Root Cause Analysis Template

[For Use by the Industry]

7/12/2010

Created by the Industry

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Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT
Introduction
This template will help the Root Cause Analysis (RCA) team collect information, perform analyses and determine the cause of the
events. This document also provides guidance for analyzing problems by addressing the policies, procedures and processes; utility
system operation and equipment failure; and human performance. Note the majority of human performance failures are
attributed to the lack of policies, procedures and training.
When the event cause is determined the team should discuss corrective actions to take so that the event will not happen again.
It may be valuable for the team to share the lesson with the industry.

Action Plan
As the team conducts its RCA ask the questions that are described in the template. Attach reference documentation as necessary.

Root Cause: A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html

Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT
Performance
Category

Description

Sub-category

Evaluation

Comment

Ask these questions for all

categories
(1) Does it exist?
(2) Did this cause the event?
(3) Is something missing?
(4) Is there an opportunity to
correct?
(5) Other thoughts to consider?
Policies and
procedures

This category
deals with the
corporate
policies and
procedures.
System policies
and procedures

(1) Does the organization

have a policy or procedure
that applies?
(2) Does the policy or
procedure work?
(3) If not what changes are
needed?

Work direction

(1) What was the work

direction?
(2) How was the work
direction given? Verbally?
In writing?
(3) leads
Did the
employee
Root Cause: A root cause is an initiating cause of a causal chain which
to an
outcomeconfirm
or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html

Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT
expectations?
Communications

(1) How did the parties

communicate? Verbally?
In writing?
(2) Was third part
communication followed?

Training

(1) Does a training procedure

exist? If no why not?
(2) Was the employee
trained? If no why not?

Quality Control

(1) Does a QC program exist?

(2) If no why not?

Barriers

(1) Are there any barriers that

caused negative results?
(2) Do policies or procedures
exist that are causing the
problem?
(3) Does money exist that can
fix the problem?

Human
performance

(1) Do policies and

procedures exist?
(2) If not will relevant
policies and procedures be
developed and
implemented?

Root Cause: A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html

Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT
(3) If they exist will they be
improved?
(4) Did the person fail to
follow training, policies,
and procedures?
(5) Are there logical reasons
for the human
performance failure?

System
operation and
equipment

Repeat failure

(1) Has this event happened

before?
(2) Why?
(3) Why not?
(4) What can be done to keep
the same event from
happening again?

Operation,
maintenance

(1) Do policies and

procedures exist?

This section
applies to how
the system is
performing or
not performing.
The same set of
questions
applies to the
pieces of
equipment.

Root Cause: A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html

Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT
system policies
and procedures

Design

Management
systems

(2) If not will relevant

policies and procedures be
developed and
implemented?
(3) If they exist will they be
improved?

(1) Does a design problem

exist?
(2) Did the entity contact the
equipment supplier or
manufacturer?
(3) Did this cause the event?
(4) Is something missing?
(5) Is there an opportunity to
correct?
(6) Any other thoughts to
consider?

(1) Do policies and

procedures exist?
(2) If not will relevant
policies and procedures be
developed and
implemented?

Root Cause: A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html

Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT
(3) If they exist will they be
improved?

Defective parts

(1) Did parts fail? Why?

(2) What improvements can
be made?
(3) Has the entity contacted
the manufacturer? Why
not?

Quality Control

(1) Was the process inspected

for flaws?
(2) Was the work area
inspected for problems?
(3) Why not?

Training

(1) Was staff trained?

(2) If no then why not?
(3) Any improvements
needed?
(4) Should the entity propose
changes to the equipment
supplier or manufacturer?

Repeat failure

(1) Why are the same

mistakes occurring?
(2) Any improvements
needed?
(3) Should the entity propose

Root Cause: A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html

Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT
changes to the equipment
supplier or manufacturer?

Human
Performance

This area deals

with the human
element.
Individual

(1) Was the employee

adequately prepared to
perform the tasks?
(2) If no then why not?
(3) What improvements can
be made?

Team

(1) Was the team adequately

prepared to perform its
work?
(2) If no then why not?
(3) What improvements can
be made?

Management
System policies
and procedures

(1) Do policies and

procedures exist?
(2) If not will relevant
policies and procedures be
developed and
implemented?
(3) If they exist will they be
improved?

Root Cause: A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html

Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT

Training

(1) Does a training procedure

exist? If no why not?
(2) Was the employee
trained? If no why not?

Communications

(1) How did the parties

communicate? Verbally?
In writing?
(2) Was third part
communication followed?

Quality Control

(1) Was the process inspected

for flaws?
(2) Was the work area
inspected for problems?
(3) Why not?

Work Direction

(1) What was the work

direction?
(2) How was the work
direction given? Verbally?
In writing?
(3) Did the employee confirm
expectations?

Environment

(1) Was the work

Root Cause: A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html

Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT
environment bearable?
Safe?
Work load balanced?
Staff overworked?
Proper safeguards in
place?
(6) Other factors exist that
made it difficult to
perform tasks?
(2)
(3)
(4)
(5)

Barriers

(1) Are there any barriers that

caused negative results?
(2) Do policies or procedures
exist that are causing the
problem?
(3) Does money exist that can
fix the problem?

Repeat failure

(1) Why are the same

mistakes occurring?
(2) Any improvements
needed?
(3) Should the entity propose
changes to the equipment
supplier or manufacturer?

Corrective
Action Plan
Root Cause: A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html

Root Cause Analysis Template

The user should address these questions during the RCA

DRAFT
Repeat failure
Cost to correct

Lesson Learned
opportunity

Should this event be shared with

the industry?

For more details see the Events Analysis process documentation

Root Cause: A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an
undesirable outcome.
en.wikipedia.org/wiki/Root_cause. The root cause is the event or combination of events that initiate a failure.
Updated July 12, 2010
www.acceleratedanalysis.com/glossary.html