ROOT CAUSE GUIDANCE 根本原因指南
GETTING TO THE ROOT OF THE PROBLEM
“Root Cause Analysis (RCA) is a methodology that helps us find the real causes of a problem to be able to correct. By using the methodology we are able to identify the root causes of a problem so the corrective actions put in place to eliminate the problem are directed not only at the symptoms but also at the root causes and therefore corrective efforts yield permanent results.”
OVERVIEW 總述
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 root Cause analysis seeks to identify the origin of a problem it uses a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:
1 determine what happened
2 determine why it happened
3 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 are now facing they are usually three basic types of causes:
1. Physical causes – tangible, material items failed in some way (for example, a damaged
machine guard failed and resulted in an injury to the worker)
2. 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 checked the machine,
which led to the incident)
3. 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 machine guard maintenance,
and everyone assumed someone else had ensured the guard was in good working order)
Root Cause analysis 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.
PROCEDURE
Root Cause analysis 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?
Step Three: identify Possible Causal factors
? What sequence of events lead to the problem?
? What conditions allow the problem to occur?
? What other problems surround the occurrence of the central problem?
Step Four: identify the root Cause(s)
? Why does the causal factor exist?
? What is the real reason the problem occurred?
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?