The Analysis part of FRACAS can at times be the most difficult, challenging and even fun (yes, fun!) phase of the overall FRACAS process. This phase is focused on determining the cause(s) of the failure.
Let’s start with a couple of definitions of two different types of failure analysis – Apparent Cause Analysis (ACA) and Root Cause Failure Analysis (RCFA).
- ACA seeks to determine why the problem occurred based on reasonable effort and the analysis leader’s experience. The emphasis is mainly to correct a particular event or problem without an effort to identify the underlying contributor causes or root causes to the problem. It is a less formal investigation method that focuses on the immediate causes of a specific incident/failure.
- RCFA is a process to identify, analyze, correct, contain, and prevent (corrective and preventive actions) recurrence of a particular event or problem, to determine the most basic causes for an undesirable condition which, if eliminated, changed or controlled, would have prevented the problem from recurring (corrective actions) or occurring (preventive actions).
The fundamental difference in ACA vs. RCFA is determining the root cause of the failure. Simply stated, if you wish to prevent the same failure from happening again and again and again…then you must do an RCFA.
So, what’s a “Root Cause”?
Root Cause – The deepest cause, in the causal chain (the path going from the root cause to the symptoms of the failure incident), that can be resolved. In other words, for a given failure incident, Root Cause is the factor that, when you correct or eliminate it, the failure incident goes away and doesn’t come back.
Below are some identifying characteristics of a Root Cause:
- Clearly a major cause of the failure incident’s symptoms
- Has no productive deeper cause – the key word here is “productive”, otherwise you risk digging forever
- Can be resolved – attempting to resolve an issue beyond the organization’s control is fruitless
- Resolving it will not lead to additional failure incidents
- There is no better root cause – all alternatives have been considered
Key Risk: Missing the True Root Cause
[Potential reasons for missing the true root cause; leaving the continued exposure to the risk… temporary and potentially ineffective corrective actions]
- Incorrect Team Composition
- The Team Lead doesn’t understand how to perform an independent investigation and doesn’t have the right expertise on the team
- Incorrect Data Classification
- The investigation is based on assumptions rather than objective evidence
- Lack of Objectivity/Incorrect Problem Definition
- The team begins the investigation with a likely root cause and looks for evidence to validate it, rather than collecting all of the pertinent data and coming to an objective root cause
- Revenue, Cost and/or Schedule Constraints
- A limited investigation takes place in the interest of minimizing impacts to revenue, cost and/or schedule
- Rush to Judgment
- The investigation is closed before all potential causes are investigated
- Lack of Management Commitment
- The Team Lead and team members are not given management backing to pursue root cause; quick closure is emphasized
- Lack of Insight
- Sometimes the team just doesn’t get the inspiration that leads to resolution
In next week’s tip, we’ll continue with the Analysis part of the FRACAS process, and discuss some of the Analysis tools that can be used to determine the root cause of a failure.
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