The documentation and supporting reports required for any Root Cause Analysis can be varied and there are a few essential supporting reports you will need before any RCA can be carried out. These reports would be included within the RCA process and can be broken down into various categories and depending on the nature of the problem the industry / service.
People
One of the first steps in the data collection phase is to gather any documents related to the actual incident or problem, including written statements from any interviews carried out from those involved. These will help to build a timeline of events which is essential to the RCA charting process. It’s often helpful during interviews to have witnesses make sketches- this can help with recall and timeline.
Procedures
Any manuals or documentation for processes, including company procedure documents, information pertaining to any standards, compliance, laws or work practices or production data as well as any available failure history or previous investigations. Any information you can collate regarding procedures will also be enormously helpful whilst carrying out an RCA.
Hardware
It’s also a good idea to have photos or video of any hardware included in the investigation, especially where there is any failed parts/equipment or Health & Safety incident. Gathering this should be a part of any initial incident or failure investigation and can be used to cover off any evidence requirements for the RCA.
Software & Data
Any data reports or trend analysis data , schematics or diagrams showing all significant components, asset lists, parts, or tasks (and their interconnections) of a circuit, device, flow, process, or project. These can be used in conjunction with the photos or video previously mentioned and will also help when drilling down in to a system / process to uncover other causes of a problem.
Costs & Lost Revenue
Any quantifiable documentation relating to costs incurred or revenue lost.
The Environment
The physical workplace environment as well as sudden change to that environment are factors that need to be identified and documented. Factors to include within the report would be (but not limited to) weather conditions, housekeeping, the layout of machinery and storage areas, lighting, visibility, ventilation, temperature, noise levels etc.
All of the above reports or documentation will be extremely important whilst working on an RCA and will make it easier to find both action and/or conditional causes. They’re also a critical component when mapping cause and effect.
The RCA Chart
Once the charting process is complete, an RCA report will need to be written based on the findings. Regardless of software, the report should always be concise, well written, and include:
- A definition of the Problem
- Solutions, action items & associated causes
- The person responsible for implementation and any completion dates
- The cause and effect chart
- Any cost information
- Contact names of all stakeholders
- Date of report and start date of the investigation
Master corrective action tracking log
There are a wide variety of software solutions based around the implementation and tracking of solutions, corrective actions or preventative actions. The chosen solution should be fit for purpose to record the recommendations pertaining to each corrective action including: notification, follow-up, and escalation of overdue tasks as well as any systemic issues.
Roles & responsibilities documentation
This is documentation that sets out the roles and responsibilities of people during an investigation and will include who is responsible for the below tasks. This information should be agreed on and a specific procedure documented:
- First Responder: The role of a First Responder is to gather as much information and preserve as much evidence as reasonably possible when a trigger incident occurs.
- Incident investigation lead: Assigns roles to team members
- Evidence Gatherer: Initiates the evidence collection effort
- Evidence Preservation Coordinator: Responsible for evidence preservation
- Communications Coordinator (Major events – Corp): Point source contact for external communications
- Interview Coordinator: Coordinates/manages interviewing process
These do not need to be individual people; one person could perform more than one of these tasks.
Documented policy for trigger points
Investigation triggers are the point at which a formal RCA is initiated and should be based on organisational strategic objectives and KPI’s. Without these ceilings being formalized and recorded, indecision can arise regarding when to perform the RCA. This in turn, could result in wasted resources and incur unnecessary and additional costs.
FMEA & FMECA Documentation
Failure Modes and Effects Analysis (FMEA) is a systematic, proactive method for evaluating a process to identify where and how things might fail and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change. The things that these reports would help with would be:
- Has FMEA/FMECA been carried out, to highlight and consider the potential failures and risks?
- Has the actual failure experienced been thought of in the FMEA/FMECA?
- What was the failure mitigation strategy chosen (maintenance task, redesign, rtf etc.)?
A documented report for FMEA / FEMECA would inform the organisation if the strategy was implemented and actioned, and the information within this is extremely beneficial when conducting an RCA.
In conclusion, effective data collection, reporting and documentation is extremely important within the RCA process as it helps communicate the potential causes of a problem as well as the actions / solutions to implement so the problem does not reoccur. The documentation associated with the RCA process also helps us embed the RCA process within the top, middle & bottom of any organization.
