An immediate cause is the direct, obvious cause of the incident,

usually as an unsafe act or condition, such as not wearing PPE.

The root or underlying cause is the events or condition that allowed
the immediate cause to develop, such as poor company culture and
management controls.
A root cause is defined as a factor that caused a nonconformance
and should be permanently eliminated through process
improvement. Root cause analysis is defined as a collective term that
describes a wide range of approaches, tools, and techniques used to
uncover causes of problems.

THE BASICS OF ROOT CAUSE ANALYSIS

----------
Root cause analysis is an approach for identifying the underlying causes of an incident

so that the most effective solutions can be identified and implemented. It’s typically used

when something goes badly, but can also be used when something goes well. Within an

organization, problem solving, incident investigation, and root cause analysis are all

fundamentally connected by three basic questions:

 What’s the problem?

 Why did it happen?

 What will be done to prevent it from happening again?

SYMPTOM OF THE PROBLEM

“The Weed” above the surface (obvious)

THE UNDERLYING CAUSES

“The Root” below the surface (not obvious)

 Download our FREE Cause Mapping® template

No special software required! Learn how to leverage root cause analysis across your organization

using Microsoft Excel

DOWNLOAD NOW!

THE CAUSE MAPPING METHOD OF ROOT

CAUSE ANALYSIS
----------

Root cause

analysis is about digging beneath the surface of a problem. However, instead of looking

for a singular “root cause,” we shift your problem-solving paradigm to reveal a system of
causes. When using the Cause Mapping method, the word root in root cause

analysis refers to causes that are beneath the surface.

Most organizations mistakenly use the term “root cause” to identify one main cause.

Focusing on a single cause can limit the solutions set, resulting in the exclusion of

viable solutions. A Cause Map provides a simple visual explanation of all the causes

that contributed to the incident. The root is the system of causes that reveals all of the

different options for solutions. The result … multiple opportunities to mitigate risk and

prevent problems.

THREE PROBLEM-SOLVING STEPS

----------
Root causes analysis using the Cause Mapping methods consists of three steps:

Define the issue by its impact to overall goals. People often disagree over how to define

the problem. You can get alignment when the problem is defined by the impact to the

goals.
Break the problem down into a visual map. Using a Cause Map provides a thorough

explanation revealing all of the causes required to produce the problem.

Prevent or mitigate any negative impact to the goals by selecting the best solutions.

Effective solutions should make a change to how people execute work process.

BETTER COMMUNICATION, BETTER ANALYSIS

----------

A Cause Map is

a simple diagram showing how and why a particular issue occurred. It begins with a few

Why questions (5 Whys), then expands into as much detail as necessary to (thoroughly)

explain even the most challenging issues (30+ Whys). The Cause Map creates a visual

dialogue, making it easier to communicate what’s known and what needs a little more

digging. People can see how all of the pieces fit together to produce a particular
incident.The better an organization gets at explaining its problems, the better it

becomes at finding smart solutions.

Too many companies use generic buckets like human error and procedure not followed

to classify an entire incident. These are low-resolution investigations that result in weak

solutions. Clearly communicating detail is essential. Cause Mapping flattens problem

solving by deferring to the people in the organization who know how well current

processes actually work. A strong prevention culture makes it easier for people to share

what they know. Front-line personnel, management, and technical experts are all an

integral part of a company’s overall problem-solving efforts.

CAUSE MAPPING® METHOD

--------------

JOIN US FOR THE NEXT CAUSE MAPPING ROOT

CAUSE ANALYSIS PUBLIC WORKSHOP ON
SEPTEMBER 10 – 12 IN DALLAS, TX !

THE CAUSE MAPPING® METHOD

----------
Cause Mapping® is a root cause analysis method that improves the way people

analyze, document, communicate, and solve problems. In many companies, problem

solving is a confusing maze of different tools, baffling terms, and puzzling categories.

An investigation should make a problem clearer, not more complicated. Cause Mapping

demystifies root cause analysis. It’s an uncomplicated approach, grounded in the

basics, that people find easy to learn and straightforward to apply. The Cause Mapping
 method leverages fundamental principles to improve both the effectiveness and

efficiency of problem solving. Three key principles of Cause Mapping are:

 Systems approach

Reveal the system of causes to mitigate risk.

 Visual communication

Take advantage of the power of visual communication.

 Simple and effective

Don’t stray from the basics.

 A PROBLEM WELL DEFINED IS A PROBLEM
HALF SOLVED
----------
A clearly defined problem is an important step of the problem-solving process. Without a

clear problem statement, people can drift off course, waste valuable time, and miss

opportunities to solve the problem. The “problem” with defining problems is that

everyone has a different perspective on what the “real” problem is. The Cause Mapping

method uses a structured problem outline that reveals 3 key benefits to effective

problem solving. A well-defined problem at onset will help you avoid the common pitfalls

that can derail your investigations.

Three key benefits of a well-defined problem:

1. Problem alignment

2. Total impact – gaps & risks

3. Guidance on level of detail for analysis

Download our FREE Cause Mapping® template

No special software required! Learn how to leverage root cause analysis across your organization

using Microsoft Excel

DOWNLOAD NOW!
 WHAT IS A CAUSE MAP?
----------

A Cause Map provides a visual explanation of why an incident occurred. It connects

individual cause-and-effect relationships to reveal the system of causes within an issue.

A Cause Map can be very basic or it can be extremely detailed depending on the issue.

HOW TO READ A CAUSE MAP

----------
Start on the left. Read to the right saying “was caused by” in place of the arrows.

Investigating a problem begins with the problem and then backs into the causes by

asking Why questions. The questions begin, “Why did this effect happen?” The

response to this question provides a cause (or causes), which is written down to the

right.
The next question is again, “Why did this effect happen?” The cause that was written

down last becomes the effect for the next Whyquestion. Anyone who’s ever had a three-

year-old in their life will immediately recognize how Why questions change a cause into

an effect. This is fundamentally how causes and effects link together to create a chain

of events. Writing down 5 Whys, as shown below, is a great way to start an investigation

because it’s so simple.

In the Cause Mapping method, a problem within an organization is defined as a

deviation from the ideal state. A Cause Map always begins with this deviation, which is

captured as the impact to the organization’s overall goals.

In addition to the standard Why questions, which tend to create linear cause-and-effect

relationships, the Cause Mapping method also asks “What was required to produce this

effect?” Anything that is required to produce an effect is a cause of that effect. This

question, “What was required?,” allows you to build a detailed Cause Map that provides

a more complete representation of the actual issue.

WHY DOES THE CAUSE MAP READ LEFT TO

RIGHT?
----------
It should be noted that the popular fishbone cause-and-effect diagram starts with the

problem on the right and builds the causes to the left. It was created by Kaoru Ishikawa

(1915-1989) in Japan. The fishbone diagram builds from right to left because the

Japanese language reads from right to left. The Cause Mapping method actually uses
Ishikawa’s convention by asking Why questions in the direction we read. The fishbone is

widely recognized as one of the standard quality tools. Ishikawa was a pioneer with his

approach. The fishbone cause-and-effect diagram is part of every Six Sigma program. A

Cause Map builds on the original lessons with the fishbone with some subtle but

important distinctions.

How does the Cause Map differ from the fishbone approach?

A fishbone starts

with just one, single problem, which doesn’t reflect the nature of real-world issues. It

reads right to left because the Japanese language reads that direction. It mixes causes

and possible causes without specifying evidence. And, it breaks apart the fundamental

cause-and-effect relationships within an issue by grouping the causes into general

categories.

5-Whys on a Cause Map

The 5-Why approach is an excellent example of basic cause-and-effect analysis. Just

as a journey of a thousand miles begins with the first step, every investigation,

regardless of size, begins with one Why question. The Why questions then continue,
passing through five, until enough Why questions have been asked (and answered) to

sufficiently explain the incident. The 5-Why approach, created by Sakichi Toyoda (1867

– 1930), the founder of Toyota, is a simple way to begin any investigation. A Cause Map

can start with just one Why question and then expand to accommodate as

many Why questions as necessary. Some refer to the Cause Mapping method as “5-

Whys on Steroids.”

Some causes are linked with “AND” in between

 ANDs show where more than one cause is

required. When an effect has more than one cause, both causes are placed on the

Cause Map. Each cause is connected to the effect with AND placed in between. These

causes are independent of each other, but they are both required to produce that effect.

An AND is needed when people provide different, yet valid, explanations of a cause.

People think of cause-and-effect as a simple one-to-one relationship: an effect has a

cause. In reality, every effect has causes.

ROOT CAUSE INVESTIGATION TRAINING

----------
ThinkReliability offers a variety of Cause Mapping Workshops to help managers to front-

line personnel learn how to thoroughly investigate complex problems, identify solutions,

and establish problem-solving processes within your organization.

All workshops can be presented at your site or online with a live instructor, so you can

choose the root cause investigation training format that works best for your

organization’s goals. We also offer a certification program to allow you to become a

Cause Mapping champion in your organization.

Need training that’s customized specifically for your organization? Contact us for a

quote
DOWNLOAD OUR WORKSHOP COMPARISON CHART
 CAUSE MAPPING™ ROOT CAUSE ANALYSIS
WORKSHOPS – FOR FACILITATION LEADS AND
PARTICIPANTS
These are our core workshops for becoming better at analyzing, documenting,

communicating and solving problems. People attend these workshops to improve their

skills in problem solving, incident investigation, root cause analysis and risk mitigation.

The following root cause investigation training options are delivered by a ThinkReliability

instructor at the client’s site, but can also be presented effectively, over the web, to

meet a client’s specific needs.

Cause Mapping Root Cause Analysis Fundamentals: From 5-Why to a

Complete RCA1-Day
----------

For Investigators, Contributors, Participants, and Team Members

Geared towards managers and supervisors across all business functions, this one-day

workshop covers the concepts, lessons and steps of the Cause Mapping method,

including a focus on 5-Why Cause Mapping, while building in some case studies,

examples and exercises. Participants will establish a foundation for analyzing and

preventing problems using cause-and-effect thinking. Attendees will learn how to drive a

prevention-focused (vs blame) investigation, how to avoid problem miscommunications

and will discover how a thorough problem explanation reveals better solution options to

reduce risk, increase reliability and improve work processes.

LEARN MORE

Cause Mapping Root Cause Analysis for Facilitators(Most Popular Workshop)

2-days
----------
For Facilitation Leads and Root Cause Analysis Specialists

This workshop covers the foundation of the Fundamentals workshop, and includes

facilitation skills to lead a group through a comprehensive problem investigation from

start to finish. Attendees work through multiple exercises and case studies to apply the

lessons they’ve learned. Every attendee learns how to start a quick analysis that can

expand into a detailed explanation of exactly what happened. The course also covers

important insights for documenting and presenting a complete investigation.

LEARN MORE

Cause Mapping Root Cause Analysis for Facilitators + Documentation3-days

----------

For Facilitation Leads and Root Cause Analysis Specialists – Includes Documentation

Skills

This is the Facilitator Workshop with an additional day of documentation skills.

Attendees will learn all the tips, tricks and shortcuts for documenting an entire incident

within Microsoft Excel®. The workshop covers each element of the Cause Mapping

Template including how to add and edit diagrams, drawings and photos for a clearer

investigation. Examples for how investigations should be presented to management are

also provided. Each attendee will need to bring their laptop for the 3rd day.
LEARN MORE

Cause Mapping Root Cause Analysis Online Workshop4 Modules

----------

For Facilitation Leads and Root Cause Analysis Specialists – Includes Documentation

Skills
This is the online version of our Cause Mapping for Facilitators + Documentation

Workshop, presented in a series of 3-hour modules online. Attendees will learn in

addition to the fundamentals of Cause Mapping and facilitating an investigation, all the

tips, tricks and shortcuts for documenting an entire incident within Microsoft Excel®.
LEARN MORE

5-WHY CAUSE MAPPING™ WORKSHOPS – FOR

FRONTLINE PROFESSIONALS
Troubleshooting and Problem Solving

These workshops provide the people on the frontline with a quick and simple way to

start analyzing any problem. The frontline frequently sees problems at their earliest

stage, before they blow up into something major. Frontline people are an essential part

a risk mitigation strategy. Including them changes the problem-solving capability of an

organization.

5-Why Cause Mapping for FrontlineHalf-day

----------

For Frontline Problem Solvers, Technicians, Troubleshooters, Operations, Maintenance,

Craft

The 5-Why Cause Mapping Workshop explains root cause analysis, and dives into 5-

Why Cause Mapping benefits and concepts. Using examples and case studies,

attendees learn the DOs and DON’Ts of 5-Whys, the three steps to Cause Mapping, the

important role of evidence, the basics of critical thinking and how to develop useful

troubleshooting guides. Skills from this workshop give the frontline a better resource in
larger problem investigations and improves the way they explain an issue to

management.
LEARN MORE

5-Why Cause Mapping for Frontline + Application1-day

----------

For Frontline Problem Solvers, Technicians, Troubleshooters, Operations, Maintenance,

Craft – Includes Application Practice

This course covers the material in the 5-Why Cause Mapping for Frontline in the

morning then allows time in the afternoon for attendees to apply what they’ve learned.

In order for participants to apply what they have learned to company-specific problems,

situations, incidents and issues, client case studies can be organized in advance of the

workshop with input from supervision and management or they can be identified during

the morning session. Working these examples during the training provides the group

with a head start on their current problems. This class develops problem lookouts within

the company.
LEARN MORE

LEADERSHIP OVERVIEW – FOR MANAGEMENT &

EXECUTIVES
High Reliability Leadership1-3 Hours
----------
This workshop provides leaders with a clear understanding of how cause-and-

effect thinking improves an organization’s ability to analyze, document,

communicate and prevent problems. An overview is provided of the concepts,

lessons and steps of Cause Mapping and how it aligns with the scientific method

for a consistent approach to all problems. Leaders need to know what

expectations should be for people who attended the Cause Mapping and 5-Why

Cause Mapping workshops. This session also provides several Human

Performance & Work Process Reliability examples to explain how errors occur

and what some organizations do to make them significantly lower. The

relationship between problems and work processes is an important take-away for

leadership to understand what Highly Reliable Organizations do and how the

approach can be applied within their groups Root Cause

Analysis (RCA)
This article explains the Root Cause Analysis (RCA) in a
practical way. After reading you will understand the basics of
this powerful problem solving method.

What is a Root Cause Analysis (RCA)?

Root Cause Analysis (RCA) is a method of problem solving
that aims at identifying the root causes of problems or
incidents. Root Cause Analysis is based on the principle that
problems can best be solved by correcting their root causes
as opposed to other methods that focus on addressing the
symptoms of problems. Through corrective actions, the
underlying causes are addressed so that recurrence of the
problem can be minimized. It is utopian to think that a single
corrective action will completely prevent recurrence of the
problem. This is why root cause analysis is often considered
to be an iterative process.

Root Cause Analysis is used as a tool for continuous

improvement. If a Root Cause Analysis is used for the first
time, it is a reactive way of identifying and solving problems.
This means that an analysis is performed after a problem or
incident has occurred. By gaining experience with root cause
analysis, its use changes from reactive to proactive, so that
problems can be anticipated in time. Root Cause Analysis is
not a strictly defined methodology. There are many different
tools, processes and philosophies that have been developed
based on Root Cause Analysis.

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However, there are five approaches that can be identified in

practice:

1. Safety-based root cause analysis – Its origin can

be mainly be found in accident analyses, safety and
healthcare.
2. Production-based root cause analysis – Its origin
can be mainly be found in the area of quality control
and industrial manufacturing.
3. Process-based root cause analysis – This is the
follow-up from production and business processes.
4. Failure-based root cause analysis – Its origin can
be found in Engineering and maintenance.
5. Systems-based root cause analysis – its origin
can be found in the amalgamation of the approaches
 mentioned above and this is combined with ideas
from change management, risk management and
systems analysis.

Despite the fact that there seem to be no clear definition of

the differences in the objectives among the various
approaches, there are some common principles that can be
considered to be universal. It is also possible to define a
general process for performing an Root Cause Analysis.

The basic process

The basic process consists of a number of basic steps. These
corrective measures will lead to the true cause of the
problem.

1. Define the problem or the factual description of the

incident. Use both qualitative and quantitative
information (nature, size, locations and timing) of the
results in question.
2. Collect data and evidence and classify them along
a time line of incidents until the eventual problem or
incident is found. Each special deviation in the form of
behaviour, condition, action and passivity must be
recorded in the time line.
3. Always ask ‘why’ to identify the effects and record
the causes associated with each step in the sequence
toward the defined problem or incident.
4. Classify the causes within the causal factors that
relate to a crucial moment in the sequence including
the underlying causes.
 5. If there are multiple causes, which is often the case,
document these, preferably in order of sequence for a
future selection. Identify all other harmful factors.
6. Think of corrective actions or improvement
measures that will ensure prevention of recurrence
with a sufficient degree of certainty. Explore whether
corrective actions or improvement measures can be
simulated in advance so that the possible effects
become noticeable, also with respect to the other
underlying causes.
7. Think of effective solutions that can prevent
recurrence of the causes and to which all involved
colleagues can agree. These solutions must comply
with the intended goals and objectives and must not
cause any new and unforeseen problems.
8. Implement the solutions (corrective actions) that
have been made by consensus.
9. Monitor the effectiveness of the solutions
(corrective actions) closely and adjust if necessary.
10. Other methods for problem-solving and
problem prevention may be useful.
11. Identify and address any other causes that
may be harmful factors in the process.

Please note: steps three, four and five are the most critical
part of the corrective measures because these have proved
to be successful in practice.

Root cause analysis tools

Other well-known Root cause analysis techniques and tools
are listed below:
Barrier analysis

This root cause analysis technique is often used in the

industrial sector.

It was developed to identify energy flows and focus on

possible blocks for those flows in order to determine how and
why the obstacles cannot prevent the energy flows from
causing damage.

Current Reality Tree

This complex but powerful method developed by Eliahu M.

Goldratt is based on representing causal factors in a tree
structure. This method uses rules of logic. The method starts
with a short list of the undesirable factors we see around us
that will subsequently lead to one or more underlying causes.

Change analysis

This research methodology is often used for problems or

accidents and demonstrates how the problem has presented
itself from different perspectives.

5 times why
In the Japanese analysis method 5 whys the question ‘why’ is
asked five times. The 5 whys technique was originally
developed by Sakichi Toyoda, and was used to trace the root
cause of the problems within the manufacturing process of
Toyota Motors.

Fishbone diagram

This root cause analysis method is also known as the

fishbone diagram. The Ishikawa diagram is a much preferred
method of project managers to perform a Root Cause
Analysis.

Kepner Tregoe method

The Kepner Tregoe Method is a Root Cause Analysis method

based on facts in which the possible causes are
systematically excluded in order to find the real cause. This
method also disconnects the problem is from the decision.

RPR Problem Diagnosis

This is an ITIL aligned method designed to determine the

root cause of IT problems.

It’s Your Turn

What do you think? What is your Root Cause Analysis
experience? Do you recognize the practical explanation or do
you have additions? What are in your opinion success factors
for conducting a Root Cause Analysis?

Share your experience and knowledge in the comments box

below.

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