Root Cause Analysis Methodologies

Root Cause Analysis (RCA) is a structured process used to identify the underlying reasons behind an incident, failure, misconduct, compliance breach, workplace accident, performance problem, or employment-related dispute. The objective is not merely to identify what happened, but to determine why it happened, so that corrective and preventive measures can address the underlying cause.

In employment and HR contexts, RCA can be useful for analysing repeated absenteeism, workplace accidents, disciplinary incidents, payroll errors, discrimination complaints, data breaches, employee grievances, compliance failures, and organisational failures.

1. Basic stages of Root Cause Analysis

A typical RCA process involves:

1. Define the problem – Clearly describe the incident or failure.
2. Collect evidence – Gather documents, records, statements, policies, emails, system logs and other relevant material.
3. Establish the chronology – Determine what happened and when.
4. Identify immediate causes – Determine the direct events that produced the problem.
5. Identify contributing factors – Examine people, processes, technology, supervision and organisational conditions.
6. Determine root causes – Identify the underlying systemic reasons.
7. Test the proposed causes – Ensure conclusions are supported by evidence rather than assumptions.
8. Develop corrective actions – Address the identified causes.
9. Monitor implementation – Check whether corrective measures actually prevent recurrence.

In employment disputes, an RCA should not be used as a substitute for a legally required disciplinary inquiry. Where an employee may face disciplinary consequences, the employee must receive the procedural safeguards required by applicable law and service rules.

2. Five Whys Method

The Five Whys technique repeatedly asks "Why?" until the underlying cause is identified.

Example

Suppose an employee repeatedly submits inaccurate payroll data.

• Why was the payroll data inaccurate?
  Because incorrect employee information was entered.
• Why was incorrect information entered?
  Because the employee relied on an outdated spreadsheet.
• Why was the spreadsheet outdated?
  Because there was no automatic synchronisation with the HR system.
• Why was there no synchronisation?
  Because the process had never been technologically integrated.
• Why had integration not been implemented?
  Because responsibility for maintaining the payroll process was unclear.

The RCA therefore moves beyond blaming the employee and identifies a process and governance problem.

Advantages

• Simple to understand.
• Inexpensive.
• Useful for straightforward operational problems.
• Helps distinguish symptoms from underlying causes.

Limitation

A problem may have multiple root causes, so stopping after exactly five questions can produce an incomplete analysis.

3. Fishbone / Ishikawa Analysis

The Fishbone Diagram, also called the Ishikawa Diagram, categorises possible causes of a problem.

Common categories include:

• People – training, workload, competence, communication.
• Process – inadequate procedures or unclear responsibilities.
• Technology – software failure or poor system design.
• Management – supervision, decision-making and resource allocation.
• Environment – workplace conditions.
• Measurement – inadequate monitoring or performance indicators.

Employment example

If workplace safety incidents increase, an RCA team may examine:

People → inadequate training
Process → defective safety procedure
Technology → poorly maintained machinery
Management → inadequate supervision
Environment → unsafe working conditions
Measurement → failure to monitor near-misses

This prevents the organisation from automatically treating the individual employee as the sole cause.

4. Fault Tree Analysis

Fault Tree Analysis (FTA) begins with an undesirable event and works backwards to identify combinations of events that could have caused it.

For example:

Major workplace data breach

→ unauthorised access
→ AND/OR
→ weak password controls
→ excessive employee access privileges
→ failure to revoke former employee's access
→ inadequate monitoring.

FTA is particularly useful where several conditions must combine before an incident occurs.

It can therefore help organisations determine whether an incident resulted from:

• individual conduct;
• system weaknesses;
• inadequate controls;
• management failures; or
• a combination of factors.

5. Failure Mode and Effects Analysis (FMEA)

FMEA is a preventive methodology. Instead of waiting for a failure, an organisation identifies potential failure modes in advance.

For each possible failure, the organisation may assess:

• severity;
• likelihood of occurrence; and
• likelihood that the failure will be detected.

An organisation can then prioritise preventive controls.

HR example

For employee onboarding:

FMEA is particularly valuable for compliance, HR technology, payroll, employee data protection and workplace safety.

6. Pareto Analysis

Pareto Analysis uses the idea that a relatively small number of causes may account for a large proportion of problems.

For example, an organisation experiencing 100 employee complaints may categorise them as:

• 40 – workload;
• 25 – management communication;
• 15 – payroll problems;
• 10 – leave administration;
• 10 – other issues.

The organisation can investigate the largest recurring categories first.

However, Pareto analysis is a prioritisation technique, not proof that the most frequent cause is necessarily the legal or fundamental root cause.

7. Barrier Analysis

Barrier Analysis asks what controls were supposed to prevent an incident and why those controls failed.

For example:

Unauthorised access to employee records

Expected barriers:

1. Password authentication.
2. Role-based permissions.
3. Multi-factor authentication.
4. Access monitoring.
5. Exit-process access revocation.

If the breach occurred because a former employee's account remained active, RCA should examine not only the employee's conduct but also the failure of the organisation's access-revocation process.

8. Root Cause Analysis and Employee Discipline

RCA must be carefully distinguished from disciplinary proceedings.

If an employee is suspected of misconduct, an employer should not simply conduct an internal RCA and treat its conclusion as proof of guilt. Depending on the applicable employment rules, a proper disciplinary process may require:

• clear charges;
• disclosure of relevant material;
• opportunity to respond;
• examination of evidence;
• appropriate inquiry procedures;
• impartial decision-making; and
• reasoned conclusions.

The Supreme Court has repeatedly emphasised that disciplinary proceedings must comply with applicable procedural and natural-justice requirements. In Ranjit Singh v. Union of India, the Court held that where the disciplinary authority proposes to disagree with an inquiry officer's findings, the employee must receive an opportunity to respond to the proposed disagreement.

Similarly, Union of India v. Bishamber Das Dogra discussed the importance of supplying the inquiry report and providing an opportunity to make a representation, while recognising that the effect of procedural defects depends upon the circumstances and prejudice involved.

Important Case Laws

1. Managing Director, ECIL v. B. Karunakar

(1993) 4 SCC 727

The Supreme Court recognised the importance of supplying the inquiry report to a delinquent employee and providing an opportunity to respond before disciplinary action is finalised.

RCA relevance: An organisation cannot rely upon an internal investigation while bypassing legally required procedural safeguards where disciplinary consequences are involved.

2. K.L. Tripathi v. State Bank of India

(1984) 1 SCC 43

The Court considered the application of natural justice in disciplinary proceedings and recognised that the requirements depend upon the circumstances and nature of the inquiry.

RCA relevance: The methodology used to identify a root cause should be appropriate to the nature of the incident and should not be applied mechanically.

3. Punjab National Bank Ltd. v. Kunj Behari Misra

(1998) 7 SCC 84

The Supreme Court held that where the disciplinary authority disagrees with the inquiry officer, the employee must be given an opportunity to respond to the proposed disagreement before a final finding is recorded.

RCA relevance: An RCA conclusion should not simply replace the findings of a properly constituted disciplinary inquiry without following the applicable procedure.

4. State of U.P. v. Shatrughan Lal

(1998) 6 SCC 651

The Supreme Court emphasised the importance of providing relevant material and a meaningful opportunity to the employee in disciplinary proceedings.

RCA relevance: Evidence collected during an RCA may become important in employment proceedings, making proper documentation and disclosure particularly significant.

5. Union of India v. Alok Kumar

(2010) 5 SCC 349

The Supreme Court examined procedural fairness in departmental inquiries and explained that natural justice must be considered in the factual context of the case. Courts examine whether a procedural defect actually affected the fairness of the proceeding.

RCA relevance: An RCA should distinguish between a technical procedural defect and a defect that materially affects the reliability or fairness of the investigation.

6. State of Rajasthan v. Heera Lal

(2015) 3 SCC 131

The Supreme Court dealt with disciplinary findings and the limits of judicial interference with findings arising from departmental proceedings.

RCA relevance: Investigators should create a clear evidentiary record linking factual findings to the conclusions reached.

7. Chairman, LIC v. A. Masilamani

(2013) 6 SCC 530

The Supreme Court explained the consequences of an improperly conducted disciplinary inquiry and the circumstances in which the matter may need to be remitted for a proper inquiry. The principle has subsequently been reaffirmed by the Court.

RCA relevance: A defective internal investigation should not automatically be treated as a valid basis for disciplinary punishment.

8. DGM, State Bank of India v. Ajai Kumar Srivastava

(2021) 2 SCC 612

The Supreme Court explained that judicial review of disciplinary proceedings primarily examines the decision-making process, including natural justice, statutory procedure and whether findings are supported by evidence, rather than functioning as a normal appeal on factual merits.

RCA relevance: A properly documented, evidence-based RCA helps demonstrate how an organisation reached its conclusions, but the investigation must still comply with applicable employment law.

9. Evidence that should be examined during RCA

A sound employment-related RCA may examine:

• employment contracts;
• HR policies;
• attendance records;
• performance records;
• emails and communications;
• witness statements;
• CCTV or access records where lawfully available;
• system logs;
• training records;
• previous complaints;
• risk assessments;
• audit reports;
• disciplinary history where legally relevant;
• organisational charts;
• delegation of responsibility; and
• relevant statutory or regulatory requirements.

The investigator should distinguish between facts, assumptions, allegations and conclusions.

10. Root Cause vs Immediate Cause vs Contributing Cause

This distinction is important because simply disciplining an employee may address the immediate event without addressing the systemic cause.

11. Legal Principles for a Defensible RCA

A legally sound RCA should generally follow these principles:

1. Evidence-based conclusions – Avoid conclusions unsupported by evidence.
2. Objectivity – Investigate causes rather than beginning with a predetermined conclusion.
3. Document preservation – Preserve relevant records.
4. Fair opportunity – Where employee misconduct is being investigated, follow applicable procedural requirements.
5. Confidentiality – Limit sensitive information to persons with a legitimate need to know.
6. Proportionality – Corrective measures should correspond to the nature of the identified problem.
7. Systemic analysis – Examine management, process and technological failures alongside individual conduct.
8. Corrective and preventive action – RCA should produce practical measures rather than merely assign blame.
9. Follow-up – Verify whether corrective measures actually eliminated or reduced the underlying risk.

Conclusion

Root Cause Analysis is fundamentally a problem-solving and risk-management methodology. Techniques such as Five Whys, Fishbone Analysis, Fault Tree Analysis, FMEA, Pareto Analysis and Barrier Analysis help organisations move from identifying an incident to understanding its underlying causes.

In employment law, however, RCA should be integrated carefully with natural justice, disciplinary procedures, evidentiary requirements and applicable labour/service rules. The central objective should be to identify whether the problem arose from individual conduct, inadequate processes, management failures, technological weaknesses, or a combination of these factors, and then implement corrective and preventive measures accordingly.