Insufficient training | Insufficient maintenance |
Incorrect maintenance procedures | Poor communication |
Insufficient tools | Inadequate supervision |
Human error | Latent human error |
Equipment failure | Design flaws |
Data quality issues | System failure |
Integration failure | Misinterpretation of data |
Procedural errors | Lack of procedures |
Lack of process | Process flaws |
Software defects | Inadequate documentation |
Environmental factors | Unclear roles |
Lack of authority | Lack of accountability |
Poor user interfaces | Lack of planning |
Workflow flaws | Inaccurate measurements |
Incorrect configuration | Cultural factors |
Inadequate feedback mechanisms | Incorrect analysis |
Lack of precision and accuracy | Lack of testing |
Test scripts flawed or insufficient | Change control failures |
Supply failures | Infrastructure failures |
Disasters and other major disruptions | Inadequate inspection |
Inadequate logging | Insufficient monitoring |
Lack of notifications | Lack of ownership |
Insufficient capacity | Insufficient durability |
Management failure | Quality assurance failure |
Insufficient quality control | Improper installation |
Improper calibration | Process was not followed |
Procedures were not followed | Issues were not escalated |
Inadequate troubleshooting | Equipment unfit for purpose |
Equipment operated beyond service life | Software operated beyond end-of-support |
Failure to recognize warning signs | Failure to investigate notifications |
Wrong parts or components used | Wear and tear |
Insufficient error handling | Poor architectural design |
Ineffective version control | Flawed deployment practices |
Over-automation – human checks required | Lack of automation |
Unmanaged risk | Insufficient risk controls |
What Qualifies as a Root Cause?
A root cause is the fundamental or underlying reason that something happened. Determining a root cause can be a complex undertaking that can be easily influenced by unjustified assumptions or the motivations of those investigating root cause. A root cause is the most fundamental explanation that has no deeper cause behind it. As such, root cause analysis requires challenging each proposed root cause to see if there is a deeper cause. This can benefit from a technique known as 5-whys whereby you ask the question "why?" five times in succession.5-Whys
Ask the question "why?" five times in succession to determine a root cause. For example, if your lunch burns you could perform a root cause analysis as follows:Incident: Lunch burned
Why? The oven was too hot.
Why? Trying to save time by cooking on high temperature. This is a high risk approach to preparing lunch that backfired.
Why? Only have 20 minutes for lunch.
Why? Under pressure to complete project that is behind schedule.
Why? The project requirements were poorly defined and there were many clarifications required over the course of the project that delayed things.
Actionable Causes
Any two people or groups that perform 5-whys are likely to come up with different root causes at level five. One particular issue here is that you can end up blaming society or some deep institutional causes for all problems. This isn't helpful as it is probably not within your power to address these causes. As such, it is helpful to select a root cause that is actionable.Incident: Lunch burned
Why? The oven was too hot.
Why? Took a risk by cooking on high temperature but did not mitigate that risk by closely watching the food.
Why? Stressed out by project, mind not focused on lunch.
Why? Project is behind schedule.
Why? Did not push client for well-defined requirements early enough in the project lifecycle.
The example above focuses on things that the person making lunch could have done to avoid the burnt lunch at different levels of their life. This produces the easily actionable cause that they didn't watch the food and the deeper cause that they didn't manage their project requirements very well.Why? The oven was too hot.
Why? Took a risk by cooking on high temperature but did not mitigate that risk by closely watching the food.
Why? Stressed out by project, mind not focused on lunch.
Why? Project is behind schedule.
Why? Did not push client for well-defined requirements early enough in the project lifecycle.