🔍

Facilitating RCA

How to Run an Effective Root Cause Analysis Session

When to Do an RCA?

⚠️

Safety Incidents

Always investigate safety events

🌍

Environmental

Any release or near-miss

⏱️

Major Downtime

Over 4 hours production loss

🔄

Repeat Failures

3rd time in 6 months

💰

High Cost

Over €10,000 impact

👁️

Near Misses

Could have been serious

80% of Success is Preparation

1 Gather Facts

  • Maintenance logs
  • Operator statements
  • Alarm history
  • Photos of failed component

2 Build Timeline

  • Normal operation → failure → recovery
  • Visual anchor for discussion
  • Helps spot gaps in knowledge

3 Right People

  • Someone who was there
  • Equipment expert
  • Process knowledge
  • Decision maker (4-6 total)

4 Room & Time

  • Whiteboard essential
  • 2 hours minimum
  • Pre-read sent 24h ahead

The 5-Why Method

1
Why did the pump fail?
→
The bearing seized
2
Why did the bearing seize?
→
It ran without lubrication
3
Why no lubrication?
→
Oil level was low
4
Why was oil low?
→
Leak in the oil seal
5
Why is there a leak?
→
Seal installed incorrectly 3 months ago → Training gap!

Facilitator Techniques

1 Vary Your Questions

Same question, different angles

"What caused that?" "What allowed this to happen?" "What would have prevented it?"

2 Challenge Assumptions

Push back gently on quick conclusions

"Seals just wear out" → "How old was it? What's expected life?"

3 Fact vs Opinion

Ask for data when possible

"Operations ran it too hard" → "Can we check the logs?"

4 Park Good Ideas

Don't dismiss solutions, capture them for later

"Good thought, let's capture that for when we discuss actions"

Fishbone Diagram (Ishikawa)

🔧 Machine

Equipment condition, design

📋 Method

Procedures, schedules

🛢️ Material

Parts quality, supplies

👷 Manpower

Training, workload, skills

📏 Measurement

Monitoring, gauges

🌍 Environment

Conditions, context

→

PROBLEM

Pump Failure

Use sticky notes • One idea per note • Brainstorm all causes, then investigate likely ones

Common Traps to Avoid

🛑

Stopping Too Early

"The seal failed" is not a root cause. Keep asking why until you find systemic causes.

👆

Blame

"John should have checked" loses the team. Ask: "What system should have ensured it was checked?"

📊

Too Many Causes

15 root causes = zero root causes. Prioritize the 2-3 that matter most.

❓

Vague Actions

"Improve training" isn't actionable. Need: name, specific task, due date.

📅

No Follow-Up

RCA without follow-up is just a meeting. Schedule 30-day check before leaving.

Closing the Session

1

Summarize Timeline

Confirm what happened, in sequence. Get agreement.

2

State Root Causes

List the 2-3 systemic causes. Get verbal agreement.

3

Review Actions

Each action: owner + due date. Get commitment.

4

Schedule Review

30-day follow-up in calendars before people leave.

Get the RCA Toolkit

Download free RCA template & facilitator checklist

One-page report format included

reliox.org

The goal isn't a perfect report — it's preventing the problem from happening again

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