommend and Implement Solutions

• What can you do to prevent the problem from happening again?
• How will the solution be implemented?
• Who will be responsible for it?
• What are the risks of implementing the solution?

Analyze your cause-and-effect process, and identify the changes needed for various systems. It's also important that you plan ahead to predict the effects of your solution. This way, you can spot potential failures before they happen.

One way of doing this is to use Failure Mode and Effects Analysis   (FMEA). This tool builds on the idea of risk analysis to identify points where a solution could fail. FMEA is also a great system to implement across your organization; the more systems and processes that use FMEA at the start, the less likely you are to have problems that need RCA in the future.

Impact Analysis   is another useful tool here. This helps you explore possible positive and negative consequences of a change on different parts of a system or organization.

Another great strategy to adopt is Kaizen   , or continuous improvement. This is the idea that continual small changes create better systems overall. Kaizen also emphasizes that the people closest to a process should identify places for improvement. Again, with Kaizen alive and well in your company, the root causes of problems can be identified and resolved quickly and effectively.

Root Cause Analysis is a useful process for understanding and solving a problem.

Figure out what negative events are occurring. Then, look at the complex systems around those problems, and identify key points of failure. Finally, determine solutions to address those key points, or root causes.

You can use many tools to support your RCA process. Cause and Effect Diagrams   and 5 Whys   are integral to the process itself, while FMEA   and Kaizen   help minimize the need for RCA in the future.

As an analytical tool, RCA is an essential way to perform a comprehensive, system-wide review of significant problems as well as the events and factors leading to them.

Click on the button below to download a template that will help you log problems, likely root causes and potential solutions. Thanks to Mind Tools Club member weeze for providing the basis for this.

Download Worksheet

This site teaches you the skills you need for a happy and successful career; and this is just one of many tools and resources that you'll find here at Mind Tools. Subscribe to our free newsletter , or join the Mind Tools Club and really supercharge your career!

Rate this resource

The Mind Tools Club gives you exclusive tips and tools to boost your career - plus a friendly community and support from our career coaches! 

Comments (58)

• Over a month ago Michele wrote Hi Kwasi, You are most welcome. Completing a root cause analysis ensures that you identify the core issue to any problem. Michele Mind Tools Team
• Over a month ago Kwasi wrote This is a good start for my career. As it provides profound details of training for a successful career. Thanks for the opportunity.
• Over a month ago minhserge wrote The content of this article is very more so it 's not easy to follow well

Please wait...

Home » Diagram » Unveiling Insights: A Visual Guide to Root Cause Analysis with Visual Paradigm’s 5 Whys Infographic Tool

Unveiling Insights: A Visual Guide to Root Cause Analysis with Visual Paradigm’s 5 Whys Infographic Tool

• Posted on November 6, 2023
• / Under Diagram , Infographics
• / With 1 Comment

Introduction

Root cause analysis is a pivotal aspect of problem-solving, and the 5 Whys technique has proven to be an invaluable tool in uncovering the underlying issues behind a problem. In this guide, we’ll explore how Visual Paradigm, a robust diagramming tool, can be employed to create visually engaging and insightful 5 Whys infographics. By seamlessly integrating the power of Visual Paradigm with the systematic approach of the 5 Whys, we aim to provide a comprehensive framework for efficient root cause analysis.

What is 5 Whys Analysis?

The 5 Whys is a powerful technique for problem-solving and root cause analysis. When combined with Visual Paradigm, a versatile diagramming tool, you can create effective infographics to visually represent the 5 Whys analysis. Here’s a comprehensive guide on using Visual Paradigm for creating a 5 Whys infographic:

Step 1: Install Visual Paradigm

Make sure you have Visual Paradigm installed on your system. You can download it from the official website and follow the installation instructions.

Step 2: Open Visual Paradigm

Launch the Visual Paradigm application and create a new project or open an existing one.

Step 3: Select a Diagram Type

Visual Paradigm offers various diagram types. For the 5 Whys, you can choose either a Fishbone Diagram (Ishikawa) or a Cause and Effect Diagram.

• Go to the “Diagram” menu.
• Select “Fishbone Diagram” or “Ishikawa Diagram.”
• Select “Cause and Effect Diagram.”

Step 4: Add the Problem Statement

Identify and add the problem statement at the head of the fishbone or cause-and-effect diagram. This is the issue you are investigating using the 5 Whys.

Step 5: Create Main Categories

For the Fishbone Diagram, these are typically the major categories that could contribute to the problem. For a Cause and Effect Diagram, these are the main branches extending from the problem statement.

Step 6: Ask the First “Why”

Under each main category or branch, add subcategories or sub-branches to represent possible causes. For each subcategory, ask the first “Why.” Why did this happen? Add these as child elements.

Step 7: Repeat the Process

For each answer to the first “Why,” continue asking “Why” and adding subcategories. Repeat this process until you reach the root causes of the problem.

Step 8: Customize and Format

Enhance the visual appeal of your infographic by customizing colors, shapes, and text styles. Visual Paradigm provides a range of formatting options.

Step 9: Add Details

Include additional information, such as data, evidence, or notes, to support each cause. This helps in a more comprehensive understanding of the problem.

Step 10: Save and Share

Once your 5 Whys infographic is complete, save your project and export the diagram in a preferred format (e.g., image or PDF). You can share it with your team or stakeholders for further analysis or decision-making.

• Use clear and concise language in your diagram.
• Encourage collaboration by sharing the Visual Paradigm project file with team members.

By following these steps, you can leverage Visual Paradigm to create a visually appealing and informative 5 Whys infographic for effective root cause analysis.

5 WHYS Root Cause Analysis Example – Car Won’t Start

Edit this Diagram

5 Whys Root Cause Analysis Example – An electronic Mixer Stopped Working

5 Whys Root Cause Analysis Example – Caught Speeding

By repeatedly asking the question, “Why?”, you can peel away the layers of an issue and get to the root cause of a problem. Keep asking “Why?” until you reach an actionable level.

This guide walks you through the process of utilizing Visual Paradigm to construct a 5 Whys infographic, fostering a deeper understanding of the issues at hand. From the installation of Visual Paradigm to the customization of your infographic, each step is carefully outlined to ensure a seamless and effective root cause analysis. Whether you choose the Fishbone Diagram or the Cause and Effect Diagram, Visual Paradigm offers a user-friendly interface for visually representing the interconnected causes of a problem. Elevate your problem-solving capabilities by combining the analytical prowess of the 5 Whys with the visual prowess of Visual Paradigm.

• What’s New
• Infographics
• Terms of Service
• Privacy Policy
• Security Overview
• Report Abuse

Root Cause Analysis (RCA), Explained

Root Cause Analysis (RCA) is the best way to find out what causes an issue in your IT operations (ITOps) . In other words, it is a great versatile analysis method for corrective action that is inherent to the ITIL framework . It’s a comprehensive approach that all managers can appreciate.

In the IT industry, this method is invaluable since its ability to swiftly and effectively address problems is what distinguishes proactive IT Service Management (ITSM) . But it’s not just for solving-problem that is valuable; RCA fosters a culture of continuous improvement , learning, and innovation without playing the blaming game. 

So, if you want to transform problems to predictable and manageable events in the hopes of navigating the complexities of your IT operations  with confidence, keep on reading. 

We’ll explore everything that is to know about RCA and how to tailor a method that aligns with your organization’s goals.

Let 's get started.

Table of contents

Itil and root cause analysis, why do you need rca, 5 root cause analysis methods.

• How do you do RCA?
• 5 Root Cause Analysis examples

Root Cause Analysis is a method used to understand the causes of a problem or incident. It’s pretty much the rubric used within the ITIL framework to standardize Problem Management .  

As you may know, Problem Management is one of the processes under the Service Operation phase of ITIL , which aims to manage the lifecycle of all problems that could or do affect IT services.

Both ITIL and RCA embody the principle of continuous improvement. In theory, such integration is not just a procedural requirement, it's a strategic approach. And in practice, the synergy between both happens when this method is used to investigate the cause of problems so we can implement solutions long-term instead of temporary fixes. 

All of these lead to fewer disruptions and more reliable services. With that comes a robust knowledge base that will help your team make informed decisions when preventing future problems.

The Definitive Guide to Problem Management

It goes without saying that organizations need a problem-solving method that is effective. And more importantly, one that doesn’t merely address the immediate symptoms of a failure.

Keep in mind that problems are often complex, with not just a single cause but multiple contributing factors. Hence, there is a lot of value in digging deeper into problems to improve your operations. 

So, why do you need to implement RCA ? Because not only your business resilience depends on preemptively mitigating potential disruptions and downtime , but also because understanding root causes is as much about preventing negative outcomes as it is about replicating success.

Benefits of performing RCA

• RCA helps in streamlining processes and removing bottlenecks that lower your IT team’s productivity.
• On that note, an environment with fewer disruptions also contributes to better work quality and employee morale.
• With this method the likelihood of customers facing the same issues repeatedly diminishes. Reliable products and services improve consumer satisfaction and loyalty.
• Over time, root cause analysis saves an organization time, money, and resources because repeated repairs or adjustments are not necessary.
• Most importantly, you’ll get peace of mind, since you are building a stable and predictable operational environment. 

9 Ways to Do Proactive IT Support – And Switch From The Break/Fix Model

In fact, there are several ways in which your organization can conduct Root Cause Analysis . The choice of method depends on the complexity of the issue, the level of detail required in the analysis, the available data and resources, and the desired outcome of the RCA process. 

Let’s check them out.

The 5 Whys method involves asking the question "Why?" repeatedly to peel away the layers of symptoms and reach the core issue. It's a straightforward technique that doesn't require statistical analysis, making it accessible for anyone to use. However, its simplicity can also be a limitation, as it might not be suitable for complex problems with multiple root causes.

For instance, let’s say users are experiencing slow response times when accessing the company's internal Customer Relationship Management (CRM) system .

• Why? The CRM system's server is experiencing high latency.
• Why? The server's CPU usage is consistently at 100% during peak business hours.
• Why? A recent update to the CRM software introduced a memory leak that increases CPU usage over time.
• Why? The update was not fully tested in a simulated production environment before deployment.
• Why? The IT department has been under-resourced and couldn't allocate time for comprehensive testing due to back-to-back project deadlines.

2. Failure Mode and Effects Analysis (FMEA)

FMEA is a step-by-step approach for identifying all possible failures in a design, a manufacturing or assembly process, or a product or service. It's particularly useful in early stages of development, as it helps to prevent problems before they occur. FMEA evaluates the severity, likelihood, and detectability of failures to prioritize which ones need to be addressed first.

3. Fishbone Diagram (Ishikawa Diagram)

When your issue is complex and you need a structured analysis, the Fishbone Diagram , also known as the Ishikawa Diagram, is a visual tool used to systematically identify and present all possible causes of a deeper problem. It helps teams brainstorm and categorize causes into groups such as methods, machines, materials, people, environment, and measurement. 

4. Pareto Analysis

To focus on where to allocate the efforts of your team as well as identifying the most significant issues go with Pareto Analysis , based on the Pareto Principle (80/20 rule). It’s used to prioritize problems or causes to focus on those that will have the greatest impact if solved. Your team will create a Pareto chart, where causes are listed on the X-axis, and the frequency or impact of the causes is shown on the y-axis.

5. Fault Tree Analysis (FTA)

Fault Tree Analysis is a top-down, deductive analytical method used to explore the causes of specific events (usually adverse events). It uses a graphical representation of various parallel and sequential causes that can lead to the event. FTA is particularly useful in industries like aerospace and nuclear power, where preventing failures is critical.

How to choose the right RCA method?

The context of the issue at hand will help you choose the right RCA method , as each one has its own strengths. These are some of the considerations you could take when choosing a method that that aligns with the issue's nature, your objectives, and your organization's capabilities:

• Simple issues only need basic methods like the 5 Whys, while complex problems require detailed analysis techniques like FMEA or FTA.
• Data-intensive methods like FMEA are suitable when detailed information is available. With limited data, the Fishbone Diagram is key as it’s based on expert judgment.
• Consider the expertise within your team and the resources to dedicate. Some methods require specialized knowledge or tools.
• Remember that compliance with industry-specific RCA standards may dictate the method choice as it is the case for aviation.

How to do Root Cause Analysis?

RCA is based on the premise that it is more effective to systematically prevent and solve underlying issues rather than just treating symptoms. The process is relatively straightforward and typically involves these key steps to perform RCA :

• Knowing the problem : Clearly defining the problem or issue that has occurred.
• Collecting data : Gathering all relevant information about the problem, including when and where it occurred, and under what conditions.
• Analyzing data : Using various RCA methods (such as the 5 Whys, Fishbone Diagram, FMEA, etc.) to explore potential causes.
• Identifying the root cause(s) : Determining the underlying factors that led to the problem.
• Developing solutions : Proposing and implementing solutions that address these root causes.
• Monitoring : Assessing the effectiveness of the solutions over time to ensure the problem does not recur.

Now, to integrate RCA within the broader organizational processes, you might also consider these actions or principles: 

• Don’t isolated problem-solving, instead make RCA a standard practice across all levels and departments.
• Encourage the formation of cross-functional teams, since perspectives can shed light on overlooked aspects of a problem.
• Focus on improvements and solutions, not on the blaming game.
• Prioritize root causes based on their impact and the feasibility of implementing solutions, which means dealing with the most critical aspects first.
• Go deeper. The first conclusions may not always uncover the deepest root cause.
• Find proper evidence. Assumptions, guesses, and opinions are not sufficient.
• Invest in specialized software tools can streamline the RCA process. AI-driven RCA tools hold great promise. 
• Establish mechanisms to monitor and review the outcomes of RCA efforts regularly.
• Shift the focus from reactive problem-solving to prevention. How can your team anticipate potential issues and be prepared?

8 Steps to Build a Solid Problem Management Process

5 root cause analysis examples.

The root analysis approach is versatile and systematic, which means it’s applicable to various fields such as ITSM , manufacturing, aviation, healthcare, and more. 

These are some examples of RCA adaptability and impact on our everyday lives.

1. Car manufacture defects

If a car manufacturer notices an unusual rate of returns due to a specific engine component failure a simple RCA could reveal that the component is failing due to a flaw in the manufacturing process where incorrect temperature settings during heat treatment weaken the metal. 

The root cause is identified as a misconfigured machine. All your team has to do is to reconfigure the machine settings and retrain staff on the correct procedures.

2. Ineffective sterilization process at a hospital

In case a hospital experiences a higher than average rate of post-surgical infections in one of its wards, a root analysis may uncover that the sterilization process for surgical instruments was compromised. 

The cause is traced back to a recently changed cleaning solution that was not effective against all types of bacteria. The most reasonable thing to do is for the hospital to return to the previously effective cleaning solution and probably do additional checks for sterilization effectiveness.

3. IT system outages

This is generic, but think of an IT company that faces frequent, unexplained outages of its customer service platform. Through RCA, it's discovered that the outages coincide with high traffic volumes that exceed the system's capacity. 

At this point it is obvious that what happened is due to inadequate scaling policies for cloud resources. So what has to be done is to invest in more robust infrastructure to handle peak loads.

4. Equipment failure in aviation

Let’s say an airline finds that a particular model of aircraft frequently requires unscheduled maintenance for landing gear issues. RCA identifies that the landing gear problem is due to premature wear of a hydraulic seal. 

Further investigation reveals that the issue stems from a recent switch to a cheaper hydraulic fluid that lacks certain lubricative properties. The best they can do is to switch back to the original hydraulic fluid and replace the affected seals.

5. A retail chain experiences a high employee turnover

Lastly, imagine that a retail chain is experiencing higher than industry average turnover rates among its store employees. An RCA conducted through exit interviews and employee surveys reveals that the primary cause of dissatisfaction is inflexible scheduling that doesn't consider employee availability or preferences. 

The company implements a new scheduling system that allows for greater employee input into their schedules.

Final thoughts

Our advice would be that you build a constructive RCA process focused on understanding how and why a problem occurred, rather than attributing blame to individuals or teams. If you take this principle into consideration, you’ll encourage a culture of openness and learning, where the goal is improvement rather than punishment.

Also, when it comes to problem-solving through RCA, causes and symptoms are equally necessary to track down for knowledge base purposes, but the aim is to go to the root of the problem. Identify them and allocate your team’s efforts accordingly. And so, be methodical and evidence-driven as we know from experience that identifying patterns makes all potential issues predictable events.

Lastly, for IT operations, where the complexity and volume of data are substantial, AI-driven RCA would be particularly beneficial to better forecast potential future disruptions. As this technology develops, we’ll see quick diagnosed issues in software and hardware, predicting failures, and suggesting corrective actions. 

With this in mind, we might be exploring self-optimization, freeing up IT teams to focus on strategic initiatives rather than being bogged down by routine problem-solving.

The key is to focus on investing, involving, and integrating!

Read other articles like this : ITIL , Problem Management , root cause analysis

Read other articles like this:

Evaluate invgate as your itsm solution, 30-day free trial - no credit card needed.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.16(2); 2024 Feb
• PMC10908306

Root Cause Analysis: Unraveling Common Laboratory Challenges

Dharini srinivasaragavan.

1 Oral Pathology and Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND

Karthikeyan Ramalingam

Pratibha ramani.

Diverse errors occur in a pathology laboratory and manual mistakes are the most common. There are various advancements to replace manual procedures with digitized automation techniques. Guidelines and protocols are available to run a standard pathology laboratory. But, even with such attempts to reinforce and strengthen the protocols, the complete elimination of errors is yet not possible. Root cause analysis (RCA) is the best way forward to develop an error-free laboratory, In this review, the importance of RCA, common errors taking place in laboratories, methods to carry out RCA, and its effectiveness are discussed in detail. The review also highlights the potential of RCA to provide long-term quality improvement and efficient laboratory management.

Introduction and background

Pathologists must have expertise in lab management in addition to diagnostic skills, as labs are now considered to be one of the highest sources of revenue [ 1 ]. Laboratory management has also become an essential aspect, especially with the advent of accreditation. All the activities involved in the lab procedures influence the overall management of a pathology lab [ 2 ]. The system starts with receiving samples, recording all the initial patient details followed by processing and carrying out the tests, and ends with reporting. Hence an appropriate design of the lab management system (LMS) ensures that every demanding requirement in the daily routine of handling samples is fulfilled. The advantages of an appropriate LMS involve expansion of business, increased sample testing, and thus eventually fostering high revenues [ 2 , 3 ]. One promising approach that aids in maintaining a standard lab management system is root cause analysis (RCA). RCA identifies the various reasons for the outcome and helps to initiate corrective action (Figure ​ (Figure1 1 ).

Diagrammatic representation of root cause analysis (Image credit - Dharini Srinivasaragavan, Karthikeyan Ramalingam)

Root cause analysis

Root cause analysis (RCA) states that there could be one or more causes for every event. RCA plays an important role in avoiding the cascading effect of multiple incidents (apparent/unobserved events) that lead to a final defect (critical/observable event) which is more devastating [ 4 ]. Hence RCA is a systematic approach that focuses on finding flaws that could be refined for better performance and predictable outcomes. 

An RCA team is assembled to examine the observed event and to determine required changes on a systematic basis. Analyzing and defining the issue of concern is the primary step in RCA following which listing and assessment of all contributing factors are carried out. A comprehensive data collection of each step is helpful for better evaluation and to ascertain their interrelationships. During the RCA process, the team must consider intermediate actions constituting strategies to immediately improve the process and to prevent repeat events. Such actions must be consulted with the higher authorities to emphasize the identification of specific targets and achieve significant risk reduction [ 5 ]. Thus, RCA should be clear and exact, providing proper in-depth information for any issue of concern (Figure ​ (Figure1 1 ).

Root cause analysis (RCA) states that there can be one or more causes for every event [ 4 ]. This kind of cascading effect leads to a final defect that is appreciably more devastating than the apparent faults [ 5 ]. There are various approaches to carry out this analysis (Figure ​ (Figure2 2 ).

Methodologies reported in the literature to carry out root cause analysis (Image credit - Dharini Srinivasaragavan, Karthikeyan Ramalingam)

Asking why five times for any issue can help in identifying the bottom of the problem [ 6 ]. For instance, in a pathology laboratory, the possible five whys and how the reasons for unsatisfied hematoxylin and eosin (H&E) stained sections can be identified are as follows: “Why was the staining unsatisfactory? The staining procedure needs to be improved. Why was the staining protocol not followed? The staining protocol was followed by the technician but the stains used were not in good condition. Why were the stains not in good condition? The stains might have been contaminated due to incomplete or improper washing during the staining procedures. Why were the stains not changed periodically? The new stains were not available in the laboratory. Why was the laboratory stock insufficient? The reagents were not ordered from the store as per schedule”.

Thus, RCA of a problem of unsatisfactory staining was identified as insufficient reagents. A proper cutoff value for each laboratory reagent could be created, a weekly audit of available stock should be performed, and the deficiency should be noted with the immediate purchase of required reagents. Thus, RCA could be utilized to avoid this problem in the future. 

Fishbone diagram

Fishbone analysis, also called cause and effect diagram or Ishikawa diagram, is a visualization tool more like a mind map. It is called the Ishikawa diagram since it was invented by Dr. Karur Ishikawa, a Japanese quality control expert. It helps to find almost all the possible causes for a problem or when we plan for action by including thoughts and ideas from team members [ 5 , 6 ].

The concerned issue must be written on the right side of the whiteboard. An arrow should be drawn ending to the concerned issue. Preferably six major categories that led to the issue must be written as primary branches. Each major category should list all the possible causes under it. Thus, the fishbone should be filled with multiple possibilities that could cause the concerned issue [ 6 , 7 ]. By following the above-mentioned procedure, the root cause of a problem could be identified and resolved.

Other methods

A scatter chart employs dots to depict numeric variable values, facilitating the observation of relationships between these variables. It is valuable for identifying correlations, whether positive, negative, or nonexistent, among the variables under consideration. Scatter charts find applications in quality assessment, root cause analysis, and decision-making. It includes correlation analysis, It is a versatile tool in quality improvement, providing a visual representation of data that facilitates analysis, decision-making, identification of trends and patterns, root cause analysis, process optimization, performance measurement, support for decision-making, continuous monitoring of processes, and quality control. It aids in identifying areas for improvement and supports evidence-based interventions to enhance overall product or service quality.

In failure mode and effect analysis (FMEA), the initial step involves identifying failure modes, followed by an effect analysis where the consequences of each cause are analyzed. This process helps uncover potential pitfalls and assess the impact of proposed changes on system design. The key concepts in FMEA include severity (S) - a measure of the seriousness of the consequences of a failure. It is typically rated on a scale from 1 to 10, with higher values indicating more severe consequences. Occurrence (O) - an assessment of the likelihood or frequency of a failure mode occurring. It is also rated on a scale from 1 to 10, with higher values indicating a higher likelihood. Detection (D) - a measure of the likelihood that the failure mode will be detected before reaching the customer. It is also rated on a scale from 1 to 10, with higher values indicating a lower likelihood of detection. Risk priority number (RPN) - calculated by multiplying severity, occurrence, and detection ratings (RPN = S * O * D). Higher RPN values indicate higher-priority failure modes. Thus, FMEA is a valuable tool for proactive risk management, fostering a culture of continuous improvement and helping to enhance the reliability and quality of the processes, products, and systems.

In fault tree analysis (FTA), the problem is visualized as a tree, with probable causes listed as branches. The root cause is identified by examining the causes and their occurrences. The steps in FTA are: 1) Define the top event - clearly define the undesired event or failure that is the primary focus of the analysis. This is the "top event." 2) Identify basic events - identify the basic events that could contribute to the top event. These are the root causes or factors that may lead to the failure. 3) Construct the fault tree - use logic gates to represent the relationships between events. 'AND' gates indicate that all input events must occur for the output event to occur, 'OR' gates indicate that at least one input event must occur, and 'NOT' gates indicate negation. 4) Assign probabilities - assign probabilities to basic events to represent the likelihood of their occurrence. These probabilities are used to calculate the overall probability of the top event. 5) Analyze and evaluate - analyze the fault tree to determine the probability of the top event occurring. Evaluate the critical paths and contributing factors. 6) Mitigation and prevention - identify potential measures or actions to mitigate the risk of the top event. These measures could involve improving system design, implementing safeguards, or enhancing operational procedures. 7) Documentation and communication - document the fault tree analysis, including the identified events, logic gates, probabilities, and conclusions. Communicate the findings to relevant stakeholders. Thus FTA is a powerful tool for understanding and managing risks associated with complex systems. It helps to proactively address potential failures and develop strategies to enhance the reliability and safety of their systems.

Pareto analysis, named after the Italian economist Vilfredo Pareto, is a technique used to prioritize and focus efforts on the most significant factors contributing to a problem or goal. It is based on the principle that a small number of causes (the "vital few") usually account for the majority of the effects, while a larger number of causes (the "trivial many") contribute less significantly. Pareto analysis graphically separates various aspects of a problem, aiding in directing improvement efforts effectively. The Pareto chart, incorporating both a line graph and a bar chart, highlights significant issues based on cumulative effects.

Define, Measure, Analyze, Improve, and Control (DMAIC) is a structured approach that utilizes data-driven decision-making, root cause analysis, continuous improvement, and standardization. DMAIC investigates the reasons for an issue from its definition to controlling all root causes. Its role in the overall success of Six Sigma is crucial, requiring the identification of root causes and the development of solutions. DMAIC involves defining and measuring the issue, analyzing collected data to understand root causes, improving actions, and implementing control measures.

The eight dimensional (8D) problem-solving process is a structured, team-oriented approach widely used in various industries to address and resolve complex problems. The goal of the 8D process is to identify the root cause of a problem, develop effective corrective actions, and prevent the recurrence of the issue. Each "D" represents a step in the process. In 8D problem-solving, the root cause is investigated through a meeting using statistical data. The process involves team formation, defining the problem, temporary action, root cause analysis, permanent corrective action, validation, prevention, and closure. The 8D method is a team-oriented approach combining tools from various disciplines to solve critical production problems.

Change analysis in quality control refers to the process of observing, analyzing, and documenting changes in a system, process, or product over a period of time. This method involves a careful and systematic examination of variations or alterations to identify potential causes and effects. Change analysis is crucial for ensuring that modifications, whether intentional or unintentional, do not negatively impact the quality and performance of the system. Change analysis emphasizes observing changes over a longer period to identify potential causes of issues. It is considered an easy and effective approach. Kenner-Tregoe problem-solving and decision-making, akin to DMAIC, involves situation analysis, problem analysis, solution analysis, and potential problem analysis. This systematic approach helps address causes and significantly improves working conditions [ 7 , 8 ].

Common challenges

Three crucial aspects where errors occur frequently in a pathology laboratory are represented in Figure ​ Figure3 3 . 

Pictorial representation of commonly encountered challenges in pathology laboratory (Image credit - Dharini Srinivasaragavan, Karthikeyan Ramalingam)

The common challenges encountered in a pathology laboratory like sample rejections, patient misidentification, quality monitoring turnaround time, and safety are discussed below.

Sample Rejections

Laboratory test results serve as the backbone for clinical decision-making as the precision of results has a direct impact on the patient’s management [ 9 ]. Broadly, there are three phases in the lab investigation which include the pre-analytical phase, analytical phase, and post-analytical phase. With advancements in the analytical phase and improvements in the quality maintenance protocols, analytical errors were comparatively less common among the three phases [ 10 ]. On the other hand, 80 to 93% of the errors were attributed to the pre-analytical phase [ 11 ]. This is because the processes are still manual and often subjected to repeat sampling which ultimately burdens the patients. Human errors constitute about 82.6% while only 4.3% are technical. A study by Chavan et al. reported 174 rejected out of 48,889 samples. RCA carried out in this study revealed that most of the sample rejections were identified in the intensive care unit (ICU), hematolymphoid cancer unit, and wards. Some of the potential causes identified were hemolyzed samples, clotted samples, labeling errors, and sample contamination with intravenous fluids. Following four years of training programs, these errors were reduced significantly. Favorable outcomes of the training programs depend on relevant training design, the ability of the trainee to understand, the assessment of the trainee, and the trainee’s ability to apply the skills learned in their workplace. In addition, periodic conduction of retraining was also important [ 12 ]. It was also recommended to incorporate activities in the training design and share the results. This brings prominent changes in the trainee’s behavior as the results stimulate a sense of contest [ 13 ]. 

Patient Misidentification

Many laboratories use direct label printers but manual data entry/recording is still performed within a few stages such as embedding, sectioning, and staining. Printed labels are then utilized for permanent identification and storage. Misidentification can happen during this process [ 14 ]. RCA on misidentification found the following potential causes: slide-labeling in batches, interruption and diversion during labeling, misinformation from manual data entry, misplaced and lost specimens, reporting into the incorrect patient medical record, and small fonts that make visualization difficult [ 15 ]. With careful consideration of each of these possibilities, the error rate could be reduced. The drawbacks of manual writing can be avoided by the implementation of automatic barcode systems for sample handling [ 16 ]. 

Quality Monitoring and Turnaround Time

Quality monitoring (QM) is essential in a lab to acknowledge errors and make continuous efforts to minimize them to maintain a standard quality. The majority of findings from institutional laboratories in India showed compromised sensitivity and specificity along with delayed laboratory reports [ 17 ]. According to the current principles, pathology labs must have a structured, systematic, and organized QM procedure focusing on enhancing patient safety, minimizing error, and guaranteeing prompt report delivery. Additionally, improved performance could be facilitated by quality assurance that incorporated both internal and external quality monitoring [ 18 ]. Sandra et al. listed the possible errors occurring in a lab setup and discussed the steps undertaken to minimize them [ 19 ]. The most notable root causes of the failures of immunohistochemistry were identified to be a lack of standardization procedures and inconsistent monitoring of the qualitative and quantitative parameters [ 20 ]. 

Turnaround time (TAT) is another crucial metric for assessing the quality of a lab. TAT indicates the amount of time required for a laboratory test from order receipt to result generation for the clinician or patient [ 21 , 22 ]. Efficient clinical workflow is mandatory to maintain TAT for every sample. RCA could be used to identify various factors influencing TAT including technician's availability, pathologist’s experience, automation, infrastructure, and continuous training of laboratory personnel [ 23 ]. Storage of samples and reagents influences delayed reporting. Improperly stored or expired reagents can lead to a large number of highly compromised false positive and negative results. It results in repeat biopsies [ 24 ]. In addition, comprehensive management of documents is also crucial. Equipment calibration and maintenance must be done regularly. Each laboratory must have its standard operating procedures (SOP) consisting of lists with elaborative instructions for every procedure that the lab performs [ 25 ]. Khan et al. emphasized the use of simple guidelines like mentioning the laboratory’s directions on the outpatient department (OPD) card could substantially reduce the TAT and subsequently improve patient satisfaction [ 26 ]. 

RCA on the most frequent errors occurring in anesthesia cases of complex procedures were found to be fine skills of the experts and knowledge deficiencies, poor time management, lack of communication, unfamiliarity with the equipment, and drug-related errors [ 27 ]. RCA has also been used to identify the causes of myocardial infarction deaths [ 28 ]. In addition, in terms of frozen sections, the central placement of the pathology department is close to the operating room and improved communication with surgeons had better outcomes [ 29 ]. 

Recommendations

To improve the overall quality of a laboratory, an RCA team/group should be set up to review the feedback and conduct error audits at periodic intervals. It will be highly effective to implement procedural and behavioral changes resulting in error reduction. Implementation of several simple techniques mentioned so far in each step and discussion with the reporting pathologists for appropriate lab management and development can bring significant changes.

Conclusions

Root cause analysis has been an eye-opener that aids in revealing new insights in almost all disciplines. Especially in laboratories with pertinent quality assurance practices and error detection followed by system design change, the performance can be improved. Numerous factors need to be considered including well-defined diagnostic criteria, precise instrumentations, access to clinical data, appropriate communication between clinicians and pathologists, appropriate sampling and handling, management of excessive workloads, inexperienced pathologists, shortage of skilled technicians, complex cases including specialized pathologists, and so forth. Hence, for any field, root cause analysis is very helpful for long-term consistent improvement in any profession.

The authors have declared that no competing interests exist.

Author Contributions

Concept and design:   Karthikeyan Ramalingam, Dharini Srinivasaragavan, Pratibha Ramani

Acquisition, analysis, or interpretation of data:   Karthikeyan Ramalingam, Dharini Srinivasaragavan

Drafting of the manuscript:   Karthikeyan Ramalingam, Dharini Srinivasaragavan, Pratibha Ramani

Critical review of the manuscript for important intellectual content:   Karthikeyan Ramalingam, Pratibha Ramani

Supervision:   Karthikeyan Ramalingam