Top

Published in:

2025 | OriginalPaper | Chapter

19. Root Cause Analysis (RCA)

Authors : José L. Rodríguez-Álvarez, Jorge Luis García Alcaraz, Cayetano Navarrete-Molina, Arturo Soto-Cabral

Published in: Lean Manufacturing in Latin America

Publisher: Springer Nature Switzerland

Activate our intelligent search to find suitable subject content or patents.

search-config

AI-assisted search

Off

Abstract

This chapter delves into the RCA manufacturing tool, examining its development and significance and the benefits it offers when properly implemented. In addition, it explores the critical success factors for adoption and recommendations for implementation. Moreover, a bibliometric review was conducted to analyze the RCA-based problem-solving approach in the industry, identifying the authors, institutions, and countries that have contributed the most scientific papers and those that have been most cited. Lastly, an applied case study is presented, demonstrating the step-by-step implementation of an RCA based on the 8D’s methodology to resolve a quality issue detected by a customer in a corrugated cardboard box. Using One-Way ANOVA, the cause of the problem was initially validated. The effect was then quantified, enabling the customer to identify the critical quality variable that needs to be maintained. It is important to note that RCAs do not necessarily require substantial investment to eliminate the root cause of a problem. Instead, the use of statistical tools and methodologies, whether classical or based on artificial intelligence and big data, can provide a cost-effective solution.

Dont have a licence yet? Then find out more about our products and how to get one now:

Springer Professional "Wirtschaft+Technik"

Online-Abonnement

Mit Springer Professional "Wirtschaft+Technik" erhalten Sie Zugriff auf:

über 102.000 Bücher
über 537 Zeitschriften

aus folgenden Fachgebieten:

Automobil + Motoren
Bauwesen + Immobilien
Business IT + Informatik
Elektrotechnik + Elektronik
Energie + Nachhaltigkeit
Finance + Banking
Management + Führung
Marketing + Vertrieb
Maschinenbau + Werkstoffe
Versicherung + Risiko

Jetzt Wissensvorsprung sichern!

inform now

Springer Professional "Technik"

Online-Abonnement

Mit Springer Professional "Technik" erhalten Sie Zugriff auf:

über 67.000 Bücher
über 390 Zeitschriften

aus folgenden Fachgebieten:

Automobil + Motoren
Bauwesen + Immobilien
Business IT + Informatik
Elektrotechnik + Elektronik
Energie + Nachhaltigkeit
Maschinenbau + Werkstoffe

Jetzt Wissensvorsprung sichern!

inform now

previous chapter The PDCA (Plan-Do-Check-Act) Cycle

next chapter Value Stream Mapping (VSM)

Abdi Z, Ravaghi H (2017) Implementing root cause analysis in Iranian hospitals: challenges and benefits. Int J Health Plan Manag 32(2):147–162CrossRef

Al-Samarraie H, Hurmuzan S (2018) A review of brainstorming techniques in higher education. Think Ski Creat 27:78–91. https://doi.org/10.1016/j.tsc.2017.12.002CrossRef

Andersen B, Fagerhaug T (2006) Root cause analysis. Quality Press

Velásquez RMA, Lara JVM (2019) Root cause analysis for shunt reactor failure in 500 kV power system. Eng Fail Anal 104:1157–1173. https://doi.org/10.1016/j.engfailanal.2019.06.076CrossRef

Barber LK, Kuykendall LE, Santuzzi AM (2023) How managers can reduce “always on” work stress in teams: an optimal work availability framework. Organ Dyn 52(3):100992. https://doi.org/10.1016/j.orgdyn.2023.100992CrossRef

Barsalou MA (2014) Root cause analysis: a step-by-step guide to using the right tool at the right time. CRC Press

Ben-Daya M (2009) Failure mode and effect analysis. In: Handbook of maintenance management and engineering. Springer, pp 75–90

Berry K, Krizek B (2000) Root cause analysis in response to a “near miss.” J Healthc Qual 22(2):16–18CrossRef

Bilsel RU, Lin DKJ (2012) Ishikawa cause and effect diagrams using capture recapture techniques. Qual Technol & Quant Manag 9(2):137–152. https://doi.org/10.1080/16843703.2012.11673282CrossRef

Bowie P, Skinner J, de Wet C (2013) Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. BMC Health Serv Res 13(1):50. https://doi.org/10.1186/1472-6963-13-50CrossRef

Briand L, El Emam K, Melo WL (1995) Ainsi: an inductive method for software process improvement: concrete steps and guidelines. University of Maryland at College Park

Braithwaite J, Westbrook MT, Mallock NA, Travaglia JF, Iedema RA (2006) Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health Care 15(6):393–399. https://doi.org/10.1136/qshc.2005.017525CrossRef

Carroll JS, Rudolph JW, Hatakenaka S (2002) Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant. Qual Saf Health Care 11(3):266–269. https://doi.org/10.1136/qhc.11.3.266CrossRef

Castellanos V, Albiter A, Hernández P, Barrera G (2011) Failure analysis expert system for onshore pipelines. Part–I: structured database and knowledge acquisition. Expert Syst Appl 38(9):11085–11090. https://doi.org/10.1016/j.eswa.2011.02.153

Chao GH, Iravani SM, Savaskan RC (2009) Quality improvement incentives and product recall cost sharing contracts. Manage Sci 55(7):1122–1138CrossRef

Chen H-R, Cheng B-W (2010) A case study in solving customer complaints based on the 8Ds method and Kano model. J Chin Inst Ind Eng 27(5):339–350. https://doi.org/10.1080/10170669.2010.495508CrossRef

Chen S, Long X, Jin G, Zeng Z (2023) An unsupervised root cause analysis method for satellite on-orbit anomalies based on causal discovery. Adv Space Res 72(9):3842–3855. https://doi.org/10.1016/j.asr.2023.07.054CrossRef

Chen MY, Kiciman E, Fratkin E, Fox A, Brewer E (2002) Pinpoint: problem determination in large, dynamic internet services. In: Proceedings international conference on dependable systems and networks, 23–26 June 2002, pp 595–604. https://doi.org/10.1109/DSN.2002.1029005

Cho K-T, Shin KG (2016) Fingerprinting electronic control units for vehicle intrusion detection. In: 25th USENIX security symposium (USENIX Security 16), pp 911–927

Choksi VR, Marn C, Piotrowski MM, Bell Y, Carlos R (2005) Illustrating the root-cause-analysis process: creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging. J Am Coll Radiol 2(9):768–776CrossRef

Damele G, Bazzana G, Andreis F, Aquilio F, Arnoldi S, Pessi E (1996) Process improvement through root cause analysis. In: Achieving quality in software: proceedings of the third international conference on achieving quality in software, Springer, pp 35–47

Darmawan MD, Firmansah W, Zulwaqar MST, Cahyapala RA (2023) Damage analysis of Caterpillar C9 Acert machine using root cause analysis method at PT. XYZ. Int Res J Innov Eng Technol 7(5):171

Denniss S (2017) A case study: the benefits and challenges of root cause analysis presented through a real world example from the rail industry. Saf Reliab 37(4):197–216. https://doi.org/10.1080/09617353.2018.1471189CrossRef

DeZoort FT, Pollard TJ (2023) An evaluation of root cause analysis use by internal auditors. J Account Public Policy 42(3):107081. https://doi.org/10.1016/j.jaccpubpol.2023.107081CrossRef

Doggett AM (2005) Root cause analysis: a framework for tool selection. Qual Manag J 12(4):34–45. https://doi.org/10.1080/10686967.2005.11919269CrossRef

Du M, Li F, Zheng G, Srikumar V (2017) Deeplog: anomaly detection and diagnosis from system logs through deep learning. In: Proceedings of the 2017 ACM SIGSAC conference on computer and communications security, pp 1285–1298

Dubey R, Gunasekaran A, Childe SJ, Papadopoulos T, Hazen BT, Roubaud D (2018) Examining top management commitment to TQM diffusion using institutional and upper echelon theories. Int J Prod Res 56(8):2988–3006. https://doi.org/10.1080/00207543.2017.1394590CrossRef

Duncan R, Brown H (1984) Root cause analysis of outages in combined-cycle power plants. In: Turbo expo: power for land, sea, and air. American Society of Mechanical Engineers, p V004T010A002

e Oliveira E, Miguéis VL, Borges JL (2023) Automatic root cause analysis in manufacturing: an overview & conceptualization. J Intell Manuf 34(5):2061–2078. https://doi.org/10.1007/s10845-022-01914-3

Fadnavis S, Najarzadeh A, Badurdeen F (2020) An assessment of organizational culture traits impacting problem solving for lean transformation. Procedia Manuf 48:31–42CrossRef

Ferrari A-M, Jones B (2012) Value and cost effectiveness of conducting a root cause analysis. In: International pipeline conference. American Society of Mechanical Engineers, pp 559–567

Goel S, Chen V (2008) Integrating the global enterprise using Six Sigma: business process reengineering at general electric wind energy. Int J Prod Econ 113(2):914–927. https://doi.org/10.1016/j.ijpe.2007.12.002CrossRef

Goldratt EM (1994) It’s not luck. North River Press, MA, Great Barrington

Guideline D (1992) Root cause analysis guidance document. US Department of Energy, Washington

Hatamura Y, Ilno K, Tsuchlya K, Hamaguchi T (2003) Structure of failure knowledge database and case expression. CIRP Ann 52(1):97–100. https://doi.org/10.1016/S0007-8506(07)60540-XCrossRef

Hussin H, Ahmed U, Muhammad M (2016) Critical success factors of root cause failure analysis. Indian J Sci Technol 9(48):1–10CrossRef

Johnson L, Bhutani V, Karp K, Sivieri E, Shapiro S (2009) Clinical report from the pilot USA Kernicterus Registry (1992 to 2004). J Perinatol 29(1):S25–S45CrossRef

Joshuva N, Pinto T (2016) Study and analysis of process capability of 4000 ton mechanical press using 8D method. In: Proceedings of the national conference on advances in mechanical engineering science, Hangzhou, China, pp 9–10

Julisch K (2003) Clustering intrusion detection alarms to support root cause analysis. ACM Trans Inf Syst Secur 6(4):443–471CrossRef

Kaswan MS, Rathi R (2020) Green lean Six Sigma for sustainable development: integration and framework. Environ Impact Assess Rev 83:106396. https://doi.org/10.1016/j.eiar.2020.106396CrossRef

Kumar Phanden R, Sheokand A, Kumar Goyal K, Gahlot P, Ibrahim Demir H (2022) 8Ds method of problem solving within automotive industry: tools used and comparison with DMAIC. Mater Today Proc 65:3266–3272. https://doi.org/10.1016/j.matpr.2022.05.383CrossRef

Latino MA, Latino RJ, Latino KC (2019) Root cause analysis: improving performance for bottom-line results. CRC PressCrossRef

Lee A (2024) Root cause analysis of incidents. In: Smithers GW (ed) Encyclopedia of food safety, 2nd edn. Academic Press, Oxford, pp 151–161. https://doi.org/10.1016/B978-0-12-822521-9.00227-6

Lestyánszka-Škůrková K (2017) Implementation of a system quality tool to reduce the costs of scrap loss in industrial enterprise. Zeszyty Naukowe Quality Production Improvement

łgorzata Steinder M, Sethi AS (2004) A survey of fault localization techniques in computer networks. Sci Comput Program 53(2):165–194

Ma Q, Li H, Thorstenson A (2021) A big data-driven root cause analysis system: application of Machine Learning in quality problem solving. Comput Ind Eng 160:107580. https://doi.org/10.1016/j.cie.2021.107580CrossRef

Medina-Oliva G, Iung B, Barberá L, Viveros P, Ruin T (2012) Root cause analysis to identify physical causes. In: 11th International probabilistic safety assessment and management conference and the annual european safety and reliability conference, PSAM11-ESREL 2012, p CDROM

Mena C, Adenso-Diaz B, Yurt O (2011) The causes of food waste in the supplier–retailer interface: evidences from the UK and Spain. Resour Conserv Recycl 55(6):648–658. https://doi.org/10.1016/j.resconrec.2010.09.006CrossRef

Mohsen Alawag A, Salah Alaloul W, Liew MS, Ali Musarat M, Baarimah AO, Saad S, Ammad S (2023) Critical success factors influencing total quality management in industrialised building system: a case of Malaysian construction industry. Ain Shams Eng J 14(2):101877. https://doi.org/10.1016/j.asej.2022.101877CrossRef

Osborn AF (1953) Applied imagination

Paradies M, Busch D (1988) Root cause analysis at Savannah River plant (nuclear power station). In: Conference record for 1988 IEEE fourth conference on human factors and power plants, 5–9 June 1988, pp 479–483. https://doi.org/10.1109/HFPP.1988.27547

Pereira T, Neves ASL, Silva FJG, Godina R, Morgado L, Pinto GFL (2020) Production process analysis and improvement of corrugated cardboard industry. Procedia Manuf 51:1395–1402. https://doi.org/10.1016/j.promfg.2020.10.194CrossRef

Pourrajab M, Basri R, Daud SM, Asimiran S (2015) The resistance to change in implementation of total quality management (TQM) in Iranian schools. TQM J 27(5):532–543. https://doi.org/10.1108/TQM-04-2013-0044CrossRef

Qin Y, Liu H (2021) Application of value stream mapping in supply chain: a case study on an Amazon retail. In: 2021 IEEE international conference on industrial engineering and engineering management (IEEM), 13–16 December 2021, pp 213–217. https://doi.org/10.1109/IEEM50564.2021.9672930

Ransom DL (2007) A practical guideline for a successful root cause failure analysis. In: Proceedings of the 36th turbomachinery symposium. Texas A&M University, Turbomachinery Laboratories

Rathi R, Chandra Gopi Reddy M, Lakshmi Narayana A, Lakshmi Narayana U, Saeedur Rahman M (2022) Investigation and implementation of 8D methodology in a manufacturing system. Mater Today Proc 50:743–750. https://doi.org/10.1016/j.matpr.2021.05.273CrossRef

Realyvásquez-Vargas A, Arredondo-Soto KC, García-Alcaraz JL, Macías EJ (2020) Improving a manufacturing process using the 8Ds method. A case study in a manufacturing company. Appl Sci 10(7):2433

Reason J (1990) Human error. Cambridge University PressCrossRef

Reid I, Smyth-Renshaw J (2012) Exploring the fundamentals of root cause analysis: are we asking the right questions in defining the problem? Qual Reliab Eng Int 28(5):535–545CrossRef

Romano E, Murino T, Asta F, Costagliola P (2013) Lean maintenance model to reduce scraps and WIP in manufacturing system: case study in power cables factory. WSEAS Trans Syst 12(12):650–666

Seyed Alinezhad H, Roohi MH, Chen T (2022) A review of alarm root cause analysis in process industries: common methods, recent research status and challenges. Chem Eng Res Des 188:846–860. https://doi.org/10.1016/j.cherd.2022.10.041CrossRef

Shaqdan K, Aran S, Daftari Besheli L, Abujudeh H (2014) Root-cause analysis and health failure mode and effect analysis: two leading techniques in health care quality assessment. J Am Coll Radiol 11(6):572–579. https://doi.org/10.1016/j.jacr.2013.10.024CrossRef

Simanjuntak RH, Iskandar IJJoM, Civil Engineering I (2022) Pressurization system on Aircraft Boeing 737-300F, Aircraft MSN: 28567 during flight Hanoi to Bangkok: problem solving and root cause analysis. J Mech Civ Ind Eng 3(3):56–59

Sobek II DK, Smalley A (2008) Understanding A3 thinking: a critical component of Toyota’s PDCA management system. Productivity Press

Stair C, Morphy P, Chipperfield S, Harris S, ONeal D, Pewitt M (2004) Identifying the root cause of a deepwater GoM infant sand control failure. In: SPE annual technical conference and exhibition? SPE, pp SPE-90004-MS

Talbi N, Batti A, Ayad R, Guo Y (2009) An analytical homogenization model for finite element modelling of corrugated cardboard. Compos Struct 88(2):280–289CrossRef

Tomić B, Spasojević Brkić V (2011) Effective root cause analysis and corrective action process. J Eng Manag Compet 1(1/2):16–20

Vo B, Kongar E, Suárez-Barraza MF (2020) Root-cause problem solving in an industry 4.0 context. IEEE Eng Manag Rev 48(1):48–56. https://doi.org/10.1109/EMR.2020.2966980

Wagner TP (2014) Using root cause analysis in public policy pedagogy. J Public Aff Educ 20(3):429–440CrossRef

Wald H, Shojania KG (2001) Root cause analysis. Making health care safer: a critical analysis of patient safety practices, p 51

Wallace CA, Motarjemi Y (2023) Chapter 45-incident management and root cause analysis. In: Andersen V, Lelieveld H, Motarjemi Y (eds) Food safety management, 2nd edn. Academic Press, San Diego, pp 957–970. https://doi.org/10.1016/B978-0-12-820013-1.00040-1

Wan X, Cen L, Yue W, Xie Y, Chen X, Gui W (2024) Failure mode and effect analysis with ORESTE method under large group probabilistic free double hierarchy hesitant linguistic environment. Adv Eng Inform 59:102353. https://doi.org/10.1016/j.aei.2024.102353CrossRef

Wilson PF, Dell LD, Anderson GF (1996) Root cause analysis: a tool for total quality management. J Healthc Qual 18(1):40CrossRef

Wilson FP, Dell LD, Anderson GFJ (1993) Root cause analysis: a tool for total quality management. ASQ

Wu AW, Lipshutz AK, Pronovost PJ (2008) Effectiveness and efficiency of root cause analysis in medicine. JAMA 299(6):685–687CrossRef

York D, Jin K, Song Q, Li H (2014) Practical root cause analysis using cause mapping. In: Proceedings of the international Multiconference of engineers and computer scientists

Yu LX, Amidon G, Khan MA, Hoag SW, Polli J, Raju G, Woodcock J (2014) Understanding pharmaceutical quality by design. AAPS J 16:771–783CrossRef

Title: Root Cause Analysis (RCA)
Authors: José L. Rodríguez-Álvarez
Jorge Luis García Alcaraz
Cayetano Navarrete-Molina
Arturo Soto-Cabral
Publisher: Springer Nature Switzerland
Book: Lean Manufacturing in Latin America
Print ISBN: 978-3-031-70983-8

Electronic ISBN: 978-3-031-70984-5

Copyright Year: 2025
DOI: https://doi.org/10.1007/978-3-031-70984-5_19