What is a RCA investigation?
Root Cause Analysis (RCA) is an investigation into a problem to determine the root cause or root failure. If the problem is identified by the investigator, he or she may then be able to establish the solution to the dilemma. The problem or the procedure used that caused the problem is made right.
As an example of the RCA: a floating roof rolling ladder failure occurred. The failure occurred when a rag froze to the rolling ladder rail and the wheel caught on the rag and as the roof raised the ladder buckled. Root cause was the rag. If a Route Cause analysis was made the ultimate failure mechanism would be the same, however the recommendations for future operation would be different.
The route to the failure was more than the rag. The rag got in that position because the gauger left it there. The gauger used the rag to clean his gauging tape. There were no procedures given to the gauger for this operation since the gauger was to simply gauge the tank and record readings on the gauger's chart.
The analysis in this case found that the gauger was never trained in the operation or in the hazards of debris left on the tank. The failure was a buckled rolling ladder however it could have been a fire due to old oily rags accumulated on the roof and the gauger's platform. There was no disposal receptacle for oily rags. There were no rules for disposal of oily rags.
The route cause of the failure1. No training for the gauger in how to gauge tanks properly2. No training in the dangers of spontaneous combustion3. No company procedures for the disposal of oily rags4. No system to check employee compliance to rules and procedures.
Not following this route brings us the failure. The root cause is important but the route to the failure gives the operator of the tank facility the opportunity to implement procedures to eliminate the root and other conditions that actually may be more dangerous.