585:) in every case including non-RCA investigations. One method is to list the defenses on chart or a virtual white board. Then, for each defense, look at the information and data that was gathered for evidence of the effectiveness of that defense. We are actually looking for deficiencies or gaps in performance where the administrative requirements were not met, or where the physical or cyber barriers were bypassed. These initial gaps in performance are merely symptoms of deeper-seated causes. We use these symptomatic performance gaps to develop lines of inquiry questions as outlined below, to pursue the symptoms back to their points of origin (i.e. the root causes) using cause-and-effect analysis.
646:
the RCA team, although the team is an excellent source of guidance for the issue owners. The Extent of Cause reviews are conducted to determine the extent of the damage or impact that the root causes and contributing factors had on humans, equipment, or facilities. Extent of Cause reviews are an
Achilles heel in the vast majority of organizations and a primary reason why RCAs and corrective action plans fail to prevent recurrence. Also, care must be taken to avoid corrective action plans that simply add more administrative requirements and more training to the organization. To avoid this, use the
942:
periodic inspection of the lubrication subsystem every two years, while the current lubrication subsystem vendor's product specified a 6-month period. Switching vendors may have been due to management's desire to save money, and a failure to consult with engineering staff on the implication of the change on maintenance procedures. Thus, while the "root cause" shown above may have prevented the quoted recurrence, it would not have prevented other – perhaps more severe – failures affecting other machines.
524:
472:
that are in place to manage operations and prevent events. A great way to use root cause analysis is to proactively evaluate the effectiveness of those defenses by comparing actual performance against applicable requirements, identifying performance gaps, and then closing the gaps to strengthen those defenses. If an event occurs, then we are on the right side of the model, the reactive side where the emphasis is on identifying the root causes and mitigating the damage.
619:. Socratic questions keep the investigation flowing down to the next deeper causal factors until the organization runs out of answers, or the last causal factor is beyond the organization's control. There are many skills involved in conducting an effective cause-and-effect analysis, including facilitation skills, communication skills, and Socratic questioning. When conducted properly, this will take the RCA down to the deepest-seated root causes. A word of caution:
66:
25:
223:
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for all expected scenarios do not exist, instead they are created after the fact based on issues seen as 'worthy'. As a result the analysis is often limited to those things that have monitoring/observation interfaces and not the actual planned/seen function with focus on verification of inputs and outputs. Hence, the saying "there is no root cause" has become common in the IT industry.
664:. This requires specifying a set of metrics or indicators that will be monitored prior to and after the corrective actions are implemented, so we can measure their impact. If the desired results are not achieved, which in most cases is a significant reduction in the magnitude or frequency of the event or problem, then the RCA must be reopened as it was not effective.
608:) and other tools that provide us with insights into performance gaps. There should not be any curiosity questions, questions that reflect "confirmation bias" (i.e. asking a leading question so they answer what the RCA team thinks are the causes), or questions that are accusatory in nature that will cause those helping the investigation to close down and withdraw.
481:
mechanism had a pump that was not pumping sufficiently, hence the lack of lubrication. Investigation of the pump shows that it has a worn shaft. Investigation of why the shaft was worn discovers that there is not an adequate mechanism to prevent metal scrap getting into the pump. This enabled scrap to get into the pump and damage it.
471:
model. In the center of the model is the event or accident. To the left, are the anticipated hazards and the line of defenses put in place to prevent those hazards from causing events. The line of defense is the regulatory requirements, applicable procedures, physical barriers, and cyber barriers
447:
Proactive management, conversely, consists of preventing problems from occurring. Many techniques can be used for this purpose, ranging from good practices in design to analyzing in detail problems that have already occurred and taking actions to make sure they never recur. Speed is not as important
645:
From a management perspective, the RCA effort is not complete without a comprehensive corrective action plan to address the root causes, the contributing factors, and the "Extent of the Causes." The corrective action plan should be developed by the issue owners and does not require participation by
614:
Once we have developed a robust set of lines of inquiry questions from the factual evidence collected, the applicable requirements, and an analysis of the available data, we can take those questions to the organization's subject matter experts. This begins the process of cause-and-effect analysis.
930:
Second, gathering data and evidence, and classifying them along a timeline of events to the final problem, can be nontrivial. In telecommunications, for instance, distributed monitoring systems typically manage between a million and a billion events per day. Finding a few relevant events in such a
856:
supported by pre-existing fault trees or other design specs. Instead a mixture of debugging, event based detection and monitoring systems (where the services are individually modelled) is normally supporting the analysis. Training and supporting tools like simulation or different in-depth runbooks
668:
To be effective, root cause analysis must be performed systematically. The process enables the chance to not miss any other important details. A team effort is typically required, and ideally all persons involved should arrive at the same conclusion. In aircraft accident analyses, for example, the
591:
After gathering available information, organizing it into charts with timelines and other data, after analyzing available data, and after conducting an analysis of our defenses, we use those insights to generate great questions. These questions will become our lines of inquiry for cause-and-effect
463:
A factor is considered the "root cause" of a problem if removing it prevents the problem from recurring. Conversely, a "causal factor" is a contributing action that affects an incident/event's outcome but is not the root cause. Although removing a causal factor can benefit an outcome, it does not
558:
for the event, and to identify the line of the defenses that should have prevented the event (i.e. the administrative requirements, and physical and cyber barriers). Available databases should also be queried and analyzed (such as corrective action program and safety program databases), and data
941:
Fourth, causal graphs often have many levels, and root-cause analysis terminates at a level that is "root" to the eyes of the investigator. Looking again at the example above in industrial process control, a deeper investigation could reveal that the maintenance procedures at the plant included
677:
The goal of RCA is to identify the root cause of the problem with the intent to stop the problem from recurring or worsening. The next step is to trigger long-term corrective actions to address the root cause identified during RCA, and make sure that the problem does not resurface. Correcting a
627:
methods, are not rigorous enough for conducting a root cause analysis. The
Fishbone is from the 1940s and the 5-Whys is from the 1930, and there are much more advanced methods available. Look for methods that were developed in this century (the year 2000 and later), as they are more likely to
510:
As an unrelated example of the conclusions that can be drawn in the absence of the cost/benefit analysis, consider the tradeoff between some claimed benefits of population decline: In the short term there will be fewer payers into pension/retirement systems; whereas halting the population will
480:
Imagine an investigation into a machine that stopped because it was overloaded and the fuse blew. Investigation shows that the machine was overloaded because it had a bearing that was not being sufficiently lubricated. The investigation proceeds further and finds that the automatic lubrication
495:
Compare this with an investigation that does not find the root cause: replacing the fuse, the bearing, or the lubrication pump will probably allow the machine to go back into operation for a while. However there is a risk that the problem will simply recur until the root cause is dealt with.
559:
analysis tools such as Pareto charts, process maps, fault trees, and other tools that provide us with insights into performance gaps. Any number of data analysis tools can be brought to bear, including data analysis tools from Lean Six Sigma, statistical analysis tools, and others such as
542:
and event descriptions (as failures, for example) are helpful and usually required to ensure the execution of appropriate root cause analyses. Problem statements are the North Star of the RCA as it keeps the team focused on what they are investigating and prevents them from going
549:
Most RCAs begin with a fact finding session to gather available information such as witness statements, the chronology of events and applicable requirements for the evolutions that were taking place at the time of the event. The information can be used to establish a
455:
Root cause analysis is often used in proactive management to identify the root cause of a problem, that is, the factor that was the leading cause. It is customary to refer to the "root cause" in singular form, but one or several factors may constitute the
749:>>> 21 CFR Subpart J: 21CFR820.100(a) – Corr./Preventive Action: (A) Each manufacturer shall establish and maintain procedures for implementing corrective and preventive action. The procedures shall include requirements for:
514:
Costs to consider go beyond finances when considering the personnel who operate the machinery. Ultimately, the goal is to prevent downtime; but more so prevent catastrophic injuries. Prevention begins with being proactive.
592:
analysis. The questions must be unbiased, and to prevent any bias from the RCA team from tainting the investigation, questions should be tied to a specific defense, or to a specific insight from our data analysis (e.g.,
724:“Measures shall be established to assure that conditions adverse to quality such as failures, malfunctions, deficiencies, defective material and equipment, and non-conformances are promptly identified and corrected.
826:
is to resume a faulty IT service as soon as possible (reactive management), whereas problem management deals with solving recurring problems for good by addressing their root causes (proactive management).
634:
The best way to chart the results of an RCA investigation is to start populating the final chart from the start. This process has become much easier with the advent of virtual white boards. In a single
881:(e.g., to identify the source of an infectious disease), where causal inference methods often require both clinical and statistical expertise to make sense of the complexities of the processes.
488:
root cause could be a design issue if there is no filter to prevent the metal scrap getting into the system. Or if it has a filter that was blocked due to a lack of routine inspection, then the
1543:
772:...Root Cause Analysis for patient deaths and graft failures, including factors the program has identified as likely causal or contributing factors for patient deaths and graft failures;
639:, we can display the timelines, the lines of defenses, the data analysis, the lines of inquiry questions, the cause-and-effect analysis, the root causes, and the corrective action plan.
484:
The apparent root cause of the problem is that metal scrap can contaminate the lubrication system. Fixing this problem ought to prevent the whole sequence of events from recurring. The
431:
Reactive management consists of reacting quickly after the problem occurs, by treating the symptoms. This type of management is implemented by reactive systems, self-adaptive systems,
727:
In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined, and corrective action taken to prevent recurrence.”
714:
Root cause analysis is used in many application domains. RCA is specifically called out in the United States Code of
Federal Regulations in many of the Titles. For example:
1413:
Abubakar, Aisha; Bagheri Zadeh, Pooneh; Janicke, Helge; Howley, Richard (2016). "Root cause analysis (RCA) as a preliminary tool into the investigation of identity theft".
581:
After identifying the defenses in place that should have prevented the event or accident, it is highly recommended to conduct an analysis of defenses (traditionally called
531:
Despite the different approaches among the various schools of root cause analysis and the specifics of each application domain, RCA generally follows the same four steps:
359:), etc. Root cause analysis is a form of inductive (first create a theory based on empirical evidence ) and deductive (test the theory with empirical data) inference.
927:
First, important information is often missing because it is generally not possible, in practice, to monitor everything and store all monitoring data for a long time.
1456:
Key steps to conducting an effective root cause analysis, which tools to use for root cause identification, and how to develop effective corrective actions plans.
233:
735:>>> 14 CFR Chapter III, Subchapter C, Part 437, Subpart C, §437.73 Anomaly recording, reporting and implementation of corrective actions.
582:
1179:
1055: – solving a problem or resolving a conflict by bringing about structural changes in underlying structures that provoked or sustained these problems
1435:
758:
Verifying or validating the corrective and preventive action to ensure that such action is effective and does not adversely affect the finished device;
924:
Without delving in the idiosyncrasies of specific problems, several general conditions can make RCA more difficult than it may appear at first sight.
766:>>> 42 CFR PART 488, SURVEY, CERTIFICATION, AND ENFORCEMENT PROCEDURES > Subpart E—Survey and Certification of Long-Term Care Facilities
503:: does the cost of replacing one or more machines exceed the cost of downtime until the fuse is replaced? This situation is sometimes referred to as
852:
Its use in the IT industry cannot always be compared to its use in safety critical industries, since in normality the use of RCA in IT industry is
244:
1785:
1551:
938:
Third, there may be more than one root cause for a given problem, and this multiplicity can make the causal graph very difficult to establish.
1509:
511:
require higher taxes to cover the cost of building more schools. This can help explain the problem of the cure being worse than the disease.
660:
After a pre-determined period after the implementation of the corrective action plan, an effectiveness review is scheduled to evaluate the
896:. In the manufacture of medical devices, pharmaceuticals, food, and dietary supplements, root cause analysis is a regulatory requirement.
818:
Root cause analysis is frequently used in IT and telecommunications to detect the root causes of serious problems. For example, in the
391:
are taken to prevent the problem from recurring. The name of this process varies from one application domain to another. According to
1657:
1200:
571:
data mining). Another consists in comparing the situation under investigation with past situations stored in case libraries, using
130:
102:
738:
A permittee must record each anomaly that affects a safety-critical system, subsystem, process, facility, or support equipment.
831:
468:
109:
83:
38:
1610:
1386:"CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKAGING, LABELING, OR HOLDING OPERATIONS FOR DIETARY SUPPLEMENTS"
186:
178:
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Identifying the action(s) needed to correct and prevent recurrence of non- conforming product and other quality problems;
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as guidelines for developing effective corrective actions that have a much higher likelihood of preventing recurrence.
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conclusions of the investigation and the root causes that are identified must be backed up by documented evidence.
388:
1422:
Babaoglu, O.; Jelasity, M.; Montresor, A.; Fetzer, C.; Leonardi, S.; van
Moorsel, A.; van Steen, M., eds. (2005).
1513:
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A permittee must identify all root causes of each anomaly and implement all corrective actions for each anomaly.
98:
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problem is not formally part of RCA, however; these are different steps in a problem-solving process known as
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1443:
838:
647:
1790:
1415:
Proc. 2016 International
Conference On Cyber Security And Protection Of Digital Services (Cyber Security)
1360:"CURRENT GOOD MANUFACTURING PRACTICE, HAZARD ANALYSIS, AND RISK-BASED PREVENTIVE CONTROLS FOR HUMAN FOOD"
1630:
691:
661:
932:
721:>>> 10CFR Part 50, Appendix B, Criterion XVI, “Corrective Actions” (also adopted by NQA-1)
452:
of the diagnosis. The focus is on addressing the real cause of the problem rather than its effects.
423:
There are essentially two ways of repairing faults and solving problems in science and engineering.
1835:
1712:
1643:
842:
44:
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Investigating the cause of nonconformities relating to product, processes, and the quality system;
439:. The goal here is to react quickly and alleviate the effects of the problem as soon as possible.
237:
that states a
Knowledge editor's personal feelings or presents an original argument about a topic.
769:§488.61 Special procedures for approval and re-approval of organ transplant programs.
560:
436:
123:
76:
1564:
Identify best practice techniques and behaviours to perform effective Root Cause
Analysis (RCA)
449:
615:
Once we pose a question to the affected organization, we use their answer to pose a follow-up
1764:
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1314:
885:
500:
240:
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8:
1436:"Root Cause Analysis for Civil Aviation Authorities and Air Navigation Service Providers"
1424:
Self-star
Properties in Complex Information Systems; Conceptual and Practical Foundations
1247:"A Narrative Review of Methods for Causal Inference and Associated Educational Resources"
1024:
982:
823:
601:
404:
352:
1717:
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tools and can include change analysis, comparative timeline analysis and task analysis.
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320:
985: – Failure analysis system used in safety engineering and reliability engineering
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1286:
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1266:
1027: – Set of statistical processes for estimating the relationships among variables
905:
889:
651:
539:
432:
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348:
328:
1544:"Root Cause Analysis for Safety Management Practitioners & Business Area Owners"
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used for identifying the root causes of faults or problems. It is widely used in
312:
1518:"FactSheet: The Importance of Root Cause Analysis During Incident Investigation"
1052:
336:
1180:"Dredging River's PCB's Could Be a Cure Worse Than the disease, G. E. insists"
1824:
1606:"Root Cause Analysis and Monitoring Tools: A Perfect Match" by Irene Carrasco
1270:
784:
605:
392:
340:
316:
834:, where root-cause analysis is often used to investigate security breaches.
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account for the new dynamics of the modern sociotechnical work environments.
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597:
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A great way to look at the proactive/reactive picture is to consider the
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Distinguish between the root cause and other causal factors (e.g., using
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Establish a timeline from the normal situation until the problem occurs
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1000: – Investigation of failures associated with legal intervention
65:
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703:
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344:
332:
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1464:
Formal
Development of Reactive Systems; Case Study Production Cell
1412:
1334:"CURRENT GOOD MANUFACTURING PRACTICE FOR FINISHED PHARMACEUTICALS"
1245:
Landsittel, Douglas; Srivastava, Avantika; Kropf, Kristin (2020).
1233:
16:
Method of identifying the fundamental causes of faults or problems
967: – Eight disciplines of team-oriented problem solving method
699:
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1600:
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1132:
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RCA generally serves as input to a remediation process whereby
1570:
Wilson, Paul F.; Dell, Larry D.; Anderson, Gaylord F. (1993).
1811:
1696:
1312:
1431:
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mass of irrelevant events is asking to find the proverbial
819:
234:
personal reflection, personal essay, or argumentative essay
1244:
1595:
1572:
Root Cause
Analysis: A Tool for Total Quality Management
1385:
1359:
1333:
589:
Generating focused, unbiased lines of inquiry questions:
1492:
Toyota Production System: Beyond Large-Scale Production
1038:
Pages displaying short descriptions of redirect targets
1029:
Pages displaying short descriptions of redirect targets
783:
The example above illustrates how RCA can be used in
1494:. Portland, Oregon: Productivity Press. p. 17.
1057:
Pages displaying wikidata descriptions as a fallback
1020:
Pages displaying wikidata descriptions as a fallback
1018: – graphical breakdown used in problem solving
672:
90:. Unsourced material may be challenged and removed.
1601:BlueDragon Integrated Problem-solving System (IPS)
1569:
1076:
993:Pages displaying short descriptions with no spaces
1473:Temporal Verification of Reactive Systems: Safety
1313:Office of Regulatory Affairs (26 December 2019).
1006: – Causal diagrams created by Kaoru Ishikawa
1822:
1462:Lewerentz, Claus; Lindner, Thomas, eds. (1995).
1461:
1177:
1119:
547:Gathering, organizing and analyzing information:
1198:
961: – Structured problem improvement approach
791:, e.g. to control the production of chemicals (
1651:
1525:Occupational Safety and Health Administration
1390:Electronic Code of Federal Regulations (eCFR)
1364:Electronic Code of Federal Regulations (eCFR)
1338:Electronic Code of Federal Regulations (eCFR)
979: – Analysis of potential system failures
832:computer security incident management process
888:(e.g., to analyze environmental disasters),
813:
779:Manufacturing and industrial process control
1574:. Milwaukee, Wisconsin: ASQ Quality Press.
1470:
1106:
53:Learn how and when to remove these messages
1658:
1644:
1315:"Corrective and Preventive Actions (CAPA)"
822:service management framework, the goal of
955: – Iterative interrogative technique
662:effectiveness of those corrective actions
643:Corrective Actions to Prevent Recurrence:
366:Identify and describe the problem clearly
281:Learn how and when to remove this message
263:Learn how and when to remove this message
205:Learn how and when to remove this message
150:Learn how and when to remove this message
1596:Problem Solving Map (PSMap) RCA software
522:
1440:International Air Transport Association
527:Example of a root cause analysis method
464:prevent its recurrence with certainty.
442:
362:RCA can be decomposed into four steps:
1823:
1538:
1093:
709:
426:
383:between the root cause and the problem
1639:
1626:"Fundamentals of Root Cause Analysis"
837:RCA is also used in conjunction with
518:
505:the cure being worse than the disease
1621:"Sologic Root Cause Analysis Method"
1616:"Cause Mapping a visual explanation"
1508:
1489:
1430:
1300:
1220:
1178:Andrew C. Revkin (7 December 2000).
1145:
1089:
860:
216:
161:
88:adding citations to reliable sources
59:
18:
1665:
1471:Manna, Zohar; Pnueli, Amir (1995).
899:
492:root cause is a maintenance issue.
13:
1631:"DOE Root Cause Analysis Document"
1383:
1357:
1331:
892:(aviation and rail industry), and
177:tone or style may not reflect the
14:
1847:
1744:Failure mode and effects analysis
1589:
1426:. LNCS. Vol. 3460. Springer.
1251:Quality Management in Health Care
1159:"The Cure Worse Than the Disease"
1048:Root Cause Analysis Solver Engine
977:Failure mode and effects analysis
965:Eight disciplines problem solving
623:or the Fishbone Diagram, and the
401:Failure mode and effects analysis
395:, RCA may include the techniques
34:This article has multiple issues.
1466:. LNCS. Vol. 891. Springer.
1077:Wilson, Dell & Anderson 1993
1043:Orthogonal defect classification
1036: – Statistical linear model
787:. RCA is also routinely used in
733:TITLE 14 - AERONAUTICS AND SPACE
673:Transition to corrective actions
632:Charting the Results of the RCA:
221:
187:guide to writing better articles
166:
64:
23:
1377:
1351:
1325:
1306:
1293:
1238:
1226:
1213:
1199:Phillip Longman (9 June 2004).
536:Identification and description:
75:needs additional citations for
42:or discuss these issues on the
1192:
1171:
1151:
1138:
1125:
1112:
1099:
1082:
1069:
1034:Multivariate linear regression
1010:Issue-based information system
894:occupational safety and health
682:in IT and telecommunications,
418:
1:
1406:
919:
1611:"Apollo Root Cause Analysis"
1263:10.1097/QMH.0000000000000276
1120:Lewerentz & Lindner 1995
1012: – Argumentation scheme
839:business activity monitoring
648:Hierarchy of Hazard Controls
460:of the problem under study.
7:
1791:Statistical process control
945:
873:, RCA is routinely used in
499:The above does not include
10:
1852:
973: – Statistical method
789:industrial process control
612:Cause-and-Effect Analysis:
475:
325:industrial process control
1809:
1778:
1757:
1731:
1705:
1674:
814:IT and telecommunications
692:environmental remediation
1713:Business process mapping
1548:Sofema Aviation Services
1063:
843:complex event processing
764:TITLE 42 - PUBLIC HEALTH
747:TITLE 21 - FOOD AND DRUG
437:complex adaptive systems
1107:Manna & Pnueli 1995
830:Another example is the
561:hierarchical clustering
1490:Ohno, Taiichi (1988).
1201:"The Global Baby Bust"
658:Effectiveness Reviews:
528:
469:Bowtie Risk Assessment
450:accuracy and precision
433:self-organized systems
243:by rewriting it in an
1831:Quality control tools
1765:Design of experiments
1687:Voice of the customer
886:environmental science
845:to analyze faults in
798:RCA is also used for
652:Lean Mistake Proofing
579:Analysis of Defenses:
526:
501:cost/benefit analysis
99:"Root cause analysis"
1692:Value-stream mapping
1542:(17 November 2017).
1234:Abubakar et al. 2016
1133:Babaoglu et al. 2005
998:Forensic engineering
933:needle in a haystack
904:RCA is also used in
573:case-based reasoning
443:Proactive management
84:improve this article
1739:Root cause analysis
1554:on 17 November 2017
1025:Multiple regression
983:Fault tree analysis
824:incident management
710:Application domains
637:virtual white board
567:solutions (such as
427:Reactive management
405:Fault tree analysis
353:healthcare industry
305:root cause analysis
1718:Process capability
1206:The New York Times
1185:The New York Times
1167:. 5 November 1927.
1164:The New York Times
989:For Want of a Nail
959:A3 problem solving
865:In the domains of
847:business processes
617:Socratic questions
569:graph-theory-based
552:sequence of events
540:problem statements
529:
519:General principles
389:corrective actions
321:telecommunications
245:encyclopedic style
232:is written like a
1818:
1817:
906:change management
890:accident analysis
861:Health and safety
719:TITLE 10 - ENERGY
374:event correlation
349:medical diagnosis
329:accident analysis
319:, manufacturing,
311:) is a method of
291:
290:
283:
273:
272:
265:
215:
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207:
181:used on Knowledge
179:encyclopedic tone
160:
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152:
134:
57:
1843:
1749:Multi-vari chart
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1550:. Archived from
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1533:
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1522:
1505:
1486:
1467:
1458:
1453:
1451:
1442:. Archived from
1434:(8 April 2016).
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1079:, pp. 8–17.
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1021:
1004:Ishikawa diagram
994:
914:systems analysis
900:Systems analysis
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82:Please help
77:verification
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1558:17 November
1450:17 November
1395:28 December
1369:28 December
1343:28 December
1094:Sofema 2017
808:maintenance
804:engineering
688:remediation
602:fault trees
565:data-mining
419:Definitions
355:(e.g., for
301:engineering
1825:Categories
1407:References
1016:Issue tree
920:Challenges
538:Effective
331:(e.g., in
110:newspapers
39:improve it
1801:Poka-yoke
1667:Six Sigma
1301:OSHA 2019
1287:222146291
1271:1063-8628
1221:IATA 2016
1146:Ohno 1988
1090:IATA 2016
953:Five whys
397:Five whys
45:talk page
1530:22 March
1384:US-FDA.
1358:US-FDA.
1332:US-FDA.
1279:32991545
946:See also
875:medicine
704:medicine
621:Ishikawa
556:timeline
403:(FMEA),
345:medicine
333:aviation
706:, etc.
700:therapy
696:ecology
543:astray.
476:Example
297:science
239:Please
124:scholar
1770:Kaizen
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871:safety
867:health
684:repair
625:5-Whys
435:, and
411:, and
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1812:DMAIC
1697:SIPOC
1669:tools
1521:(PDF)
1283:S2CID
1064:Notes
347:(for
339:, or
131:JSTOR
117:books
1576:ISBN
1560:2017
1532:2019
1510:OSHA
1496:ISBN
1477:ISBN
1452:2017
1432:IATA
1397:2020
1371:2020
1345:2020
1299:See
1275:PMID
1267:ISSN
1232:See
1219:See
1144:See
1131:See
1118:See
1105:See
1092:and
1088:See
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869:and
841:and
820:ITIL
806:and
650:and
563:and
490:real
486:real
299:and
103:news
1514:EPA
1319:FDA
1259:doi
854:not
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