RCA School

Stop firefighting and start solving problems permanently.This intensive two-day course equips supervisors, engineers, and technicalleaders with proven Root Cause Analysis methodologies to investigate workplace failures and recurring issues systematically.

Master four powerful RCA techniques – 5 Whys, Fishbone diagrams, STEP, and Causal Trees – and learn when to apply each based on problem complexity. Through hands-on workshops using real industrial scenarios, you'll develop skills to facilitate collaborative investigations, distinguish symptoms from true root causes, and craft effective problem statements.

Course Outline

2 Days

8 Core Modules

DAY 1: RCA Fundamentals & Initial Techniques

Module 1: Introduction to Root Cause Analysis

Understanding what RCA is and why it matters for workplace problem-solving
Distinguishing between finding fault vs. methodical problem-solving
Learning the core RCA objectives: identify problems, improve communication skills, develop solutions
Recognising when to trigger an RCA (significance categories: Safety, Cost, Environmental, Stakeholder Impact)
Exploring RCA methodologies overview: 5 Whys, Fishbone, STEP, Cause & Effect Trees
Understanding the importance of documentation and traceability in RCA processes

Module 2: Problem Definition & Significance

Crafting effective problem statements using the "What + Where + When + Impact" formula
Determining significance of events to justify resource allocation
Distinguishing between symptoms and root causes
Establishing RCA boundaries and scope (what's in/out of scope)
Setting up the RCA team and identifying key stakeholders
Understanding the "no blame" culture essential for successful RCA

Module 3: Cause & Effect Principles

Understanding fundamental cause and effect relationships in problem-solving
Distinguishing between actions (momentary causes) and conditions (dormant causes)
Learning how effects can become causes for other effects
Exploring the logic of working backward from end effects through causes
Practicing with real-world examples (e.g., fire triangle: heat, fuel, oxygen)
Building cause and effect chains to map problem logic
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Module 4: The 5 Whys Technique

Learning the foundational 5 Whys methodology for simple to moderate problems
Understanding when 5 is not a "hard and fast" number - following logic to viable solutions
Practicing brainstorming and listing potential causes collaboratively
Developing initial problem statements quickly through iterative questioning
Identifying gaps in knowledge (facts vs. assumptions) during the process
Conducting hands-on exercises with real workplace scenarios (e.g., dosing pump failure)
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DAY 2: Advanced Techniques & Solution Development
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Module 5: Fishbone (Ishikawa) Diagrams

Understanding the Fishbone structure and when to use it for complex problems
Learning the standard categories: 6Ms (Methods, Machinery, Management, Materials, Manpower, Mother Nature) and 4Ps/4Ss
Organising causes into logical streams/categories
Brainstorming and categorising possible causes systematically
Drawing effective Fishbone diagrams that communicate clearly
Working through detailed case studies (e.g., grain screw conveyor failures)
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Module 6: Sequence Time Event Plotting (STEP)

Understanding STEP as a timeline-based RCA technique for complex sequences
Plotting events chronologically along a timeline with multiple "actors"
Identifying interactions and dependencies between events
Using STEP for problems involving multiple stakeholders and timeframes
Analyzing event sequences to prevent recurrence (e.g., engine maintenance failures)
Synthesizing timeline data to identify patterns and critical decision points
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Module 7: Causal Trees & Advanced Analysis

Learning Causal Tree methodology using "and" logic for multiple contributing factors
Working backward from the end effect to identify all necessary conditions and actions
Understanding that effects require combinations of causes (not single causes)
Distinguishing between what can be controlled vs. what cannot
Practicing with complex scenarios requiring multiple causal pathways
Integrating learnings from 5 Whys, Fishbone, and STEP into comprehensive analysis
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Module 8: Developing & Implementing Solutions

Applying the hierarchy of control: Elimination > Substitution > Engineering Controls > Administrative Controls > PPE
Understanding solution factors: mitigation of consequences, reduction of probability, feasibility
Comparing and ranking multiple solutions effectively
Distinguishing between repairs (temporary) and root cause elimination (permanent)
Creating actionable implementation plans with accountability
Documenting RCA findings and communicating results to stakeholders for buy-in and continuous improvement

What You'll Take Away

Student Expectations

The key expectation of people attending this course is that they want to move beyond firefighting and reactive responses to develop a systematic approach for solving problems at their source. It is important that participants understand the difference between repairing failures and eliminating the root causes that allow those failures to happen in the first place.

People attending the course should have some knowledge or seek to gain insights in the following. This is what they want to learn and develop by attending this course.

Experienced in dealing with recurring problems or significant one-off events that have impacted their workplace.
Understanding why problems keep happening despite repeated repairs or corrective actions.
Moving from "who is to blame" thinking to" what in our system allowed this to happen" analysis.
Building credibility with teams and management by solving problems permanently rather than temporarily.
Contributing to a safer, more reliable workplace through methodical investigation.
Understand the importance of collaborative problem-solving including how to work with technical experts, operators, engineers, and management.
Facilitating brainstorming sessions that encourage participation from all team members.
Managing group dynamics when people have different perspectives on causes and solutions.
Ensuring all voices are heard, especially from front-line workers who see problems first-hand.
Creating psychological safety so people share information openly without fear of punishment.
Work with structured problem-solving frameworks rather than relying solely on experience or intuition.
Knowing which technique to apply based on problem complexity and available information.
Organizing thoughts and evidence systematically using visual tools like diagrams and timelines.
Distinguishing between facts and assumptions during the investigation process.
Translate investigation findings into actionable improvements that get implemented and sustained.
Developing solutions that are practical, feasible, and acceptable to those who must implement them.
Prioritizing solutions based on risk reduction and resource availability.
Communicating findings clearly to decision-makers to secure support and resources.
Following through to ensure solutions are implemented and problems don't recur.

Course Objectives

Clarify when and why to conduct a Root Cause Analysis basedon the significance of events. This includes:

Determining event significance across safety, cost, environmental, and stakeholder impact categories.
Understanding the difference between problems requiring formal RCA versus those needing simpler responses.
Establishing appropriate scope and boundaries for investigations.
Building a "no blame" culture that focuses on system improvement rather than individual fault-finding.
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Master multiple RCA methodologies and understand when eachis most effective. This includes:

Applying 5 Whys for straightforward problems with clear causal chains.
Using Fishbone (Ishikawa) diagrams for complex problems with multiple contributing factors across different categories.
Employing STEP (Sequence Time Event Plotting) for problems involving timelines and multiple actors or departments.
Building Causal Trees using "and" logic to map how multiple conditions and actions combine to create failures.
Selecting the right tool based on problem characteristics, available time, and team composition.
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Develop effective problem statements and understandcause-and-effect relationships. This includes:

Crafting problem statements using the "What + Where + When + Impact" formula.
Distinguishing between symptoms (what we see) and root causes (why it happened).
Understanding actions (momentary causes) versus conditions (dormant causes).
Working backward from end effects through logical causal chains.
Identifying gaps between facts and assumptions during investigations.
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Create and implement sustainable solutions usingevidence-based decision-making. This includes:

Applying the hierarchy of control from elimination through to PPE.
Balancing consequence mitigation with probability reduction.
Evaluating solutions based on feasibility, cost-effectiveness, and risk reduction.
Distinguishing between repairs (temporary fixes) and root cause elimination (permanent solutions).
Developing implementation plans with clear accountability and timelines.
Documenting findings to create organisational learning and prevent recurrence.

Snapshot

Introduction to Root Cause Analysis

Problem Definition & Significance

Cause & Effect Principles

The 5 Whys Technique

Fishbone (Ishikawa) Diagrams

Sequence Time Event Plotting (STEP)

Causal Trees & Advanced Analysis

Developing & Implementing Solutions

Your Instructors

Mark Mackenzie

Principal

One North

Mark is a highly qualified and experienced engineer with over thirty years in maintenance, reliability and asset management. He is a Chartered Engineer, a Certified Maintenance and Reliability Professional and a Certified Fellow of Asset Management, a Fellow of Engineers Australia and an Adjunct Associate Professor.

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