ROOT

CAUSE
ANALYSIS
Ashish Vaishy (PS-B005)
Shaikh Muhammad Nadeem (QAM-10)

Root cause analysis

Root cause analysis is a method that is used to address a
problem or non- conformance, in order to get to the root
cause of the problem. It is used so we can correct or
eliminate the cause, and prevent the problem from recurring.
Define the
Problem

Recommend
and
Implement
Solutions

Identify the
Root Cause

Collect Data

Identify
Possible
Causal
Factors

Symptom Approach vs. Root Cause

Symptom Approach

Errors are often a result of

worker carelessness.

We need to train and motivate

workers to be more careful.

We dont have the time or

resources to really get to the
bottom of this problem.

Root Cause
Errors are the result of defects in the
system. People are only part of the
process.
We need to find out way this is
happening , and implement mistakes
proofs so it wont happen again.
This is critical we need to fix it for good
or it will come back and burn us.

Tools Used in Root Cause Analysis

Five
Whys

Identifying Root Causes with the Context of

the Overall Incident Investigation Process

Marine Incident Investigation Process

TITANIC

o April 14, 1912

o 900 feet long, stood 25 stories high
o Weighed an incredible 46,000 tons

o More than 2200 passenger were aboar

o Only 705 survived

nsinkable Ship

WHY DID THE TITANIC SINK?

Titanic
Sank

Effect

Because

Ship Hit
Iceberg

Cause

Titanic
Sank

Effect

Steel Plates
on Hull
Bent

Ship Hit
Iceberg

Cause
Effect

Cause
Effect
Becomes
Cause..

WHY DID THE steel bend?

Steel not
strong
enough

Titanic
Sank

Steel
Plates
On Hull
Bent

and

Ship hit
Iceberg

2 causes

Steel not
strong
enough

Loss of 1500
lives

Titanic
Sank

Steel Plates
On Hull
Bent

and

Ship hit
Iceberg

2 causes

Steel not
strong
enough

Impact to
Safety Goals

Loss of 1500
lives

Titanic
Sank

Steel Plates
On Hull
Bent

and

Ship hit
Iceberg

2 causes

Impact to
Safety Goals

Steel not
strong enough

Loss of 1500
lives

Titanic
Sank

Impact to
Vessel Goals

Loss of Ship

Steel Plates
On Hull
Bent

and

Ship hit
Iceberg

2 causes

WHY DID THE

TITANIC SINK?
Impact to
Safety
Goals

WHY DID THE

TITANIC hit the
iceberg?
Steel not
strong
enough

Loss of
1500 lives

Titanic
Sank

Steel
Plates
On Hull
Bent

and
Iceberg
and

Impact to
Vessel
Goals

Loss of
Ship

Ship hit
Iceberg

Ship did not

turn
suffeciently
and

2 causes
Ship in water

WHY DID THE

TITANIC SINK?

Impact to
Safety
Goals

WHY DID THE

TITANIC hit the
iceberg?

Loss of
1500
lives

Steel not
strong
enough
Titanic
Sank

Steel
Plates
On Hull
Bent

Speed of
the ship

and
Iceberg
and

Impact to
Vessel
Goals

Loss of
Ship

Ship hit
Iceberg

Ship did not

turn
suffeciently
and

2 causes

Ship in
water

WHY DID THE WHY DID THEy not

TITANIC
see the iceberg?
SINK?
Impact
to
Safety
Goals

Did not
have
binoculars

Loss of
1500
lives

Water
Filled
Hull

Titanic
Sank

Key to
binocular
not on ship

Openi
ng in
Hull

Steel
Plates
On Hull
Bent

WHY DID THE

TITANIC hit the
iceberg?
Extra
slags in
rivets

Steel not
strong
enough
Iceberg

Speed of
the ship

and
and

Impact
to
Vessel
Goals

Ship hit
Iceberg

Loss of
Ship

Crew not
trained

WHY DID so many

people die?

Not
enough
life boats

Ship did
not turn
sufficiently
and
Ship in
water

Crew did
not see
the
iceberg

The ultimate purpose is

to ensure that the
identified causes do not
occur again.

ossible Solutions.

o More lifeboats

o Improve the pump design of the hull

o Strengthen the steel quality

o Iceberg surveillance program

o Improve the communication process

Wishing you a
Romantic life ahea
Thank you