RCA - Root Cause Analysis

RCA - Root Cause Analysis

• 1.
  - Abhishek Agnihotry - any query mail me at  - agnihotry@gmail.com 1/31/2013 1
• 2.
  Scope: •Problem control, errorcontrol and proactive Problem Management are all within the scope of the Problem Management process. In terms of formal definitions, a 'Problem' is an unknown underlying cause of one or more Incidents or of a Major Incident, and a 'Known Error' is a Problem that is successfully diagnosed and for which a Work-around or FIX has been identified. 1/31/2013 2
• 3.
  Input and Outputof Problem Management Inputs: • Incident details from Incident Management • Configuration details from (CMDB) • Any defined Work-around (from Incident Management). Outputs: • Known Errors • A Request for Change (RFC) • An updated Problem record (Work-around / Fix) • for a resolved Problem, a closed Problem record • Response from Incident matching to Problems and Known Errors • MIS 1/31/2013 3
• 4.
  Root Cause Analysis– Review by Application Owners RCA provided by PM team Problem Sent to the and Error Application Control owners (slide 5) RCA analysis by application owners Approved Yes No Request to PM team for rectified RCA based on App owners recommendations 1/31/2013 4
• 5.
  Problem & ErrorControl PM Problem Identify and Record Identification and Error Recording Problem Asses Errors Classification CM Problem Record Error Investigation and Resolution RFC Diagnosis Root Cause Detected Close Error record and KEDB Associated Change successfully Updated Problem(s) Implemented 1/31/2013 5
• 6.
  Root Cause Analysis- a REACTIVE method of identifying event(s) causes General principles of RCA: • To be effective, RCA must be performed systematically, and root causes identified backed up by documented evidence. • There may be more than one RC for an event or a problem • The purpose of identifying all solutions to a problem is to prevent recurrence at lowest cost in the simplest way, the simplest or lowest cost approach is preferred. • To be effective, the analysis should establish a sequence of events or timeline to understand the relationships between contributory (causal) factors, root cause(s) and the defined problem or event to prevent in the future. 1/31/2013 6
• 7.
  Root Cause Analysis- evaluation 1st : Is it readable? If it is readable it will be grammatically correct, the sentences will make sense, it will be free of internal inconsistencies, terms will be defined, it will contain appropriate graphics, and the like. 2nd : Does it contain a complete set of all of the causal relationships? If it did contain a "complete set of all of the causal relationships" one could (at least): ◦ 1. Trace the causal relationships from the harmful outcomes to the deepest conditions, behaviors, actions, and inactions. ◦ 2. Show that the important attributes of the harmful outcomes were completely explained by the deepest conditions, behaviors, actions, and inactions. 1/31/2013 7
• 8.
  Root Cause Analysis– Level of Causes  Physical cause – Specific physical item that if corrected/replaced would fix the problem  System cause – Possible underlying cause of physical failure Problem sympto ms Physical cause System cause 1/31/2013 8
• 9.
  Root Cause Analysis– Barriers Cognitive laziness – Instead of taking the optimum result, we take the first sufficient result Overconfidence – perusing evidences supporting our own belief rather than allowing the idea to represent the truth Recency bias – Assume the same cause for two recent problem symptoms and therefore not performing a more rigorous investigation Availability bias – Rely on available data rather than collecting / gathering more relevant or reliable data Anchoring bias – latching on to the first data and its indication while ignoring possibility conflicting evidence Confirmation bias – Looking for and accepting only data that confirms our preexisting assumption of the cause 1/31/2013 9
• 10.
  Root Cause Analysis– 7 Step problem solving model Identify the List possible ID most likely Problem Root causes Root cause Select and Evaluate effect ID potential Implement of solution solutions solution Standardize process 1/31/2013 10
• 11.
  Root Cause Analysis– Use 5 Why’s to understand the issue 5 Why’s Problem: Car will not start  This is the simplest method to Why: Dead battery find out the Root cause Why: Bad alternator  Drill deeper into problem until a Root cause is found Why: Alternator’s belt broken Why: Belt achieved end of life Why: Recommended maintenance not performed 1/31/2013 11