Root cause analysis (RCA)

IEC 62740:2015 describes the basic principles of root cause analysis (RCA) and specifies the steps that a process for RCA should include. This standard identifies a number of attributes for RCA techniques which assist with the selection of an appropriate technique. It describes each RCA technique and its relative strengths and weaknesses. RCA is used to analyse the root causes of focus events with both positive and negative outcomes, but it is most commonly used for the analysis of failures and incidents. Causes for such events can be varied in nature, including design processes and techniques, organizational characteristics, human aspects and external events. RCA can be used for investigating the causes of non-conformances in quality (and other) management systems as well as for failure analysis, for example in maintenance or equipment testing. RCA is used to analyse focus events that have occurred, therefore this standard only covers a posteriori analyses. It is recognized that some of the RCA techniques with adaptation can be used proactively in the design and development of items and for causal analysis during risk assessment; however, this standard focuses on the analysis of events which have occurred. The intent of this standard is to describe a process for performing RCA and to explain the techniques for identifying root causes. These techniques are not designed to assign responsibility or liability, which is outside the scope of this standard. Keywords: root cause analysis (RCA), RCA techniques

Grundursachenanalyse

Analyse de cause initiale (RCA)

L'IEC 62740:2015 décrit les principes basiques de l'analyse de cause initiale (RCA) et spécifie les étapes qu'il convient qu'un processus de RCA inclue. La présente norme identifie plusieurs attributs de techniques de RCA, qui aident à sélectionner la technique appropriée. Elle décrit chaque technique de RCA, ainsi que ses points forts et limites. La RCA est utilisée pour analyser les causes initiales des événements d'accent, que leurs conséquences soient positives ou négatives, mais est plus couramment utilisée pour l'analyse des défaillances et des accidents. Les causes de tels événements peuvent être de nature multiple, notamment en fonction de la conception, des processus et des techniques, des caractéristiques organisationnelles, des aspects humains et des événements externes. La RCA peut être utilisée pour étudier les causes de non-conformité en termes de qualité (ou autres) des systèmes de gestion ainsi que pour l'analyse des défaillances, par exemple lors de la maintenance ou de l'essai des équipements. La RCA est utilisée pour analyser des événements d'accent qui se sont produits, cette norme ne couvre donc que les analyses a posteriori. Il est reconnu que certaines des techniques de RCA avec adaptations peuvent être utilisées de manière proactive lors de la conception et du développement d'entités et pour l'analyse causale au cours de l'évaluation des risques; cependant, la présente norme met l'accent sur l'analyse des événements qui se sont produits. L'objectif de la présente norme est de décrire un processus en vue de réaliser une RCA et d'expliquer les techniques permettant d'identifier les causes initiales. Lesdites techniques n'ont pas été conçues pour identifier la responsabilité ou la fiabilité, car ceci ne fait pas partie du domaine d'application de la présente norme. Mots clés: analyse de cause initiale (RCA), de techniques de RCA

Analiza izvornih razlogov (RCA) (IEC 62740:2015)

Ta mednarodni standard opisuje osnovne principe analize izvornih razlogov (RCA) in določa korake, ki jih mora proces analize izvornih razlogov vključevati. Ta standard opredeljuje več lastnosti tehnik RCA, ki so v pomoč pri izbiri primerne tehnike. Vsebuje opis vseh RCA tehnik ter njihovih prednosti in slabosti. RCA se uporablja za analizo izvornih razlogov ključnih dogodkov s pozitivnimi in negativnimi rezultati, vendar se najpogosteje uporablja za analizo okvar in incidentov. Razlogi za take dogodke se lahko razlikujejo, mednje pa spadajo procesi in tehnike načrtovanja, organizacijske lastnosti, človeški dejavniki in zunanji dogodki. RCA se lahko uporablja za iskanje vzrokov za neskladnosti pri sistemih vodenja kakovosti (in drugih sistemih vodenja), kot tudi za analizo okvar, na primer pri vzdrževanju in preskušanju opreme. RCA se uporablja za analizo ključnih dogodkov, ki so se zgodili, torej ta standard zajema samo
posteriorne analize. Priznava se, da se nekatere prilagojene RCA tehnike lahko uporablja proaktivno pri načrtovanju in razvoju izdelkov in za vzročno analizo med ocenjevanjem tveganja, vendar se ta standard osredotoča na analizo dogodkov, ki so se že zgodili. Namen tega standarda je opis postopka izvedbe RCA on razlaga tehnik za prepoznavanje izvornih razlogov. Te tehnike niso zasnovane za dodeljevanje odgovornosti ali določanje krivde, kar je zunaj področja uporabe tega standarda.

General Information

Status
Published
Publication Date
02-Apr-2015
Technical Committee
Drafting Committee
Current Stage
6060 - Document made available
Due Date
03-Apr-2015
Completion Date
03-Apr-2015

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SLOVENSKI STANDARD
SIST EN 62740:2015
01-september-2015
Analiza izvornih razlogov (RCA) (IEC 62740:2015)
Root cause analysis (RCA) (IEC 62740:2015)
Ursachenanalyse (IEC 62740:2015)
Analyse de cause initiale (RCA) (IEC 62740:2015)
Ta slovenski standard je istoveten z: EN 62740:2015
ICS:
03.120.01 Kakovost na splošno Quality in general
29.020 Elektrotehnika na splošno Electrical engineering in
general
SIST EN 62740:2015 en

2003-01.Slovenski inštitut za standardizacijo. Razmnoževanje celote ali delov tega standarda ni dovoljeno.

---------------------- Page: 1 ----------------------
EUROPEAN STANDARD EN 62740
NORME EUROPÉENNE
EUROPÄISCHE NORM
April 2015
ICS 03.120.01
English Version
Root cause analysis (RCA)
(IEC 62740:2015)
Analyse de cause initiale (RCA) Ursachenanalyse
(IEC 62740:2015) (IEC 62740:2015)

This European Standard was approved by CENELEC on 2015-03-20. CENELEC members are bound to comply with the CEN/CENELEC

Internal Regulations which stipulate the conditions for giving this European Standard the status of a national standard without any alteration.

Up-to-date lists and bibliographical references concerning such national standards may be obtained on application to the CEN-CENELEC

Management Centre or to any CENELEC member.

This European Standard exists in three official versions (English, French, German). A version in any other language made by translation

under the responsibility of a CENELEC member into its own language and notified to the CEN-CENELEC Management Centre has the

same status as the official versions.

CENELEC members are the national electrotechnical committees of Austria, Belgium, Bulgaria, Croatia, Cyprus, the Czech Republic,

Denmark, Estonia, Finland, Former Yugoslav Republic of Macedonia, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia,

Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland,

Turkey and the United Kingdom.
European Committee for Electrotechnical Standardization
Comité Européen de Normalisation Electrotechnique
Europäisches Komitee für Elektrotechnische Normung
CEN-CENELEC Management Centre: Avenue Marnix 17, B-1000 Brussels

© 2015 CENELEC All rights of exploitation in any form and by any means reserved worldwide for CENELEC Members.

Ref. No. EN 62740:2015 E
---------------------- Page: 2 ----------------------
EN 62740:2015 - 2 -
Foreword

The text of document 56/1590/FDIS, future edition 1 of IEC 62740, prepared by IEC/TC 56

"Dependability" was submitted to the IEC-CENELEC parallel vote and approved by CENELEC as

EN 62740:2015.
The following dates are fixed:
• latest date by which the document has to be (dop) 2015-12-20
implemented at national level by
publication of an identical national
standard or by endorsement
(dow) 2018-03-20
• latest date by which the national
standards conflicting with the
document have to be withdrawn

Attention is drawn to the possibility that some of the elements of this document may be the subject of

patent rights. CENELEC [and/or CEN] shall not be held responsible for identifying any or all such

patent rights.
Endorsement notice

The text of the International Standard IEC 62740:2015 was approved by CENELEC as a European

Standard without any modification.

In the official version, for Bibliography, the following notes have to be added for the standards

indicated:
IEC 60300-1 NOTE Harmonized as EN 60300-1.
IEC 61025 NOTE Harmonized as EN 61025.
IEC 61649 NOTE Harmonized as EN 61649.
IEC 61163-1 NOTE Harmonized as EN 61163-1.
IEC 62508:2010 NOTE Harmonized as EN 62508:2010 (not modified).
ISO/IEC 31010:2009 NOTE Harmonized as EN 31010:2010 (not modified).
---------------------- Page: 3 ----------------------
- 3 - EN 62740:2015
Annex ZA
(normative)
Normative references to international publications
with their corresponding European publications

The following documents, in whole or in part, are normatively referenced in this document and are

indispensable for its application. For dated references, only the edition cited applies. For undated

references, the latest edition of the referenced document (including any amendments) applies.

NOTE 1 When an International Publication has been modified by common modifications, indicated by (mod), the relevant

EN/HD applies.

NOTE 2 Up-to-date information on the latest versions of the European Standards listed in this annex is available here:

www.cenelec.eu.
Publication Year Title EN/HD Year
IEC 60050 Series - International Electrotechnical Vocabulary - -
(IEV)
---------------------- Page: 4 ----------------------
IEC 62740
Edition 1.0 2015-02
INTERNATIONAL
STANDARD
NORME
INTERNATIONALE
colour
inside
Root cause analysis (RCA)
Analyse de cause initiale (RCA)
INTERNATIONAL
ELECTROTECHNICAL
COMMISSION
COMMISSION
ELECTROTECHNIQUE
INTERNATIONALE
ICS 03.120.01 ISBN 978-2-8322-2246-1

Warning! Make sure that you obtained this publication from an authorized distributor.

Attention! Veuillez vous assurer que vous avez obtenu cette publication via un distributeur agréé.

® Registered trademark of the International Electrotechnical Commission
Marque déposée de la Commission Electrotechnique Internationale
---------------------- Page: 5 ----------------------
– 2 – IEC 62740:2015 © IEC 2015
CONTENTS

FOREWORD ........................................................................................................................... 6

INTRODUCTION ..................................................................................................................... 8

1 Scope .............................................................................................................................. 9

2 Normative references ...................................................................................................... 9

3 Terms, definitions and abbreviations ............................................................................... 9

3.1 Terms and definitions .............................................................................................. 9

3.2 Abbreviations ........................................................................................................ 12

4 RCA – Overview ............................................................................................................ 12

5 The RCA process .......................................................................................................... 13

5.1 Overview............................................................................................................... 13

5.2 Initiation ................................................................................................................ 14

5.3 Establishing facts .................................................................................................. 15

5.4 Analysis ................................................................................................................ 17

5.4.1 Description .................................................................................................... 17

5.4.2 The analysis team ......................................................................................... 18

5.5 Validation .............................................................................................................. 19

5.6 Presentation of results .......................................................................................... 19

6 Selection of techniques for analysing causes ................................................................. 20

6.1 General ................................................................................................................. 20

6.2 Selection of analysis techniques ........................................................................... 20

6.3 Useful tools to assist RCA..................................................................................... 21

Annex A (informative) Summary and criteria of commonly used RCA techniques ................. 22

A.1 General ................................................................................................................. 22

A.2 RCA techniques .................................................................................................... 22

A.3 Criteria .................................................................................................................. 23

Annex B (informative) RCA models ...................................................................................... 26

B.1 General ................................................................................................................. 26

B.2 Barrier analysis ..................................................................................................... 26

B.2.1 Overview ....................................................................................................... 26

B.2.2 Strengths and limitations ............................................................................... 27

B.3 Reason’s model (Swiss cheese model) ................................................................. 27

B.3.1 Overview ....................................................................................................... 27

B.3.2 Strengths and limitations ............................................................................... 28

B.4 Systems models .................................................................................................... 28

B.5 Systems theoretic accident model and processes (STAMP) .................................. 29

B.5.1 Overview ....................................................................................................... 29

B.5.2 Strengths and limitations ............................................................................... 29

Annex C (informative) Detailed description of RCA techniques ............................................ 30

C.1 General ................................................................................................................. 30

C.2 Events and causal factors (ECF) charting ............................................................. 30

C.2.1 Overview ....................................................................................................... 30

C.2.2 Process ......................................................................................................... 31

C.2.3 Strengths and limitations ............................................................................... 31

C.3 Multilinear events sequencing (MES) and sequentially timed events plotting

(STEP) .................................................................................................................. 32

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IEC 62740:2015 © IEC 2015 – 3 –

C.3.1 Overview ....................................................................................................... 32

C.3.2 Process ......................................................................................................... 32

C.3.3 Strengths and limitations ............................................................................... 33

C.4 The ‘why’ method .................................................................................................. 35

C.4.1 Overview ....................................................................................................... 35

C.4.2 Process ......................................................................................................... 36

C.4.3 Strengths and limitations ............................................................................... 36

C.5 Causes tree method (CTM) ................................................................................... 36

C.5.1 Overview ....................................................................................................... 36

C.5.2 Process ......................................................................................................... 39

C.5.3 Strengths and limitations ............................................................................... 39

C.6 Why-because analysis (WBA) ............................................................................... 39

C.6.1 Overview ....................................................................................................... 39

C.6.2 Process ......................................................................................................... 42

C.6.3 Strengths and limitations ............................................................................... 42

C.7 Fault tree and success tree method ...................................................................... 42

C.7.1 Overview ....................................................................................................... 42

C.7.2 Process ......................................................................................................... 43

C.7.3 Strengths and limitations ............................................................................... 44

C.8 Fishbone or Ishikawa diagram ............................................................................... 44

C.8.1 Overview ....................................................................................................... 44

C.8.2 Process ......................................................................................................... 45

C.8.3 Strengths and limitations ............................................................................... 46

C.9 Safety through organizational learning (SOL) ........................................................ 46

C.9.1 Overview ....................................................................................................... 46

C.9.2 Process ......................................................................................................... 46

C.9.3 Strengths and limitations ............................................................................... 47

C.10 Management oversight and risk tree (MORT) ........................................................ 48

C.10.1 Overview ....................................................................................................... 48

C.10.2 Process ......................................................................................................... 48

C.10.3 Strengths and limitations ............................................................................... 48

C.11 AcciMaps .............................................................................................................. 49

C.11.1 Overview ....................................................................................................... 49

C.11.2 Process ......................................................................................................... 49

C.11.3 Strengths and limitations ............................................................................... 51

C.12 Tripod Beta ........................................................................................................... 51

C.12.1 Overview ....................................................................................................... 51

C.12.2 Process ......................................................................................................... 52

C.12.3 Strengths and limitations ............................................................................... 52

C.13 Causal analysis using STAMP (CAST) .................................................................. 53

C.13.1 Overview ....................................................................................................... 53

C.13.2 Process ......................................................................................................... 56

C.13.3 Strengths and limitations ............................................................................... 57

Annex D (informative) Useful tools to assist root cause analysis (RCA) ............................... 58

D.1 General ................................................................................................................. 58

D.2 Data mining and clustering techniques .................................................................. 58

D.2.1 Overview ....................................................................................................... 58

D.2.2 Example 1 ..................................................................................................... 58

D.2.3 Example 2 ..................................................................................................... 58

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– 4 – IEC 62740:2015 © IEC 2015

D.2.4 Example 3 ..................................................................................................... 59

Annex E (informative) Analysis of human performance ........................................................ 60

E.1 General ................................................................................................................. 60

E.2 Analysis of human failure ...................................................................................... 60

E.3 Technique for retrospective and predictive analysis of cognitive errors

(TRACEr) .............................................................................................................. 61

E.3.1 Overview ....................................................................................................... 61

E.3.2 Process ......................................................................................................... 62

E.4 Human factors analysis and classification scheme (HFACS) ................................. 63

E.4.1 Overview ....................................................................................................... 63

E.4.2 Process ......................................................................................................... 63

Bibliography .......................................................................................................................... 66

Figure 1 – RCA process ........................................................................................................ 14

Figure B.1 – Broken, ineffective and missing barriers causing the focus event ...................... 26

Figure C.1 – Example of an ECF chart .................................................................................. 31

Figure C.2 – Data in an event building block ......................................................................... 32

Figure C.3 – Example of a time-actor matrix ......................................................................... 34

Figure C.4 – Example of a why tree ...................................................................................... 35

Figure C.5 – Symbols and links used in CTM ........................................................................ 37

Figure C.6 – Example of a cause tree ................................................................................... 38

Figure C.7 – Example of a WBG ........................................................................................... 41

Figure C.8 – Example of a fault tree during the analysis ....................................................... 43

Figure C.9 – Example of a Fishbone diagram ........................................................................ 45

Figure C.10 – Example of a MORT diagram .......................................................................... 48

Figure C.11 – Example of an AcciMap .................................................................................. 50

Figure C.12 – Example of a Tripod Beta tree diagram ........................................................... 52

Figure C.13 – Control structure for the water supply in a small town in Canada .................... 55

Figure C.14 – Example CAST causal analysis for the local Department of health .................. 56

Figure C.15 – Example CAST causal analysis for the local public utility operations

management ......................................................................................................................... 56

Figure E.1 – Example of an TRACEr model [25] .................................................................... 61

Figure E.2 – Generation of internal error modes ................................................................... 62

Figure E.3 – Level 1: Unsafe acts ......................................................................................... 64

Figure E.4 – Level 2: Preconditions ...................................................................................... 64

Figure E.5 – Level 3: Supervision Issues .............................................................................. 65

Figure E.6 – Level 4: Organizational Issues .......................................................................... 65

Table 1 – Steps to RCA ........................................................................................................ 13

Table A.1 – Brief description of RCA techniques ................................................................... 22

Table A.2 – Summary of RCA technique criteria .................................................................... 23

Table A.3 – Attributes of the generic RCA techniques ........................................................... 25

Table B.1 – Examples of barriers .......................................................................................... 27

Table B.2 – Example of the barrier analysis worksheet ......................................................... 27

Table C.1 – Direct and indirect causal factors ....................................................................... 47

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IEC 62740:2015 © IEC 2015 – 5 –

Table E.1 – External error modes.......................................................................................... 63

Table E.2 – Psychological error mechanisms ........................................................................ 63

---------------------- Page: 9 ----------------------
– 6 – IEC 62740:2015 © IEC 2015
INTERNATIONAL ELECTROTECHNICAL COMMISSION
____________
ROOT CAUSE ANALYSIS (RCA)
FOREWORD

1) The International Electrotechnical Commission (IEC) is a worldwide organization for standardization comprising

all national electrotechnical committees (IEC National Committees). The object of IEC is to promote

international co-operation on all questions concerning standardization in the electrical and electronic fields. To

this end and in addition to other activities, IEC publishes International Standards, Technical Specifications,

Technical Reports, Publicly Available Specifications (PAS) and Guides (hereafter referred to as “IEC

Publication(s)”). Their preparation is entrusted to technical committees; any IEC National Committee interested

in the subject dealt with may participate in this preparatory work. International, governmental and non-

governmental organizations liaising with the IEC also participate in this preparation. IEC collaborates closely

with the International Organization for Standardization (ISO) in accordance with conditions determined by

agreement between the two organizations.

2) The formal decisions or agreements of IEC on technical matters express, as nearly as possible, an international

consensus of opinion on the relevant subjects since each technical committee has representation from all

interested IEC National Committees.

3) IEC Publications have the form of recommendations for international use and are accepted by IEC National

Committees in that sense. While all reasonable efforts are made to ensure that the technical content of IEC

Publications is accurate, IEC cannot be held responsible for the way in which they are used or for any

misinterpretation by any end user.

4) In order to promote international uniformity, IEC National Committees undertake to apply IEC Publications

transparently to the maximum extent possible in their national and regional publications. Any divergence

between any IEC Publication and the corresponding national or regional publication shall be clearly indicated in

the latter.

5) IEC itself does not provide any attestation of conformity. Independent certification bodies provide conformity

assessment services and, in some areas, access to IEC marks of conformity. IEC is not responsible for any

services carried out by independent certification bodies.

6) All users should ensure that they have the latest edition of this publication.

7) No liability shall attach to IEC or its directors, employees, servants or agents including individual experts and

members of its technical committees and IEC National Committees for any personal injury, property damage or

other damage of any nature whatsoever, whether direct or indirect, or for costs (including legal fees) and

expenses arising out of the publication, use of, or reliance upon, this IEC Publication or any other IEC

Publications.

8) Attention is drawn to the Normative references cited in this publication. Use of the referenced publications is

indispensable for the correct application of this publication.

9) Attention is drawn to the possibility that some of the elements of this IEC Publication may be the subject of

patent rights. IEC shall not be held responsible for identifying any or all such patent rights.

International Standard IEC 62740 has been prepared by IEC technical committee 56:

Dependability.
The text of this standard is based on the following documents:
FDIS Report on voting
56/1590/FDIS 56/1608/RVD

Full information on the voting for the approval of this standard can be found in the report on

voting indicated in the above table.

This publication has been drafted in accordance with the ISO/IEC Directives, Part 2.

---------------------- Page: 10 ----------------------
IEC 62740:2015 © IEC 2015 – 7 –

The committee has decided that the contents of this publication will remain unchanged until

the stability date indicated on the IEC web site under "http://webstore.iec.ch" in the data

related to the specific publication. At this date, the publication will be
• reconfirmed,
• withdrawn,
• replaced by a revised edition, or
• amended.

IMPORTANT – The 'colour inside' logo on the cover page of this publication indicates

that it contains colours which are considered to be useful for the correct

understanding of its contents. Users should therefore print this document using a

colour printer.
---------------------- Page: 11 ----------------------
– 8 – IEC 62740:2015 © IEC 2015
INTRODUCTION

Root cause analysis (RCA) refers to any systematic process that identifies factors that

contributed to a particular event of interest (focus event). RCA is performed with the

understanding that events are addressed by understanding the root causes, rather than the

immediately obvious symptoms. RCA aims to reveal root causes so that either the likelihood

of them occurring, or their impact if they do occur, can be changed.

An important distinction to make is that RCA is used to analyse a focus event that has

occurred and therefore analyses the past (a posteriori). However, knowledge of the root

causes of past events can lead to actions that generate improvements in the future.

This International Standard is intended to reflect current good practices in the conduct of

RCA. This standard is general in nature, so that it may give guidance across many industries

and situations. There may be industry specific standards in existence that establish preferred

methodologies for particular applications. If these standards are in harmony with this

publication, the industry standards will generally be sufficient.

This standard is a generic standard and does not explicitly address safety or accident

investigation although the methods described in this standard may be used for this purpose.

---------------------- Page: 12 ----------------------
IEC 62740:2015 © IEC 2015 – 9 –
ROOT CAUSE ANALYSIS (RCA)
1 Scope

This International Standard describes the basic principles of root cause analysis (RCA) and

specifies the steps that a process for RCA should include.

This standard identifies a number of attributes for RCA techniques which assist with the

selection of an appropriate technique. It describes each RCA technique and its relative

strengths and weaknesses.

RCA is used to analyse the root causes of focus events with both positive and negative

outcomes, but it is most commonly used for the analysis of failures and incidents. Causes for

such events can be varied in nature, including design processes and techniques,

organizational characteristics, human aspects and external events. RCA can be used for

investigating the causes of non-conformances in quality (and other) management systems as

well as for failure analysis, for example in maintenance or equipment testing.

RCA is used to analyse focus events that have occurred, therefore this standard only covers a

posteriori analyses. It is recognized that some of the RCA techniques with adaptation can be

used proactively in the design and development of items and for causal analysis during risk

assessment; however, this standard focuses on the analysis of events which have occurred.

The int
...

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