Root Cause Mastery | From Correction to Prevention

ROOT CAUSE ANALYSIS, WHERE QUALITY GROWS UP

• Every deviation tells a story.
• But too often, we fix the ending instead of understanding the plot.
• RCA isn’t paperwork, it’s a way of thinking.
• We do it not to find who erred, but how the system allowed it.

A strong Root Cause Analysis converts confusion into cause–and–effect clarity:

1) It separates symptoms from sources
2) It turns firefighting into learning
3) It transforms compliance into confidence

HUMAN ERROR ≠ ROOT CAUSE

• When an investigation ends with operator error = investigation incomplete.
• Blaming people closes the form. Understanding systems closes the loop.

Human actions are effects of system design & not the source of failure.

Ask deeper questions:
1) Was the task designed for success?
2) Was training clear, current and verified?
3) Did the environment support accuracy?
4) Was the process intuitive or fragile?

PEOPLE DON’T FAIL IN ISOLATION, PROCESSES DO.

• Fix the system and you protect the people.
• When people feel protected, they perform with ownership and pride.

PROCESS MAPPING: MAKING THE INVISIBLE VISIBLE

You can’t fix what you can’t see.

• And most root causes live between hand-offs.
• Process mapping is the x-ray of your system.

Here’s what strong RCA teams do:

1) Map the reality, not the SOP.

• That’s where risk hides.

2) Trace the touchpoints.

• Most deviations start where ownership ends.

3) Add the digital layer.

• eQMS tools turn process maps into live dashboards linking CAPAs, deviations & risk signals in real time.
• Process maps don’t just show flow, they show friction.
• And friction is where prevention begins.

SELECTING THE REAL ROOT CAUSE i.e., TESTING THE TRUTH, NOT THE ASSUMPTION

• The first cause that sounds right is rarely the one that is right.
• Every suspected cause must be tested, not trusted.

Ask:

• Does it explain all the data?
• Can you replicate the failure if reintroduced?
• Does removing it prevent recurrence?
• Is it system-driven, not coincidental?

Good investigators prove causes, they don’t just propose them. That’s how confidence replaces assumption.

Read also: 7 Tools for Root Cause Analysis

Resource Person: Bharathi Kodali