The ability to successfully identify and address the root cause is not a given and like many activities benefits from improved knowledge experience and development of individual competence.

Typically it is only by monitoring over time that we can confirm that the mitigations that have been developed as a result of analysed root causes have done the job. However, we can draw a conclusion based on our understanding of the analysis and actions that have taken place to assess if we have confidence in the steps that have been taken.

Any shortfall in expectation could for example cause the finding to be re-opened for additional analysis.

Some of the reasons that the true root cause has been miss identified are considered here :

a) Root Cause Analysis (RCA) based on assumptions rather than on objective evidence. It is essential to ensure that all data is accurately classified and clearly understood concerning the observed facts.

b) A lack of objectivity related to the potential root causes and/or incorrect problem definition. Here the RCA begins with the investigator pre-supposing the outcome. The task now becomes to make the problem fit the scenario. So rather than looking for the likely root cause, the assessor is looking for evidence to validate the “believed in” root cause.

Note that this belief can even cause influence to be exerted on other organisation employees. 

c) Cost of Investigation and time constraints. Here due to time or funding issues, only a limited investigation takes place usually this limited investigation involves arriving at the most likely root cause by examining test data and not attempting to replicate the failed condition. 

The follow-on from this is that the “actual” root cause may suggest the need for a redesign which may financially be too costly to implement. 

d) Concluding too early where the RCA is terminated or ended whilst there are still viable causes to consider. On occasion,n it is not until after a re-occurrence of the same issue is the original root cause is revisited and the act of jumping to an “early” probable cause is a major source of miss analysis. 

e) Lack of management commitment can become an issue, more so in regard to the willingness to develop mitigations that can impact the change management, sometimes due to expediency early closure without due process is encouraged (ultimately to the detriment of the organisation). 

f) Lack of Experience / Exposure to RCA - Inexperienced investigators don’t know many cause-and-effect relationships. They can’t find what they don’t know. Your knowledge (or lack of it) can get in the way of a good root-cause analysis.

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