Root Cause Analysis (RCA)

information session
&
Investigation Training
 Our Protocol

Please keep Questions to your

self until we are finished !!

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lecture ends !!!

thanks
 3
The Need for RCA

• There is a significant misunderstanding of the RCA and in many instances it would either be
incorrectly prepared or not prepared at all.

• Identifying, for example, “lack of documentation” as the root cause without getting to the real
answer as to WHY the documentation was deficient is not enough.

• As per the 2016 IRBA Public Inspections report, the highest root cause allocation was “human
error”, without drilling down to exactly WHY the issue existed or resulted in a finding (root cause
vs. symptoms).

• Those auditors that effectively identified the underlying root causes and implemented real
proactive action plans demonstrated significant improvement during follow-up inspections.
 4
RCA Introduction & Background
(cont …)
Brief history on RCA:
•Developed by Sakichi Toyoda who later founded Toyota Motor Company.

•RCA was first used during the development of Toyota’s manufacturing processes in 1958.

Definitions:
•Root Cause: The original event, action and/or condition generating an actual or potential undesirable
condition, situation, nonconformity or failure.

•RCA is a technique for identifying the underlying key cause (or causes) behind review findings,
whether specific to one audit or firm wide, so that an appropriate and achievable action (or actions) can
be taken to prevent the recurrence of negative outcomes and promote the recurrence of positive ones.
 5
RCA Introduction & Background (cont …)
 6
RCA Introduction & Background (cont …)

Visible

Not visible
 7

RCA Introduction & Background (cont …)

RCA advantages
•Leads to consistent audit quality and reduction of inspection findings.
•Adds value to the firm, partners and staff.
•There is the potential for cost reduction.
•Provides a learning process for better understanding of relationships (cause and effect; and
solutions).
•Provides a logical approach to problem solving using data that already exists.
•Reduces risk.
•Prevention of recurring failures.
•Improved performance.
•Leads to more robust systems, policies and procedures.
 8
RCA Introduction & Background (cont …)
Overall objective of RCA

Continuous improvement of audit quality within the firm

Audit
Quality
Improvement
Process
 9

Principles of RCA
The RCA cycle
 10
Principles of RCA (cont …)
The following are examples of possible causes, but they do NOT drill down to the true
ROOT cause:
- Human error
- Misunderstood the requirement
- Misunderstood the standards
- Documentation
- System error/Audit methodology
- Elaborating on the finding
- Expanding on symptoms
- The consultant messed up
- It was an oversight
- Audit procedures/software not updated, etc.

- Should find and address the real Root Cause.

- Should, therefore, address the question:
“WHAT in the system failed to make the
problem occur?”
- Until the root cause is identified, keep
asking: WHY?
 11
Principles of RCA (cont …)

Why do we have poor root cause analyses?

- We have not set criteria about what makes an acceptable corrective action plan (firms to implement
RCA and RAP Policies and Procedures).
- We continue to accept bad answers.
- People (internal and external) do not have the Root Cause Analysis culture; don’t know any process or
are not effectively trained.
- We are addressing the symptoms and not the true root of the issue.

Steps that can address poor RCA (DMAGIC):

Define the problem.

Map the process and collect data.
Analyse data and identify causes.
Gather information and evidence (asking why) until the true root cause is clear.
Implement an action plan to address the root cause(s).
Control and monitor the plan.
 12
Principles of RCA (cont …)

Using the 5 Cs

1) Criteria:
The law, regulation, contractual obligation, policy, procedure or best practice that is
expected to be followed.
2) Condition:
The factual analysis of the process as it exists.
3) Consequence/Effect:
Why the issue is important and noteworthy from a compliance, financial, or operational
standpoint.
4) Cause:
The root cause that allowed the condition to not emulate the criteria.
5) Corrective Action/Recommendation:
Change that will address the root cause – action plan.
 13
Principles of RCA (cont …)
It is important to get your mind into an investigative mode (refer to principle of professional
scepticism).

Investigating checklist example:

•Identify the procedure owner and those involved.
•Gather information:
- Data
- Employee Input
- Flowcharts of the process
- Procedures Rules of the investigation:
- Records (quantitative data)
•Has the problem occurred in the past? •Use proven root cause analysis tools.
•Identify the root cause. •Think “out of the box”.
•Brainstorm.
•Take the time needed.
•Put a plan together.
 14
Principles of RCA (cont …)
RCA techniques:
•The 5 WHYs (today’s focus).
•Failure mode and effects analysis.
•Flowcharting of the process flow, system flow and data flow.
•Fishbone diagrams.
 15
Principles of RCA (cont …)
• The objective is to learn, train and improve.
• NB! Take responsibility, accountability and action.
 16
Principles of RCA (cont …)
The 5 WHYs explained …
 17
Principles of RCA (cont …)
Real life examples…
 18
Principles of RCA (cont …)
 19
Principles of RCA (cont …)
Example of 5 WHYs in action (audit)
 20

Principles of RCA (cont …)

Finding: Failure to identify cash flow statement misclassification
Example of 5 WHYs in action (audit)
The audit staff member performing the work did not practice due First why
care or there was a lack of understanding of the subject matter.

There was a lack of direction/supervision/motivation or Second why

late/inadequate documentation because of time pressure.

Fee pressure/resource shortage or poor project management. Third why

Inexperienced senior manager. Fourth why

The audit partner did not provide training/guidance and did Fifth why
not apply his time to supervise the manager.
 21
Principles of RCA (cont …)
Keep environmental matters in mind (most root causes can be traced back to decisions,
actions or inactions by one or more engagement team members):

•Leadership and culture

•Competency of personnel
•Hiring qualified personnel
•Lack of or insufficient training
•Adequacy of technology or tools
•Departmental morale
•Resources (budget/personnel)
•Decision-making authority
 22
Principles of RCA (cont …)
Root cause examples

Resource issues:

• Competency of staff (can impact personal, ethical and attitude issues).

• Experience of staff.
• Engagement team dynamics (e.g. incompatible combinations, skills or
experience gaps, lack of continuity or over-familiarity).
• Time available (rushed jobs are rarely successful).
• Number of staff available (understaffed jobs are rarely successful).
• Lack of clarity on competencies and responsibilities.
 23
Principles of RCA (cont …)

Personal, Ethical and Attitude issues

• A mindset that is prepared to cut corners (perhaps due to complacency or a

desire to keep to original timetables and budgets).

• Unwillingness to acknowledge or learn from mistakes.

• Being unwilling or unable to direct, supervise or review effectively, even when

resources are available and procedures require this.
 24
Principles of RCA (cont …)
Process issues

• Issues arising from the firm’s policies and procedures – are they well framed; are
there gaps; are they well understood and complied with?

• Does on-the-job mentoring and reviewing happen in the way they should?

• Does the staff appraisal system drive improvement or is it cosmetic?

• Failure to consult when appropriate.

• Poor project management, incl. leaving issues to the end of the audit.
 25
Principles of RCA (cont …)
Leadership issues

•Do staff receive appropriate leadership?

•Is change effected when required?
•Is leadership cosmetic or real? (Do actions belie words?)
Client issues

•Can the firm be fairly expected to serve its client base? (Consider:
competence, resources and specialities.)
•Are review findings rooted in difficulties with client interaction? For
example, fee pressure, an unreasonable client-imposed deadline to complete
the audit, poor quality or information arriving late from the client.
 26
Principles of RCA (cont …)
Link to ISQC 1 Para. 26: “The firm shall establish policies and procedures for the acceptance
and continuance of client relationships and specific engagements, designed to provide the firm
with reasonable assurance that it will only undertake or continue relationships and engagements
where the firm:
(a) Is competent to perform the engagement and has the capabilities, including time and
resources, to do so; (Ref: Para. A18, A23)
(b) Can comply with relevant ethical requirements; and
(c) Has considered the integrity of the client, and does not have information that would lead it to
conclude that the client lacks integrity. (Ref: Para. A19-A20, A23)”

•
 27
Principles of RCA (cont …)
Remedial Action Plan (RAP) examples
When root causes are identified correctly, it is easy
to develop and implement an action
plan as follows:

•Reviewing of resourcing.
•Improving the project management.
•Increased focus on joiners or leavers.
•Coaching and guidance on related initiatives.
•Improving the integration of internal experts.
•Real-time monitoring/support teams.
•Methodology enhancements.
•Guidance and communications.
•Training (technical and soft skills).
•Supervision and review.
•Software, procedures and technical updates.
Introduction & Overview
Learning Outcomes
• Outline and discuss RCA Investigation

• Describe and promote effective investigation process

• Lead and conduct credible, thorough and proportionate RCA Investigations

How many people are treated every day
in the NHS?

Over 1 million
 Complexity of Healthcare

Number of Healthcare Diagnoses listed? > 68,000

Number of Healthcare Procedures available? > 6,000

Number of Healthcare Medications available? > 4,000

January 2010
 Complexity of Healthcare

Healthcare has grown exponentially in its complexity

This has outstripped our ability to provide care safely

Dr Atul Gawande - 2009

Investigation of Incidents

Def: Patient Safety Incident (PSI)

Any unintended or unexpected incident(s)
that could have or did lead to harm for one or more
persons receiving NHS funded healthcare

RCA framework is also applicable for the investigation of:

• Claims
• Complaints
• Other types of incident (Clinical, non-clinical, social care etc)
Number of Patient Safety Incidents occurring
in the NHS each year?

?
 Patient safety - A global issue
- True scale still unknown

Patient Safety
Incidents/
Events
Hospital blunders 'kill 90,000 patients‘
Rebecca Smith: Daily Telegraph - 29.11.07

“More than 90,000 patients die and almost

one million are harmed each year because
of hospital blunders, research suggests” ?!

Researchers found that up to half of

the mistakes made were preventable
 National Reporting and Learning System

Analysis Tools

Local Incident Reporting Data Cleansing

System National
Reporting &
Learning Reports &
System Trends
 Systems thinking
Healthcare has focused extensively on getting the best kit
and the best technical expertise. £billions is spent on
medical discovery annually.
BUT
Only a handful of people are currently ‘doing the science’
- studying how best to fit it all together safely.
We need to make the complex simple, start small, and
gradually improve the quality of our systems.
From Dr Atul Gawande - 2009
Clinical Information: 08-09
• 66 million OPD appointments in UK (Excl. N Ireland)
• 10 million had important clinical information missing
• Patients were exposed to risk at 2 million appointments

Operating Theatre equipment

(?could be applied to any healthcare equipment?)

In nearly 1 in 5 operations:-
the equipment was faulty, missing or used incorrectly
– or staff did not know where it was or how to use it.

The Health Foundation - 2010

There is a need to learn from patient safety incidents
... A systems view is needed
• Evidence from other complex high technology settings suggests that
systematic investigation of adverse incidents can expose system failures.

• System failures can be the cause of human errors.

• Root Cause Analysis (RCA) provides an effective approach.

What is Root Cause Analysis (RCA)
Def: Root Cause Analysis...
Root Cause Analysis is an evidenced based, structured investigation
process which utilises tools and techniques to identify the true causes of an
incident or problem, by understanding what, why and how a system failed.

Analysis of these system failures and true causes enables targeted and,
where possible, failsafe actions
to be developed and implemented which demonstrate significantly reduced
likelihood of recurrence
Taylor-Adams (2011)
Basic elements of RCA investigation

WHAT HOW it WHY it

happened happened happened

Unsafe Acts Human Contributory

Behaviour Factors

Solution Development & Review of effectiveness (recurrence of PSI)

‘WHO did it’

is not the objective
 The RCA Process
Getting Started

Gathering Information & Mapping the Incident

Identifying Care & Service Delivery Problems

Analysing Problems & Identifying CFs and RCs

Generating Solutions & Recommendations

Implementing Solutions

Writing the Report

Why RCA?

In depth analysis of a small number of incidents will bring greater

dividends than a cursory examination of a large number.

Vincent and Adams - 1999

Why RCA?

To err is Human
To cover up is unforgivable
To fail to learn is inexcusable
Sir Liam Donaldson

Hope is not a strategy...

Aiden Halligan
 Key Points – What is RCA?

• RCA Investigations provide a systematic means of reviewing and learning from

incidents

• The scale of the patient safety problem is still not clear...

• ...But it is significant, and to fail to learn in inexcusable

Human Error and
Error Wisdom
 Human error

“We all make errors irrespective of how much

training and experience we possess or how
motivated we are to do it right”.

Reducing error and influencing behaviour - HSG48

 Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer
in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is
taht the frist and lsat ltteer are in the rghit pclae.
The rset can be a total mses and you can sitll raed it fialry eailsy.

Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef,
but the wrod as a wlohe.
?
 The Perfection Myth
- if we try hard enough we will not
make any errors

The Punishment Myth

- if we punish people when they
make errors they will make fewer
of them
Getting the balance right

Both extremes have

their pitfalls
 How do accidents happen?

Organisation + process deficiencies - (SDPs)

Prior/unsafe conditions - Contributory factors

Unsafe acts - (CDPs) / (SRK errors)

Failed defences
Patient Safety
Incident
Service Delivery Problem (SDP)

• Latent failure
• Distant from direct patient care
• Arise from weaknesses in the organisation or environment

e.g. failure to undertake an environmental risk assessment in a ward

 Contributory factors
• Patient factors
• Individual / staff factors
• Task factors
• Communication factors
• Team & social factors
• Education & training factors
• Equipment and resource factors
• Working condition factors
• Organisational & management factors
Care Delivery Problem (CDP)

• Active failure
• Arises in process of direct patient care
• Act or omission by member of staff

e.g. failure to undertake planned 15min obs. of patient

Rasmussen’s Skill, Rule and Knowledge (SRK) model

Automatic, familiar & well

Conscious Skill practiced routines
Thought
Learning rules and
Rule rehearsing routines

Novel task
Knowledge
 Error Wisdom
Predict ‘what can go wrong today’

3
2
1 3
2
1 3
SELF 2
1
CONTEXT

T ASK
Three bucket model of error likelihood – James Reason 2004
ERROR TYPES
– based on the work of Reason, adapted by NPSA

Basic error types Routine

Reasoned
Reckless & Malicious
Violations
Intended
actions Rule & Knowledge
Based errors
Unsafe
Unsafe
acts Mistakes Skill based errors
acts Memory failures

Unintended Lapses
actions
Skill based errors
Slips Attentional failures
Def: Human Factors
The study of how humans behave physically and psychologically
in relation to particular environments, people, or procedures.
 Lessons from Human Factors Research

• Errors are common and predictable

• The causes of errors are known

• Errors are by-products of useful cognitive functions

• Errors can be prevented by designing tasks and processes to minimise

dependency on weak cognitive functions
Examples of Other Human Factors
Fatigue; Sleep deprivation
Inadequate nutrition, hydration
Overload
Training and experience
Professional courtesy
Team dynamics (isolated, divided, elite)
Leadership (weak, charismatic)

Example outcomes :
Perceptual and contextual problems ……….
Perception
Contextual clues leading to error
(Bum steers)

What tree grows from an acorn? Oak

What do you call a funny story? Joke
What sound does a frog make? Croak
What’s another word for a cape? Cloak
What do you call the white of an egg?
 Humans as Heroes

Error is normal
• Humans are bad at routine but good at compensation/recovery

• Human coping resources are good

• Humans have capacity for realistic optimism
• Good compensators have good outcomes
 Reason, PS Congress 08
Reason, PS Congress 08
Reason, PS Congress 08
 Error Types
Intended actions
Routine violations - regular short-cuts in tasks made for convenience. They are accepted by the clinical team, and sometimes by management,
normally because the procedure is badly designed.
Reasoned violations - occasional changes in procedure for good reason and with good intent. It may be an emergency or unusual situation. The
change should be discussed beforehand wherever possible and always documented afterwards.
Reckless violations - unacceptable changes in procedure. Harm is likely but not intended. There is an active lack of care.
Malicious violations - deliberate acts that are intended to cause harm or damage. They are unusual but the outcome is likely to be very serious.
Rule based mistakes - made by people undertaking tasks with some knowledge of the rules and with good intent, but they choose the wrong
solution for the problem.
Knowledge based mistakes - made by people undertaking new tasks with good intent but their limited knowledge results in a mistake. They don’t
know that they don’t know.
Unintended actions
Lapses - errors made by experienced people undertaking familiar tasks with very little conscious thought. They forget something routine when they
are not concentrating on the task or when they are interrupted.
Slips - errors made by experienced people undertaking any task. There is a slip in the action [such as dropping an instrument] which could happen to
anyone, however experienced.
Either we manage human error...

... or human error will manage us

Professor James Reason

 Key Points - Human Error

• The reasons things go wrong are fairly predictable

• Humans are generally bad at routine and good at compensation / recovery

• We need to use this wisdom to identify the true causes of incidents ... and
the most effective solutions
Gathering and Mapping
the Information
The RCA Process
Getting Started

Gathering Information & Mapping the Incident

Identifying Care & Service Delivery Problems

Analysing Problems & Identifying CFs and RCs

Generating Solutions & Recommendations

Implementing Solutions

Writing the Report

 Investigation Management

Fact-finding Analysis Conclusions

60% of the time should be Only once all Develop targeted failsafe
spent on gathering data facts have been solutions/
gathered recommendations
 Paradigms

Documentation

People
What
information
to Equipment Site
collect?
 Documentation
1. Incident report
2. Medical records
3. Local & national guidelines, policy, procedure (in operation at time of incident)
4. Local and national data on previous related incidents
5. Relevant integrated care pathways
6. Relevant audit data (clinical, risk management, H&S)
7. List of key staff involved and their informal statements/reports
8. Staff rotas
9. Training and supervision records
10.Medical equipment maintenance records
etc
People
Personnel directly involved in the incident & other witnesses

• Clinical staff
• Patient/family
• Porters
• Healthcare assistants
• Ward clerks
• Members of the public
etc
 How to retrieve information from people

1. Review entries made in clinical records

2. Conduct interviews (Cognitive interview recommended)

3. Request informal statements

“Brain writing/brain dumping” often provides more valuable
learning than formal, guided, signed witness statements.
(Still request facts and observation - not opinion)
Cognitive interviewing technique

Developed by psychologists to enable police and social workers to help

witnesses recall as much as possible, by working with what is known
about how memories are stored and retrieved.

R Milne & R Bull (1999), Investigative Interviewing

– Psychology and Practice. Wiley, Chichester
 Purpose of the interview

• To obtain useful and accurate information about incident

• To help interviewee to retrieve own memory of events

• To check unconfirmed data

Common problem with guided interview techniques &
guided witness statements

• Interviewer in control and shaping the structure of the interview

• Interviewees memory sequence may not be in the same order as the interviewer asks
questions

• Use of quick fire questions

• Interrupting interviewees

• Use of judgemental comments (+ ve or – ve)

 Memory is not a video recorder….

Memory is constructive – we rebuild events in our mind. We do not

store exact copies.

• Factors will affect what memories we STORE

• Factors will affect which memories we RETRIEVE
 Memory: factors affecting STORAGE
• Interaction between the person and the event.

• Stress - can affect the quantity of information stored, but not the quality.

• Selective Attention – witnesses remember what they think are the most
important aspects of the event.

• Trauma – can force witnesses to narrow their attention to core aspects of

the event (tunnel vision).
 Memory: factors affecting RETRIEVAL

• Stereotypes - e.g. doctors are white, middle class

• Partisan Beliefs - e.g. defending your team

• Scripts - what you expect to happen

• Emotional Factors - anxiety can make recall difficult e.g. exams

• Context - surroundings + sensory triggers can aid retrieval

• Inferences - words used in questions can influence response

 The Cognitive Interview sequence
Establish rapport (in comfortable environment) Open the Interview Phase 1
To focus on memory retrieval; transfer control; Allow retrieval Explain aims of Interview
at own pace and in own order Phase 2

Take their mind back to ; Report everything Initiate a free Report

Good listening; accept pauses; don’t interrupt Phase 3
Ask open and then closed questions Interviewing Phase 4
Change order/perspective. Focus on senses. Varied, Extensive Retrieval Phase 5

Summary Phase 6
Return to safe topic and thank interviewee Closure Phase 7

‘Investigative Interview Guidance’ www.npsa.nhs.uk/rca

 When Interviewing - consider

• Who will interview? (skills, training, reputation, objectivity)

• Trust’s procedures (they should cover investigative interviewing)

• Importance of keeping RCA separate from any disciplinary or criminal or

coroner’s investigation

• Emotions may be triggered & support needed

 Recording information

Consider advantages & disadvantages for each method

• Interviewer taking first hand report

• Third person in room taking first hand report
• Tape recorder
 Signed statements ...
... Are no longer recommended for RCA investigations

• The primary aim of RCA investigations = learning

• Therefore, ‘first hand reports’ are taken or

informal statements are requested instead

• This only needs to change if the aim / terms of reference change i.e. if an investigation
becomes a formal HR or Criminal case.

• If coroners or independent investigators require signed statements for other reasons, terms
of reference should change to reflect this.
Equipment
Identify and retain any equipment involved
• CTG machine
• Shower curtain
• Anaesthetic machine
• Infusion pump
• Drug delivery system
etc
Site
Consider the following:

• Securing the site

• Take some photographs
• Sketch the layout
• What was the position of the
equipment / people?
• Reconstruction
Paradigms
“The way we do things around here”
Reference System for Gathered Data
• A reference or tracking system will assist data gathering and allow for successful report
generation

Location Date Received Date Requested Information Requested

File c 25/10/01 24/10/01 Incident Form

24/10/01 Medical Notes
File c 26/10/01 24/10/01 Nursing Notes
24/10/01 X-Ray (s)
File c 29/10/01 24/10/01 Statements
 Key points - Data Gathering
1. Be clear about what evidence is required when planning
interviews

2. You don’t need to interview everyone.

Consider using a mix of informal statements, and first hand
reports taken from cognitive interviews and group meetings

3. Consider ‘re-testing’ evidence by exploring apparent

contradictions for clarification.
 Mapping the information

Tabular RCA Tools Time / person grid

timeline
 Progressed from the old - Narrative Chronology

Community Dentistry – failure of the chair

14 September 2000
Four weeks later the suction was found to be permanently on, on the dental chair and the
Supplier was informed. It seemed that the motor was burnt out.

21 September 2000
Seven days later the supplier came to repair the motor.
The chair seemed to be working better again and disruption was minimal over the following
three weeks.
Through the – Standard Timeline

08.24 08.32 08.38

Ambulance Emergency call Ambulance
crew received by breaks down
partly fill ambulance whilst on
diesel vehicle crew to attend 999 call
with unleaded a serious RTA
petrol at local on local
garage motorway
 To the tool adapted for the NHS - Tabular timeline
Time & Date
18 March 2002 – 20.00 18 March 2002 - 19.15
of Event
Patient seen by SHO who applied the Patient seen on the ward by Consultant Event
operation site mark Anaesthetist
SHO in first SHO job and first rotation in Patient declined regional anaesthetic. Supplementary
orthopaedics. Anaesthetic pre-assess info is recorded in Information
SHO applied site mark to an unusual part log-book and info transferred to the
of the skin (rather than thigh or knee). anaesthetic record on day of procedure, but
Below knee anti-embolic stockings put this transfer did not take place on day of
on by the patient covered the site mark. incident. This practice was adopted as
No formal guidance or training is given medical & Anaesthetic records were
to SHOs on marking op sites frequently lost.

Patient seen by consultant Notable Practice

www.npsa.nhs.uk/rca
Time-person grid
10.25 10.15 10.05 Staff
Nurses st With pt 3 With pt 1 Snr Nurse A

On break ? With pt 2 HCA 1

Nurses st With pt 1 With pt 1 Social Wker

With pt 2 ? ? Dr 1
 Group work

• Map the events

• Identify any data gaps
• Capture good practice
• Avoid moving into analysis 
 To assist quality analysis of evidence...

Include all evidence whether it finally supports or contradicts conclusions.

If there is a conflict of evidence, provide reasons for any discounted:

• Explain why one version is more credible than another

• Make clear the reasoning behind decisions where the investigation team has to decide, on the balance of
probabilities, where the truth seems to lie. (Provenance of evidence may influence this)
 Detection Factors – Decision aid
How & when was the incident identified?

During proactive risk assessment, prior to opening, a new or changed service 

At pre-admission patient assessment 

During care/treatment 
□   Via clinical assessment/observations - staff identifying a change in patient's condition e.g.

□   Via Management walkaround

□   By patient buzzer / call bell

□   By a review

□  By Incident trend

□   By nationally shared learning

□   From research / evidence

□   By complaint or claim

www.npsa.nhs.uk/rca
 Key Points – Gathering & Mapping

• Plan with care how you can best collect information from people and who you
need to interview (time management)

• Avoid at all costs the temptation to move into analysis

• Always conduct a site visit

 Root Cause Analysis

for

Effective Incident Investigation

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 • Introduction
Outline
• What is Root Cause Analysis (RCA)?
• How does RCA work?
• Tips to make your RCA more effective
• Interviewing techniques
1. ‫المقدمة‬
2. ‫ما هو تحليل السبب الجذري‬
3. ‫كيف يعمل تحليل السبب الجذري ؟‬
4. ‫ نصائح لجعل تحليل السبب الجذري الخاص بك أكثر فعالية‬.
5. ‫تقنيات المقابلة‬
What is Root Cause Analysis (RCA)?

• One of several tools suitable for after the fact investigations

• ‫واحدة من عدة أدوات مناسبة بعد التحقيقات الواقعية‬

• Most straightforward method sufficiently structured to identify, and determine

relationships between, various events and issues that may have combined to
produce the incident

• ‫كاف لتحديد العالقات بين مختلف األحداث والقضايا التي قد تكون مجتمعة إلنتاج حدث‬
ٍ ‫طريقة مباشرة مهيكلة بشكل‬
 How Does RCA Work?
‫ي‬
‫لجذر ؟‬JJ‫لسببا‬JJ‫حليلا‬JJJ‫عملت‬JJ‫يفي‬JJ‫ك‬
• Employee fell down‫لموظف‬JJ‫قط ا‬JJ‫س‬
Symptoms vs. Roots
ً ‫لموظف‬JJ‫انا‬J‫ك‬
• Employee was careless ‫مهمال‬
• Employee under time pressure‫لوقت‬JJ‫غط ا‬JJ‫حتض‬JJJ‫موظفت‬
• Under time pressure because of overlapping delivery
dates ‫خلة‬J‫لمتدا‬JJ‫ ا‬J‫لتسليم‬JJ‫واريخ ا‬JJJ‫سببت‬JJJ‫لوقتب‬JJ‫غط ا‬JJ‫حتض‬JJJ‫ت‬
• Delivery dates overlap because of poor communication
between teams
‫تتداخل تواريخ التسليم بسبب ضعف التواصل بين الفرق‬

• Poor communication exists because…

‫لسيئ موجود بسبب‬J‫ التواصل ا‬... Keep going further
”?by asking “why

106
 The Root ‫لجذر‬JJ‫ا‬

• The root cause is typically not simply machine

failure ‫آللة‬JJ‫شلا‬JJJ‫يسمجرد ف‬JJ‫ادة ل‬J‫لجذريهو ع‬JJ‫لسببا‬JJ‫ا‬
• The root cause is more typically:
• ‫ السبب الجذري هو أكثر شيو ًعا‬:
• Machine failure due to improper maintenance, contributed to by both
difficulty of maintenance access and unclear procedures, each
exacerbated by lack of procedure review because no management of
change process….(can we go further?) ، ‫لسليمة‬JJ‫لصيانة غير ا‬JJ‫سببا‬JJJ‫از ب‬J‫لجه‬JJ‫فشلا‬
‫ل‬J‫فاقمتك‬JJJ‫ ت‬، ‫ضحة‬J‫تغير وا‬J‫جراءا‬J‫لصيانة وإ‬JJ‫لىا‬JJ‫لوصولإ‬JJ‫وبة ا‬J‫ع‬JJ‫لمنص‬J‫يك‬JJJ‫ ف‬J‫اهم‬JJ‫س‬
‫لتغيير‬JJ‫ إدارة عملية ا‬J‫دم‬J‫سببع‬JJJ‫إلجراء ب‬JJ‫ة ا‬J‫جع‬J‫ مرا‬J‫دم‬J‫سببع‬JJJ‫ا ب‬J‫ منه‬...
(‫د منذلك؟‬J‫بع‬J‫لىأ‬JJ‫لذهابإ‬JJ‫مكننا ا‬JJ‫)هلي‬
• Thermocouple
Has a Root probe readingBeen
Cause high‫لي‬JJ‫ا‬JIdentified?
‫رأ ع‬J‫ق‬JJ‫راريي‬J‫ مسبار ح‬-
• Wrong manual valve opened -‫اطئ‬J‫ دليلخ‬J‫مام‬JJ‫تح ص‬JJJ‫ف‬
• Pressure set point incorrect - ‫حيحة‬JJ‫النطالقغير ص‬JJ‫ ا‬J‫قطه‬JJ‫لضغط ن‬JJ‫ا‬
• Object lifted was too heavy ‫دا‬J‫قيلج‬JJJ‫ ث‬J‫لموضوع رفع‬JJ‫انا‬J‫ ك‬-
• Procedural step performed out of order -‫لترتيب‬JJ‫ارج ا‬J‫ئية خ‬J‫إلجرا‬JJ‫لخطوة ا‬JJ‫نفيذ ا‬JJJ‫ت‬
1. Start with a descriptive statement of the incident/near miss
How Does
‫ قرب‬/ ‫للحادث‬ RCA
‫ببيان وصفي‬ ‫تبدأ‬ Work?
2- Determine what conditions, events, and/or factors might have caused (alone) or
contributed to (in combination with other conditions) the incident. These are your
primary (1o) factors (i.e., Why?)

‫ أو العوامل التي قد تسببت (وحدها) أو ساهمت (باالقتران مع الظروف األخرى) في‬/ ‫تحديد ما هي الظروف واألحداث و‬
)‫ لماذا؟‬، ‫) (أي‬1( ‫ هذه هي عواملك األساسية‬.‫الحادث‬
3- Determine conditions/events/factors that may have caused or contributed to the
primary factors. These are your secondary (2o) factors (i.e., Why?)
‫ هذه هي عواملك الثانوية‬.‫ العوامل التي ربما تكون قد سببت أو ساهمت في العوامل األساسية‬/ ‫ األحداث‬/ ‫تحديد الشروط‬
)‫ لماذا؟‬، ‫) (أي‬2(

109
 Examples of RCA Documentation

• Fishbone (cause and effect) diagram‫ياني‬JJJ‫ ب‬J‫لتأثير) رسم‬JJ‫لسببوا‬JJ‫لسمك (ا‬JJ‫ ا‬J‫عظم‬

• Simplified logic diagram - ‫مخطط منطقيمبسط‬

 Fishbone Diagram
Example

Methods
Machines
Written checklist did not
New valve access
include warnings re safe
requires ladder
ladder use
No Mgt of No hazard
Change analysis analysis of
Ladder legs uneven procedure
Lack of
Maintenance
No Trng Operator
Mgt broke wrist on
System fall from
Operator not trained ladder
Steps wet and slippery
Operator did not heed ladder Lack of
warning label Housekeeping

No discipline for People Material

previous safety
violations
Example Fishbone Diagram
‫لسمك‬JJ‫ ا‬J‫ عظم‬J‫لرسم‬JJ‫مثا‬
Example Fishbone Diagram
‫لسمك‬JJ‫ ا‬J‫ عظم‬J‫لرسم‬JJ‫مثا‬
 Example Root Cause
Diagram
Operator suffers
chemical burn on hand

Example PPE did not prevent

"AND"

Chemical splashed when

Root
it was manually added to
exposure
tank

"OR" "OR"

Cause PPE not used

PPE wrong for this
service
Procedure does not
prevent
splashing
Procedure not
followed correctly
2o

Diagram Operator did not

don available PPE
PPE not available
Chemical changed
since initial PPE
PPE assessment poor/
3o

J‫لعلىرسم‬JJ‫مثا‬
omitted
assessment Procedure unclear Deviations
not
considered
important

‫لجذرى‬JJ‫لسببا‬JJ‫ا‬
No PPE inventory
management system
No procedural HAZOP
PPE performed
PPE was Change review
hinders
not didn't consider PPE
work
considered issues
progress
important 4o

No Ma na g e me nt o f
Cha ng e p ro c e s s in p la c e 5o

Lo w a c c o unta b ility fo r
s a fe ty is s u e s

PPE assessment
poor/omitted

KEY:

"OR" Cause Factor/

Contributor

"AND" "Root"
 Example
Root
Cause
Diagram
J‫لعلىرسم‬JJ‫مثا‬
‫لجذرى‬JJ‫لسببا‬JJ‫ا‬
 Chronology of an Incident Investigation
‫لحوادث‬JJ‫يا‬JJJ‫لتحقيقف‬JJ‫لزمنيل‬JJ‫لتسلسلا‬JJ‫ا‬
1. Event occurs‫حدث‬JJ‫دثي‬J‫ح‬
2. Collect information from the scene of the event‫لحادث‬JJ‫وماتمنمكانا‬J‫لمعل‬JJ‫ ا‬J‫جمع‬
3. Gather more information (witnesses, system information, etc.) )‫لىذلك‬JJ‫ وما إ‬، J‫لنظام‬JJ‫ ومعلوماتا‬، ‫ود‬J‫لشه‬JJ‫لمعلومات(ا‬JJ‫لمزيد منا‬JJ‫ ا‬J‫جمع‬
4. Conduct detailed RCA‫لجذري‬JJ‫سببا‬JJ‫تمفصلة ل‬J‫جراءا‬J‫إ‬
5. Write an Action Plan‫كتبخطة عمل‬J‫ا‬
6. Implement the Action Plan‫لعمل‬JJ‫نفيذ خطة ا‬JJJ‫ت‬
7. Review results ‫لنتائج‬JJ‫ة ا‬J‫جع‬J‫مرا‬
8. Modify Action Plan as necessary ‫لضرورة‬JJ‫لعملحسبا‬JJ‫ديلخطة ا‬J‫ع‬JJJ‫ت‬
Tips For More Effective RCAs

• Factors concisely written yet sufficiently descriptive

• Will the logic be understandable to persons not in the session, or to you a
few years from now?
• ‫العوامل المكتوبة بإيجاز حتى اآلن وصفية كافية‬
• ‫ أو أمامكم بعد سنوات قليلة من اآلن؟‬، ‫هل سيكون المنطق مفهو ًما ألشخاص ليسوا في الجلسة‬

• Speculation is clearly identified as such ‫لنحو‬JJ‫ علىهذا ا‬J‫ضح‬J‫شكلوا‬JJJ‫لمضاربة ب‬JJ‫حديد ا‬JJJ‫ ت‬J‫تم‬JJ‫ي‬
• Actionable items are clearly defined ‫وضوح‬JJJ‫لتنفيذ ب‬JJ‫ابلة ل‬J‫لق‬JJ‫لعناصر ا‬JJ‫حديد ا‬JJJ‫ ت‬J‫تم‬JJ‫ي‬
• Conduct analysis as soon as possible after data have been gathered‫لبيانات‬kk‫ ا‬k‫مع‬k‫د ج‬k‫ع‬kk‫تممكنب‬k‫قربوق‬k‫يأ‬kkk‫لتحليل ف‬kk‫جراء ا‬k‫إ‬

• Disallow blame J‫للوم‬JJ‫ علىا‬J‫للوم‬JJ‫اء ا‬J‫لق‬JJ‫إ‬

Tips For More Effective RCAs

• Assemble a knowledgeable team J‫ريقذو خبره‬JJJ‫ ف‬J‫جميع‬JJJ‫ت‬

• Use the 80/20 Rule 80/20 ‫اعدة‬J‫لق‬JJ‫ ا‬J‫ستخدم‬J‫ا‬
• Tackle one branch at a time….
this helps keep team’s thoughts organized .
‫ هذا يساعد على إبقاء أفكار الفريق منظمة‬... ‫تعامل مع فرع واحد في كل مرة‬
• Use brainstorming techniques. ‫لذهني‬JJ‫لعصفا‬JJ‫قنياتا‬JJJ‫ ت‬J‫م‬J‫ستخدا‬J‫ا‬
• Don’t disrupt the brainstorm by trying to perfect the flow/diagram!
• Stay ½-step ahead of your team when diagramming.
• ‫ المخطط‬/ ‫!ال تعطل العصف الذهني بمحاولة تحسين التدفق‬
• ‫ق أمام فريقك خطوة بخطوة عند التخطيط‬َ ‫اب‬
• Prevent skipping levels or jumping to conclusions‫الستنتاجات‬JJ‫لىا‬JJ‫لقفز إ‬JJ‫خطيأو ا‬JJJ‫ مستوياتت‬J‫منع‬
 Focusing the Analysis‫لتحليل‬JJ‫لتركيز علىا‬JJ‫ا‬
• Consider the likelihood and magnitude of impact of each potential
cause, and assess most deeply (i.e., spend the most time on) those
most likely or that may contribute most impact.
• ‫ وقم بتقييمها بعمق أكبر (أي أن تقضي معظم الوقت‬، ‫فكر في احتمالية وحجم تأثير كل سبب محتمل‬
‫ التي قد تسهم في معظم التأثير‬J‫على) تلك التي من المرجح أو‬.
• Although the team may brainstorm 20+ potential causes, they vary in
placement along the continuum…‫كثر‬J‫عصفذهنيأل‬JJJ‫ ب‬J‫وم‬J‫ق‬JJ‫د ي‬JJ‫ريقق‬J‫لف‬JJ‫نا‬J‫ منأ‬J‫لرغم‬JJ‫علىا‬
‫لمستمرة‬JJ‫لسلسلة ا‬JJ‫ علىطولا‬J‫يموضعه‬JJJ‫ختلفف‬JJ‫ ي‬J‫نه‬J‫الأ‬JJ‫ إ‬، ‫ببًا محتماًل‬JJ‫ س‬20‫ من‬...

Happens every day Defies the laws

everywhere of physics
Conducting RCA Interviews‫لجذري‬JJ‫لسببا‬JJ‫جراء مقابالتا‬J‫إ‬-

• Create a list of questions to ask in advance

‫قم بإنشاء قائمة باألسئلة لطرحها مسبقًا‬
• Avoid conducting a Root Blame interview
‫تجنب إجراء مقابلة مع‬ Root Blame
• Ask how injured employees are doing
‫اسأل كيف حال الموظفين المجروحين‬

120
Examples Of Questions To Ask - ‫ا‬J‫طرحه‬JJ‫سئلة ل‬J‫مثلة علىأ‬J‫أ‬

• Process Equipment Questions - ‫لجة‬JJ‫ا‬J‫لمع‬JJ‫تا‬J‫دا‬J‫سئلة مع‬J‫أ‬

• Were any operating parameters (e.g., temperature, pressure, flow rates) changed just prior to the
incident (preceding minutes, hours, or days, depending on length of operation)?‫شغيل(مثل‬JJJ‫يمعلماتت‬J‫غيرت‬JJJ‫ت‬ ‫أ‬ ‫هل‬
‫لعملية)؟‬JJ‫عتما ًدا علىطولا‬J‫ ا‬، J‫أليام‬JJ‫لساعاتأو ا‬JJ‫لدقائقأو ا‬JJ‫بلا‬JJ‫لحادث(ق‬JJ‫بلوقوع ا‬JJ‫لتدفق) ق‬JJ‫دالتا‬J‫لضغط ومع‬JJ‫لحرارة وا‬JJ‫درجة ا‬

• Were operating conditions leading up to the incident recorded (e.g., strip charts, process control system
print outs, instrumentation )?
• ‫ واألجهزة)؟‬، ‫ وطبعات نظام مراقبة العمليات‬، ‫ الرسوم البيانية الشريطية‬، ‫هل سُجلت ظروف التشغيل السابقة للحادث (على سبيل المثال‬
• Were any reactants changed just prior to the incident (e.g., new chemical used, change in chemical
concentration, change in chemical vendor)?
• ‫ تغير في بائع المواد‬، ‫ تغير في التركيز الكيميائي‬، ‫ مادة كيميائية جديدة مستخدمة‬، ‫هل تغيرت أي مواد تفاعالت قبل وقوع الحادث (على سبيل المثال‬
‫الكيميائية)؟‬
• Employee Interaction -‫لموظف‬JJ‫اعلا‬J‫ف‬JJJ‫ت‬
• Was the employee involved in the incident interacting with the process equipment at the time (e.g.,
adjusting valves, performing a manual procedure, servicing, troubleshooting, calibrating)?‫لموظف‬JJ‫انا‬J‫هلك‬
‫ستكشاف‬J‫ ا‬، ‫لصيانة‬JJ‫ ا‬،‫دوي‬JJ‫جراء ي‬J‫جراء إ‬J‫ إ‬،‫لصمامات‬JJ‫بط ا‬JJ‫ ض‬،‫ل‬JJ‫لمثا‬JJ‫بيلا‬JJ‫لوقت(علىس‬JJ‫يذلك ا‬JJJ‫لجة ف‬JJ‫ا‬J‫لمع‬JJ‫تا‬J‫دا‬J‫ مع‬J‫تفاعلمع‬JJ‫لحادثي‬JJ‫يا‬JJJ‫لمتورط ف‬JJ‫ا‬
‫ايرة)؟‬J‫لمع‬JJ‫ ا‬، ‫ا‬J‫صالحه‬J‫ألخطاء وإ‬JJ‫ا‬
• Was the employee involved in the incident using support equipment at the time (e.g., ladder, extension
cord, lift devices, portable pumps for maintenance)?‫لوقت(مثل‬JJ‫يذلك ا‬JJJ‫ ف‬J‫لدعم‬JJ‫تا‬J‫دا‬J‫ مع‬J‫ستخدم‬JJ‫لحادثي‬JJ‫ا‬JJJ‫لمعنيب‬JJ‫لموظفا‬JJ‫انا‬J‫هلك‬
‫لصيانة)؟‬JJ‫ مضخاتمحمولة ل‬، J‫زة رفع‬J‫جه‬J‫ أ‬، ‫مديد‬JJJ‫لك ت‬JJ‫ س‬، J‫لم‬JJ‫س‬
Examples Of Questions To Ask - ‫ا‬J‫طرحه‬JJ‫سئلة ل‬J‫مثلة علىأ‬J‫أ‬

• Documentation‫لمعلومات‬JJ‫وثيقا‬JJJ‫ت‬
• Do written procedures exist for the operation/activity performed at the time of the incident? ‫وجد‬JJJ‫هلت‬
‫حادث‬
‫ل ؟‬JJ‫يوقتوقوع ا‬JJJ‫ ف‬J‫نفيذه‬JJJ‫ ت‬J‫م‬JJJ‫لذيت‬JJ‫لنشاط ا‬JJ‫ ا‬/ ‫لعملية‬JJ‫تمكتوبة ل‬J‫جراءا‬J‫إ‬
• Do written maintenance procedures exist for the equipment involved in the incident?
• ‫هل توجد إجراءات صيانة مكتوبة للمعدات المعنية بالحادث؟‬
• Was maintenance performed on the equipment involved in the incident?
• ‫ء الصيانة على المعدات المعنية بالحادث؟‬J‫هل تم إجرا‬
• Did clearly-written procedures exist for all tasks required for this process/equipment?
• ‫ المعدات؟‬/ ‫لعملية‬J‫هل توجد إجراءات مكتوبة بوضوح لجميع المهام المطلوبة لهذه ا‬
• Do written procedures describe the potential consequences of deviations?
• ‫هل تصف اإلجراءات المكتوبة العواقب المحتملة لالنحرافات؟‬
• Do written procedures describe the PPE required?
• ‫هل توضح اإلجراءات المكتوبة أن معدات الحماية الشخصية مطلوبة؟‬
• Systems Review J‫لنظام‬JJ‫ضا‬J‫را‬J‫ستع‬J‫ا‬
• Was the appropriate PPE available and worn? ‫لمناسبة متوفرة؟‬JJ‫لشخصية ا‬JJ‫لحماية ا‬JJ‫تا‬J‫دا‬J‫انتمع‬J‫هلك‬
• Have you received training on this process and equipment? ‫ت‬J
‫دا ؟‬J‫لمع‬JJ‫لعملية وا‬JJ‫ ا‬J‫لتدريبعلىهذه‬JJ‫لقيتا‬JJJ‫هلت‬
Focusing the Analysis -‫لتحليل‬JJ‫لتركيز علىا‬JJ‫ا‬

• Consider the likelihood and magnitude of impact of each potential cause, and assess
most deeply (i.e., spend the most time on) those which are most likely or which may
contribute most of the impact. Although the team may brainstorm 20+ potential
causes, they vary in their placement along the continuum…
• ‫ وتقييمها بعمق (أي قضاء معظم الوقت على) تلك‬، ‫النظر في احتمالية وحجم تأثير كل قضية محتملة‬
‫ على الرغم من أن الفريق قد يقوم بعصف‬.‫التي من المرجح أو التي يمكن أن تسهم في معظم التأثير‬
‫ إال أنه يختلف في موضعه على طول السلسلة المستمرة‬، ‫ سببًا محتماًل‬20 ‫ ذهني ألكثر من‬...

Happens every day everywhere Defies the laws of physics

123
Summary -‫ملخص‬

• Use Root Cause Analysis for actual or near miss incidents, to prevent
recurrence ‫كرارها‬JJJ‫ ت‬J‫منع‬JJ‫ ل‬، ‫ريبة‬JJ‫ ق‬J‫علية أو‬JJJ‫حوادثف‬JJ‫لجذريل‬JJ‫لسببا‬JJ‫حليلا‬JJJ‫ ت‬J‫م‬J‫ستخدا‬J‫ا‬

• Maximize effectiveness by gathering the right data and following the

approach outlined in this course
• ‫زيادة الفعالية من خالل جمع البيانات الصحيحة واتباع النهج المحدد في هذه الدورة‬
• Keep the analysis and its documentation as straightforward as possible,
to enhance the probability you will continue to use it in the future!
• ‫ لتعزيز االحتمالية التي ستستمر في استخدامها في‬، ‫ثائقه على قدر اإلمكان‬J‫حافظ على التحليل وو‬
‫!المستقبل‬

124
 Root Cause Analysis
To
Deliver Value Added Results
 A Brief History Behind Root Cause Analysis (RCA)
‫لجذري‬JJ‫لسببا‬JJ‫حليلا‬JJJ‫اريخ موجز وراء ت‬JJJ‫ ت‬-
• Developed by Sakichi Toyoda who later founded Toyota Motor
Company.
• ‫ الذي أسس الحقا ً شركة تويوتا‬..... ‫تم تطويره بواسطة تاويودو‬.

• RCA was first used during the development of Toyota’s

manufacturing processes in 1958.
• 1958 ‫تم استخدام ألول مرة أثناء تطوير عمليات التصنيع في تويوتا في عام‬.
Relation to the IIA Standards -J‫يه‬J‫يا‬J‫يا‬J‫اييرا‬J‫ مع‬J‫لعالقة مع‬JJ‫ا‬

• Standard 2320: Analysis and Evaluation -J‫لتقييم‬JJ‫لتحليلوا‬JJ‫ ا‬:2320 ‫لمعيار‬JJ‫ا‬

• Internal auditors must base conclusions and engagement results on
appropriate analyses and evaluations.
• ‫يجب على المراجعين الداخليين أن يرتكزوا على النتائج ونتائج المشاركة على التحليالت والتقييمات‬
‫المناسبة‬.
• Practice Advisory 2320-1: Analytical Procedures ‫تحليلية‬JJ‫ت لا‬J‫إلجراءا‬JJ‫ ا‬:1-2320 ‫الستشارية‬JJ‫ممارسة ا‬JJ‫لا‬
• Practice Advisory 2320-2: Root Cause Analysis‫جذري‬kk‫سبب لا‬kk‫حليل لا‬kk‫ ت‬:2-2320 ‫الستشارية‬k‫ممارسة ا‬kk‫لا‬
• Practice Advisory 2320-3: Audit Sampling‫عينات‬JJ‫دقيق لا‬
JJJ‫ ت‬:3-2320 ‫ممارسة‬JJ‫ت لا‬J‫ستشارا‬J‫ا‬
• Practice Advisory 2320-4: Continuous Assurance ‫مانمستمر‬J‫ ض‬:4-2320 ‫الستشارية‬JJ‫ممارسة ا‬JJ‫لا‬
Relation to the IIA Standards -J‫يه‬J‫يا‬J‫يا‬J‫اييرا‬J‫ مع‬J‫لعالقة مع‬JJ‫ا‬

• Standard 2410: Criteria for Communicating

• Communications must include the engagement’s objectives and scope as well as
applicable conclusions, recommendations, and action plans.
• Practice Advisory 2410-1 Communication Criteria
• ‫ معايير التواصل‬:2410 ‫معيار‬
• ‫يجب أن تتضمن االتصاالت أهداف المشاركة ونطاقها باإلضافة إلى االستنتاجات والتوصيات وخطط العمل السارية‬.
• ‫ معايير االتصال‬1-2410 ‫الممارسة االستشارية‬
• Standard 2420: Quality of Communications
• Communications must be accurate, objective, clear, concise, constructive, complete, and
timely.
• Practice Advisory 2420-1‫الت‬JJ‫التصا‬JJ‫ودة ا‬J‫ ج‬:2420 ‫معيار‬
• ‫يجب أن تكون االتصاالت دقيقة وموضوعية وواضحة وموجزة وبناءة وكاملة وفي الوقت المناسب‬.
• 1-2420 ‫الممارسة االستشارية‬
 What is Root Cause Analysis?
‫ي‬
‫لجذر ؟‬JJ‫لسببا‬JJ‫حليلا‬JJJ‫ما هو ت‬
• Root cause analysis (RCA) is defined as the identification of why an
issue occurred vs. only identifying or reporting the issue itself.
• ‫يتم تعريف تحليل السبب الجذري على أنه تحديد سبب حدوث مشكلة مقابل تحديد المشكلة نفسها أو‬
‫اإلبالغ عنها فقط‬.
• In this context, an issue is defined as a problem, error, instance of
noncompliance, or missed opportunity.
• ‫ يتم تعريف المشكلة على أنها مشكلة أو خطأ أو حالة عدم امتثال أو فرصة ضائعة‬، ‫في هذا السياق‬.
 What is Root Cause Analysis?
• ‫لجذري‬JJ‫ا‬whose
Auditors ‫لسبب‬JJ‫ا‬reporting
‫حليل‬JJJ‫ت‬only
‫ما هو‬
recommends that management fix the issue and
not the underlying reason that caused the issue are failing to add insights that
improve the longer-term effectiveness and efficiency of business processes and
thus, the overall governance, risk, and control environment.
• ‫مراجعي الحسابات الذين ال توصي تقاريرهم إال بإصالح المشكلة وليس السبب األساسي الذي تسبب في هذه‬
‫ الحوكمة‬، ‫ وبالتالي‬، ‫المشكلة فشلوا في إضافة رؤى تحسن من فعالية وكفاءة عمليات األعمال على المدى األطول‬
‫ وبيئة المراقبة‬، ‫ والمخاطر‬، ‫العامة‬.
• A core competency necessary for delivering insights is the ability to identify the
need for root cause analysis and as appropriate, actually facilitate, review,
and/or conduct a root cause(s) analysis.
• ‫إن الكفاءة األساسية الالزمة لتقديم األفكار هي القدرة على تحديد الحاجة إلى تحليل السبب الجذري وحسبما يكون‬
‫ أو إجراء تحليل األسباب الجذرية‬/ ‫ فعليًا تسهيل ومراجعة و‬، ‫مناسبًا‬.
 What is Root Cause Analysis? continued
• Internal Audit can be the ideal group to analyze issues and identify root causes given their
independence and objectivity. This perspective helps ensure biases are minimized,
assumptions are challenged, and evidence is fully evaluated.
• .‫يمكن أن تكون المراجعة الداخلية هي المجموعة المثالية لتحليل القضايا وتحديد األسباب الجذرية نظراً الستقالليتها وموضوعيتها‬
‫ وتقييم األدلة بشكل كامل‬، ‫ والطعن في االفتراضات‬، ‫ويساعد هذا المنظور في ضمان تقليل التحيزات‬.
• Internal Auditors by working across various reporting chains and departments of an organization
may have developed a broad and deep understanding of the underlying issues that may exceed
that of any single member of management which makes them best positioned to analyze an
issue. In circumstances where the root cause of an issue is a result of actions or inaction by
management, it is critical to use an objective party such as Internal Audit to investigate and
report back to Senior Management.
• ‫قد يكون مراجعي الحسابات الداخليين من خالل العمل عبر سالسل وإدارات التقارير المختلفة في أي منظمة قد طوروا فه ًما واسعًا‬
‫ في الحاالت‬.‫يل المشكلة‬J‫وعميقًا للقضايا األساسية التي قد تتجاوز ما لدى أي عضو من أعضاء اإلدارة مما يجعلهم في وضع أفضل لتحل‬
‫ فمن األهمية بمكان استخدام طرف موضوعي مثل‬، ‫التي يكون فيها السبب الرئيسي للمشكلة نات ًجا عن إجراءات أو تراخي اإلدارة‬
‫التدقيق الداخلي للتحقيق وتقديم تقرير إلى اإلدارة العليا‬.
RCA Situations‫لجذري‬JJ‫لسببا‬JJ‫التا‬JJ‫ا‬J‫ ح‬..

• RCA may be considered in any number of situations, such as

those:‫ مثل‬،‫الت‬JJ‫لحا‬JJ‫دد منا‬J‫يع‬J‫يأ‬JJJ‫ ف‬J‫عتباره‬J‫مكنا‬JJ‫ي‬:
• Involving a surprise risk event‫اجئ‬J‫دثخطر مف‬J‫ك ح‬J‫شرا‬J‫إ‬
• Process failure ‫لعملية‬JJ‫شلا‬JJJ‫ف‬
• Asset damage or loss ‫لخسارة‬JJ‫لضرر أو ا‬JJ‫ا‬
• Production stoppage‫إلنتاج‬JJ‫وقفا‬JJJ‫ت‬
• Safety incident ‫لسالمة‬JJ‫ادثا‬J‫ح‬
• Quality degradation ‫لجودة‬JJ‫دهور ا‬JJJ‫ت‬
• Or Customer dissatisfaction. ‫لعمالء‬JJ‫ رضا ا‬J‫دم‬J‫أو ع‬.
 RCA
• RCA may– be
5 asWhy’s
simple as asking “five whys”:
‫«قد تكون بسيطة مثل السؤال "خمسة أسباب‬
• The worker fell. Why? ‫ماذا ا؟‬JJ‫ل ل‬. ‫ام‬J‫لع‬JJ‫قط ا‬JJ‫س‬
• Oil on the floor. Why? ‫ماذا ا؟‬JJ‫ض ل‬
. ‫ألر‬JJ‫لنفط علىا‬JJ‫ا‬
• Broken part. Why? ‫ماذا ا؟‬JJ‫ ل‬.‫زء مكسور‬J‫ج‬
• The parts keep failing. Why? ‫ماذا ا؟‬JJ‫ل ل‬. ‫لفش‬JJ‫بقىا‬JJJ‫ألجزاء ت‬JJ‫ا‬
• Changes in procurement practices. Why? ‫ماذا ا؟‬JJ‫ ل‬.‫لشراء‬JJ‫يممارساتا‬JJJ‫تف‬J‫لتغييرا‬JJ‫ا‬
• By 5theWhys fifth why,Continued
the auditor should have identified or be close to identifying
the root cause. More complex issues may require a greater investment of
resources and more rigorous analysis.
• ‫ قد تتطلب القضايا األكثر تعقي ًدا استثما ًرا‬.‫ لماذا يجب على المدقق تحديد أو تحديد سبب الجذر‬، ‫بحلول الخامسة‬
‫أكبر للموارد وتحليالً أكثر صرامة‬.
• Prior to commencing RCA for more complex issues, auditors should consider:
– Time
– Skill sets
– ‫ يجب على المدققين مراعاة ما يلي‬، ‫قبل البدء في لمزيد من القضايا المعقدة‬:
– ‫زمن‬
– ‫مجموعات المهارات‬
Potential RCA Barriers ‫لمحتملة‬JJ‫ئقا‬J‫وا‬J‫لع‬JJ‫ا‬

• Prior to performing RCA, internal auditors should anticipate the following

potential barriers:
• ‫ يجب على المدققين الداخليين توقع الحواجز المحتملة التالية‬،‫قبل تنفيذ‬:
• Management may be reluctant to support internal audit’s role in RCA. You may need
your CAE to explain roles to Management.
• Management may resist due to time and resource commitments.
• RCA may be difficult and subjective
• RCA that leads to specific concrete observations and recommendations could be
perceived to be placing the auditor in the role of Management.
• ‫ قد تحتاج إلى الخاص بك لشرح األدوار لإلدارة‬.‫قد تكون اإلدارة مترددة في دعم دور التدقيق الداخلي في‬.
• ‫قد تقاوم اإلدارة بسبب الوقت والتزامات الموارد‬.
• ‫قد يكون صعب وموضوعي‬
• ‫يمكن تصور التي تؤدي إلى مالحظات وتوصيات محددة محددة لوضع المراجع في دور اإلدارة‬.
 Environmental
• Most root causes can be Factors
traced back to ‫بيئية‬
‫ل‬JJ‫ملا‬J‫وا‬J‫ع‬actions,
decisions, ‫ل‬JJ‫ ا‬or inactions by
one or more employees.
‫يمكن إرجاع معظم األسباب الجذرية إلى القرارات أو اإلجراءات أو عدم العمل من قبل موظف واحد أو أكثر‬.
• Some of these could be:‫كون‬JJ‫ني‬J‫مكنأ‬JJ‫ ي‬J‫عضمنهذه‬JJJ‫ب‬:
• Competence of personnel ‫ألفراد‬JJ‫ختصاصا‬J‫ا‬
• Hiring qualified personnel‫وظيفموظفينمؤهلين‬JJJ‫ت‬
• Lack of or insufficient training‫لتدريب‬JJ‫فاية ا‬J‫ ك‬J‫دم‬J‫قصأو ع‬JJ‫ن‬
• Adequacy of technology or tools‫ت‬J‫ألدوا‬JJ‫لتكنولوجيا أو ا‬JJ‫فاية ا‬J‫ك‬
• Appropriateness of organization or departmental culture‫ت‬J‫إلدارا‬JJ‫قافة ا‬JJJ‫ أو ث‬J‫نظيم‬JJJ‫مالءمة ت‬
• Health of the organization or departmental morale J‫لقسم‬JJ‫لمنظمة أو معنوياتا‬JJ‫حة ا‬JJ‫ص‬
• Level or number of resources (budget/personnel) )‫لموظفون‬JJ‫ ا‬/ ‫نية‬J‫لميزا‬JJ‫لموارد (ا‬JJ‫دد ا‬J‫لمستوىأو ع‬JJ‫ا‬
Environmental Factors ‫لبيئية‬JJ‫ملا‬J‫وا‬J‫لع‬JJ‫ا‬

• Process circumstances and other influencing items that led the person or
persons to make the decisions

• ‫ظروف العملية والعناصر المؤثرة األخرى التي قادت الشخص أو األشخاص إلى اتخاذ القرارات‬
• Decision-making authority of the person or persons involved.
Techniques ‫قنيات‬JJJ‫ت‬

• Five Whys ‫سباب‬J‫خمسة أ‬

• Failure mode and effects analysis‫ت‬J‫لتاثيرا‬JJ‫لفشلوتحليلا‬JJ‫لة ا‬JJ‫ا‬J‫ح‬
• SIPOC (Suppliers, inputs, processes, outputs, customers diagram. ‫لموردين‬JJ‫ا‬
‫لبياني‬JJ‫ ا‬J‫لرسم‬JJ‫لعمالء ا‬JJ‫ وا‬،‫لمخرجات‬JJ‫لعملياتوا‬JJ‫لمدخالتوا‬JJ‫وا‬.
• Flowcharting of the process flow, system flow, and data flow.‫ وتدفق‬J‫لنظام‬JJ‫لعملية وتدفقا‬JJ‫دفقا‬JJJ‫نسيابية ت‬J‫ا‬
‫لبيانات‬JJ‫ا‬.
• Fishbone diagrams‫يشبون‬JJJ‫مخططاتف‬
• Critical to quality metrics ‫لجودة‬JJ‫مقاييسا‬JJ‫رجة ل‬J‫ح‬
• Pareto chart ‫اريتو‬JJJ‫مخطط ب‬
• Statistical Correlation ‫ارتباط متبادلمخطط‬
RCA
1. – 5the Why’s
Write down specific problem - The worker fell. Why?
2. Write down answer; Oil on the floor. Ask 2nd Why?
3. Continue until what you consider is the true root cause is defined.
4. Don’t allow an early believable answer keep you from continuing to ask why. Broken part. Why?
5. The parts keep failing. Why?
6. Changes in procurement practices. Why?

1. ‫ لماذا ا؟‬.‫ سقط العامل‬- ‫اكتب المشكلة المحددة‬

2. ‫ لماذا؟‬2 ‫ اسأل‬.‫اكتب الجواب النفط على األرض‬
3. ‫متابعة حتى ما تعتبره هو السبب الحقيقي الحقيقي الذي يتم تحديده‬.
4. ‫ لماذا ا؟‬.‫ جزء مكسور‬.‫ال تسمح بإجابة مؤكدة مبكرة تمنعك من االستمرار في التساؤل عن السبب‬
5. ‫ لماذا ا؟‬.‫األجزاء تبقى الفشل‬
6. ‫ لماذا ا؟‬.‫التغييرات في ممارسات الشراء‬
RCA – Failure, Modes, and Effect Analysis
‫ل •تأثير‬JJ‫ا‬This
‫وتحليل‬ ، ‫وسائط‬ ،‫فشل‬‫ل‬ JJ‫ا‬
is a step-by-step approach identifying all possible failures in a
design, a manufacturing or assembly process, or a product or
service. ‫ أو‬J‫لتصميم‬JJ‫يا‬JJJ‫لمحتملة ف‬JJ‫لفشلا‬JJ‫التا‬JJ‫ا‬J‫افة ح‬JJ‫حديد ك‬JJJ‫خطوة ت‬JJJ‫هج خطوة ب‬JJ‫هذا هو ن‬
‫دمة‬J‫ أو منتج أو خ‬J‫لتجميع‬JJ‫ أو ا‬J‫لتصنيع‬JJ‫عملية ا‬.
• What is process step? ‫لعملية؟‬JJ‫ما هيخطوة ا‬
• What is key process input? ‫لرئيسية؟‬JJ‫لعملية ا‬JJ‫ما هو مدخالتا‬
• In what ways can the key inputs go wrong? ‫لرئيسية؟‬JJ‫لمدخالتا‬JJ‫ا ا‬J‫ه‬JJJ‫سوء ب‬JJJ‫نت‬J‫مكنأ‬JJ‫لتيي‬JJ‫لطرقا‬JJ‫ما هيا‬
• What is the impact on the outputs? ‫مخرجات‬
‫؟‬ ‫ل‬JJ‫لتأثير علىا‬JJ‫ما هو ا‬
• How severe is the effect to the customer? ‫لزبون؟‬JJ‫لتأثير علىا‬JJ‫ما مدىخطورة ا‬
• What causes the potential failure? ‫لمحتمل؟‬JJ‫لفشلا‬JJ‫سببا‬JJ‫لذيي‬JJ‫ما ا‬
• How often does the failure occur? ‫لفشل؟‬JJ‫حدثا‬JJ‫ مرة ي‬J‫م‬J‫ك‬
• What existing controls can prevent the failure? ‫لفشل؟‬JJ‫ ا‬J‫منع‬JJJ‫نت‬J‫مكنأ‬JJ‫لموجودة ي‬JJ‫بط ا‬J‫لضوا‬JJ‫ما ا‬
•
RCA – Failure, Modes, and Effect Analysis
How well can the failure be detected? ‫لفشل؟‬JJ‫لكشفعنا‬JJ‫مكنا‬JJ‫يفي‬J‫ك‬
• continued:
Multiply the severity, occurrence, and detection.‫لكشف‬JJ‫ وا‬،‫ وحدوث‬، ‫دة‬JJ‫ربش‬JJ‫ض‬.
• What actions can reduce the occurrence or improve detection?
‫ما هي اإلجراءات التي يمكن أن تقلل من حدوث أو تحسين الكشف؟‬
• HighSIPOC level process map showing Suppliers, Inputs, Process steps,
Outputs, and Customers‫لمدخالت‬JJ‫لموردينوا‬JJ‫ر ا‬J‫ظه‬JJJ‫لمستوىت‬JJ‫لية ا‬JJ‫ا‬J‫ريطة عملية ع‬J‫خ‬
‫لعمالء‬JJ‫لمخرجاتوا‬JJ‫لعملية وا‬JJ‫تا‬J‫ا‬J‫وخطو‬
• We see how the pieces fit together: ‫ا‬J‫مع‬ً J‫لقطع‬JJ‫تناسبا‬JJJ‫يفت‬J‫رىك‬JJ‫ن‬:
Customers Outputs Processes Inputs Suppliers
Customer 1 Output 1 Process Step Input 1 Supplier 1
1

Output 2 Input 2
Process Step
2

Customer 2 Output 3 Process 3 Input 3 Supplier 2

Output 4
Fishbone Diagram
• A bar graph that categorizes the frequency of a certain type of event.‫ث‬J‫ألحدا‬JJ‫وع معينمنا‬JJ‫تر ن‬J‫وا‬JJJ‫صنفت‬JJ‫ريطيي‬JJ‫يانيش‬JJJ‫ ب‬J‫رسم‬.
•
Pareto Chart
Could be used for customer or Hotline complaint types. ‫لساخن‬JJ‫لخط ا‬JJ‫لعمالء أو ا‬JJ‫كاوىا‬JJ‫ع ش‬J‫نوا‬J‫ا أل‬J‫مه‬J‫ستخدا‬J‫مكنا‬JJ‫ي‬.
Five Cs

• Criteria ‫ايير‬J‫لمع‬JJ‫ا‬
• Condition ‫رط‬JJ‫ش‬
• Consequence/Effect ‫أثير‬JJJ‫ ت‬/ ‫تيجة‬JJ‫ن‬
• Cause‫بب‬JJ‫س‬
• Corrective Action/Recommendation ‫لتصحيحية‬JJ‫لتوصية ا‬JJ‫ ا‬/‫لعمل‬JJ‫ا‬
 Five Cs
• Criteria ‫ايير‬J‫لمع‬JJ‫ا‬
• The law, regulation, contractual obligation, policy, procedure, or best
practice that is expected to be followed
• Condition ‫رط‬JJ‫ش‬
• The factual analysis of the process as it exists
• Consequence/Effect
• Why the issue is important and noteworthy from a compliance, financial, or
operational standpoint.
 Five
• Cause Cs
• The root cause which allowed the condition to not emulate the criteria.‫لسبب‬JJ‫ا‬
‫ايير‬J‫لمع‬JJ‫ محاكاة ا‬J‫دم‬J‫ع‬JJJ‫لة ب‬JJ‫لحا‬JJ‫ ل‬J‫مح‬JJ‫لذيس‬JJ‫لجذريا‬JJ‫ا‬.
• Corrective Action/Recommendation ‫لتصحيحية‬JJ‫لتوصية ا‬JJ‫ ا‬/‫لعمل‬JJ‫ا‬
• Change that will address the root cause, allow the current condition to
mirror best practice or other criteria and does not cost more in relation to
its effect.
• ‫ يسمح للشرط الحالي بأن يعكس أفضل الممارسات أو المعايير األخرى‬، ‫التغيير الذي سيعالج السبب الجذري‬
‫وال يكلف أكثر فيما يتعلق بتأثيره‬.
• Facts‫حقائق‬
Situation 1 - Wire
• Wire was released for $2,828,282,828.28
• Why was it released? Use 5 why’s

• ‫ دوالرًا‬2،828،282،828.28 ‫تم إصدار السلك بمبلغ‬

• ‫ لماذا‬5 ‫لماذا تم إطالقه؟ استخدم‬
• Facts
Situation 2 – Time Theft
• Two workers decided to switch schedules.
• Normally this would be OK if permission was asked, but that is not what
happened in this situation.
• ‫حقائق‬
• ‫قرر اثنان من العمال تبديل الجداول‬.
• ‫ ولكن هذا ليس ما حدث في هذا الموقف‬، ‫عادة ما يكون هذا موافقًا إذا تم طلب اإلذن‬.
• Facts
Situation 3 – Compensation
• Employees paid commission
• Falsified records

• ‫حقائق‬
• ‫دفع الموظفون عمولة‬
• ‫سجالت مزورة‬
• RCA can be used in consulting opportunities requested by Management, the Audit Committee,
by circumstances resulting from an audit, from many situations.
Adding Value - Opportunities
• I have received these opportunities from:
• Hotline calls
• H.R. requests
• Legal requests
• Line of Business requests
• Audit Committee requests
• ‫ من العديد من‬، ‫ حسب الظروف الناتجة عن المراجعة‬، ‫ لجنة التدقيق‬، ‫يمكن استخدامها في الفرص االستشارية التي تطلبها اإلدارة‬
‫المواقف‬.
• ‫لقد تلقيت هذه الفرص من‬:
• ‫مكالمات الخط الساخن‬
• ‫ طلبات‬H.R.
• ‫طلبات قانونية‬
• ‫طلبات خط العمل‬
• ‫طلبات لجنة التدقيق‬
Adding Value – How‫يف‬JJ‫لقيمة – ك‬JJ‫ا ا‬J‫مضيف‬

• Do we create analysis that management does not currently have available?

• Recommendations that Management has not considered.
• Advising Senior Management, Audit Committee, Board of Directors of
business risks and issues that they may not be aware.
• Issues that they may want independently assessed.

• ‫هل نخلق تحليالت ال تمتلكها اإلدارة حاليا؟‬

• ‫التوصيات التي لم تنظرها اإلدارة‬.
• ‫تقديم المشورة لإلدارة العليا ولجنة التدقيق ومجلس إدارة المخاطر التجارية والقضايا التي قد ال‬
‫تكون على علم بها‬.
• ‫القضايا التي قد يرغبون في تقييمها بشكل مستقل‬.
• Do we create analysis that management does not currently have available? Maybe it is
Adding Value - How
available, but they want it to be independently verified.
• Recommendations that Management has not considered.
• Advising Senior Management, Audit Committee, Board of Directors of business risks and
issues that they may not be aware.
• Issues that they may want independently assessed.
• ‫ ولكنهم يريدون التحقق منه بشكل مستقل‬، ‫هل نخلق تحليالت ال تمتلكها اإلدارة حاليا؟ ربما يكون متاحً ا‬.
• ‫التوصيات التي لم تنظرها اإلدارة‬.
• ‫عليا ولجنة التدقيق ومجلس إدارة المخاطر التجارية والقضايا التي قد ال تكون على علم بها‬J‫لمشورة لإلدارة ال‬J‫تقديم ا‬.
• ‫ مستقل‬J‫القضايا التي قد يرغبون في تقييمها بشكل‬.
• Ask Management and the Audit Committee if there are any services you can provide.
Adding Value - How
• Persuade them that you have the ability to provide value added services. If you can audit
and perform fraud investigations, you can provide value-added services.
• Make sure that you are ‘in the know’ of the Organization’s strategy, objectives, and goals.
• Don’t settle with ‘no’. Go back and inquire periodically.
• ‫اطلب من اإلدارة ولجنة التدقيق إذا كان هناك أي خدمات يمكنك تقديمها‬.
• ‫ إذا تمكنت من مراجعة حسابات‬.‫أقنعهم بأن لديك القدرة على تقديم خدمات ذات قيمة مضافة‬
‫ يمكنك تقديم خدمات ذات قيمة مضافة‬، ‫االحتيال وتنفيذها‬.
• ‫تأكد من أنك "على دراية" باستراتيجية المنظمة وأهدافها وغاياتها‬.
• ‫ عد واستفسر بشكل دوري‬."‫ال تستقر مع "ال‬.