Corrective Action Program Causal Analysis

Organizations experience incidents of every sort, some with almost imperceptible impacts and others inflicting catastrophic consequences. While impractical to mitigate all adverse events, it is imperative to prevent recurrence of the most significant incidents, important to limit the frequency and impact of moderate happenings, and necessary to only correct low impact deficiencies. Such a grade approach to corrective action implementation optimally applies the organization’s resources based on the value of event recurrence mitigation.[wcm_restrict plans=”48830, 25542, 25653″]

Condition reports documenting adverse events are prioritized across a continuum relative to the incident’s impact. (See StrategyDriven Corrective Action Program article, Condition Report Prioritization) These priorities provide the basis for a graded approach to the performance of causal analysis identifying the corrective actions necessary to prevent or mitigate event recurrence.

Types of Causal Analyses

Three common causal analyses provide a spectrum of investigation methods and depths. Each analysis type is described below:

Root Cause Analysis

Root cause analysis (RCA) is a formal investigation method used to determine the fundamental underlying cause(s) of an event or adverse trend. Root cause analysis methods logically derive the primary and contributing causes of an event; determining what happened, how it happened, and why it happened. These analyses identify the extent of the adverse condition and corrective actions to prevent event recurrence (CAPRs).

A root cause analysis is typically performed by a multidiscipline team and may take up to a month to complete.

Apparent Cause Evaluation

Apparent cause evaluation (ACE) is a limited investigation method used to identify readily apparent causes and the extent of condition of an event or problem. An apparent cause evaluation identifies corrective actions to minimize the recurrence frequency and impact of the associated event.

An apparent cause evaluation is typically performed by a knowledgeable individual or small team and may take up to a few weeks to complete.

Direct Cause Evaluation

Direct cause evaluation (DCE) is a corrective action identification method used to address simple, ‘broke-fix’ issues. A direct cause evaluation identifies the obvious corrective actions to resolve the identified failure. In worst case scenarios, troubleshooting is required to identify the necessary corrective actions.

A direct cause evaluation is typically performed by the responsible department’s Corrective Action Program Coordinator or a knowledgeable staff member and is often completed at the time of condition report processing.

Relationship between Causal Analyses and Condition Report Significance Level

Each causal analysis type requires a different amount of resources related to the depth of investigation performed. Consequently, a condition report’s significance should dictate the type of analysis performed so that the organization realizes an appropriate return on this investment.

Significance Level 1 Condition Reports

Significance Level 1 condition reports represent an issue or event resulting in a significant impact. A root cause analysis is almost always performed for Significance Level 1 issues.

Significance Level 2 Condition Reports

Significance Level 2 condition reports represent an issue or event resulting in a moderate impact. A root cause analysis is performed for more serious Significance Level 2 issues or collection of related Significance Level 2 issues. An apparent cause evaluation is performed for most Significance Level 2 issues.

Significance Level 3 Condition Reports

Significance Level 3 condition reports represent an issue or event resulting in a minor impact. An apparent cause evaluation is performed for more serious Significance Level 3 issues or collection of related Significance Level 3 issues. A direct cause evaluation is performed for most Significance Level 3 issues.

Significance Level 4 and 5 Condition Reports

Significance Level 4 condition reports represent a low-level problem, typically closed to immediate actions taken or other readily identifiable follow-up corrective actions that requires trending. Significance level 5 condition reports represent an enhancement, opportunity for improvement, or commendable behavior that does not require trending. A direct cause evaluation is performed for Significance Level 4 issues not resolved by the performance of immediate actions. No causal analysis is performed for Significance Level 5 items.

Note that collections or trends of Significance Level 4 issues are commonly captured within a rollup Significance Level 3 condition report and the appropriate causal analysis performed.[/wcm_restrict][wcm_nonmember plans=”48830, 25542, 25653″]

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About the Author

Nathan Ives is a StrategyDriven Principal and Host of the StrategyDriven Podcast. For over twenty years, he has served as trusted advisor to executives and managers at dozens of Fortune 500 and smaller companies in the areas of management effectiveness, organizational development, and process improvement. To read Nathan’s complete biography, click here.