A Compendium of Root Cause Analysis Resources

When mistakes occur, blame the process, not people.
Root Cause Analysis is the means to fix the cause, rather than treat the symptom.
• What allowed the mistake to happen?
• What will prevent mistakes from occurring in the future?
• Assume people continue to make mistakes, so build fault‒tolerance into your improvements.

Without finding the Root Cause of dysfunction, the conditions and actions that created that cause, and defining the corrective and preventive actions to remove, protect, or isolate the system from those causes - No suggested fix can be credible

Papers on Root Cause Analysis for System of Systems Projects

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• "Failures, Mishaps and Root Cause Analysis," Leadership ViTS Meeting, 3 October 2005, Bryan O'Conner, Chief, Office of Safety and Mission Assurance, NASA. See OSMA for other RCA materials.
• "Root Cause Analysis Compared," Dean L. Gano, Kennedy Space Center, 2011
• "Prevent Today's Problem from Recurring Tomorrow," Cindia Kingery, Jay Krueger, and Kien Nguyen, Jet Propulsion Laboratory, NASA
• "The problem with root cause analysis," Mohammad Farhad Peerally, Susan Carr, Justin Waring, Mary Dixon-Woods, BMJ Quality and Safety, 2017,
• "Knowledge modeling for root cause analysis of complex systems based on dynamic fuzzy cognitive maps," Weichao Yue, Xiaofang Chen, Yongfang Keke, IFAC Papers OnLine, 51-21 (2018), pp. 13-18
• "Real-Time Root Cause Analysis for Complex Technical Systems," Jan Eric Larsson and Joseph DeBor, Human Factors and Power Plants and HPRCT 13th Annual Meeting, 2007 IEEE
• "Root Cause Analysis is Part of Enterprise Risk Management," Wendell Bosen and Kristina Narvaez, The Risk Management Society, Utah Chapter, 
• “Accident Precursor Analysis and Management,” James R. Phimister, Vicki M. Bier, Howard C. Kunreuther, editors, National Academy of Engineering, 2004.
• “Premortems: Being Smart at the Start,” Gary Klein, Tim Koller, and Dan Lovallo, McKinsey & Company, March 2019.
• “Root Cause Analysis of Precursors,” William R. Corcoran, Nuclear Safety Review Concepts Corporation, Windsor, CT. (Draft)
• “Evaluation the Effectiveness of the PreMortem Technique on Plan Confidence,” Beth Veinott, Gary A. Klein, and Sterling Wiggins, Proceedings of the 7^th International ISCRAM Conference, May 2010.
• “Improving Planning: Quantitative Evaluation of the Premortem Technique in Field and Laboratory Settings,” Madeline Peabody, Michigan Technological University, 2017.
• “Why Projects Fail? How Contingency Theory Can Provide New Insights ‒ A Comparative Analysis of NASA’s Mars Climate Orbiter Loss,” Brian J. Sauser, Richard R. Reilly, and Aaron J. Shenhar, International Journal of Project Management, 27, pp. 665-679, 2009
• "Systematic literature review of project failures: Current trends and scope for future research,” Sandeep Kumar Gupta, Angappa Gunasekran, Jiju Anthony, Shivam Gupta, and Surajit Bag, Computers & Industrial Engineering, 17, pp. 274-285, 2019.
• “Why the Vasa Sank: 10 Problems and Some Antidotes for Software Projects,” Richard E. Fairley and Mary Jane Willshire, IEEE Software, March/April 2003.
• “Evaluating the Effectiveness of the PreMortem Technique on Plan Confidence,” Beth Veinott, Gary A. Klein, and Sterling Wiggins, Proceedings of the 7th International ISCRAM Conference, May 2010.
• “Project Success and Failure: What is Success, What is Failure, and How Can You Improve Your Odds for Success?”, Robert Frese, University of Missouri, St. Louis, December 16, 2003.
• “Performing a Project Premortem,” Gary Klein, Harvard Business Review, September 2007.
• “Direct Cause vs Root Cause,” David E. Peercy, INCOSE Enchantment Chapter Meeting, March 14, 2007.
• “Deepwater Horizon: Accident Investigation Report,” Deep Water Horizon Study Group, 11 March 2011.
• “CMS Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects” Center for Medicaid and Medicare Services, 
• “Corrective Action: Root Cause Analysis and Corrective Action,” Lockheed Martin Webinar, 2015.
• “Social and Technical Reasons for Software Project Failures,” Capers Jones, CrossTalk, pp. 4-9, June 2006,
• “Identifying the Reasons for Software Project Failure and Some of their Proposal Remedial through BRIDGE Process Models,” Ardhendu Mandal and S. C. Paul, JSCE International Journal of Computer Sciences and Engineering Volume 3, Special Issue‒1, 2015.
• “Causes of Software / Information Technology Project Failures in Nigerian Software Development Organizations,” F. A. Egbokhare, African Journal of Computing and ICT 7, No. 2, June 2015
• “The Cause of Project Failure,” Jeffrey K. Pinto and Samuel J. Mantel, IEEE Transactions on Engineering Management, December 1990.
• “An Analysis of Success and Failure Factors for ERP Systems in Engineering and Construction Firms,” Boo Young, Department of Civil & Environmental Engineering.
• “Effective Root Cause Analysis and Corrective Action Process,” Branislav Tomic and Vesna Spasjevic Brkic, Journal of Engineering Management and Effectiveness, Vol. 1, No. ½, pp. 16‒20, 2011.
• “Behavioral Modeling of Software Intensive System Architectures,” Monica Farah‒Stapleton and Mikhail Auguston, Procedia Computer Science, 20, pp. 270‒276, 2013.
• “Root Cause Analysis for Beginners,” James J. Rooney and Lee N. Vandem Heuvel, Quality Progress, July 2004.
• “Rationale mapping and functional modeling enhanced root cause analysis,” Marco Aurisicchio, Rob Bracewell, and Becky L. Hooey, Safety Science, 85, pp. 241‒257, 2016.
• "A Survey of Failures in the Software Development Process,” Rita Marques, Gonçalo Costa, Miguel Mira da Silva, and Pedro Gonçalves, ECIS Proceedings, 2017
• “Improving Fault Prevention with Proactive Root Cause Analysis (PRORCA Method),” Hojat Mohammadnazar, Master’s Thesis, University of Jyväskylä, 2016
• “Empirical Study of Root Cause Analysis of Software Failure,” Sandeeo Dalai, Rajender Singh Chhillar, ACM SIGSOFT Software Engineering Notes, 2013
• “Success and failure factors of adopting SAP in ERP system implementation,” Vidyaranya B. Gargeya and Cydnee Brady, Business Process Management Journal, Vol. 11, No. 5, pp. 501‒516, 2001.
• “Government ICT Project Failure Factors: Project Stakeholders’ Views,” Haslinda Sutan Ahmad Nawi, Azizah Abd. Rahman, and, Othman Ibrahim, Journal Of Research And Innovation In Information Systems, 2011.
• “Research on information systems failures and successes: status update and future directions,” Yogesh K. Dwivedi, Information Systems Frontiers, 17(1), pp. 143‒157.
• “What factors lead to software project failure?” June Verner, Jennifer Sampson, and Narciso Cerpa, Second International Conference on Research Challenges in Information Science, 2008.
• “A Taxonomy of an IT Project Failure: Root Causes,” Walid Al-Ahmad, Et Al, International Management Review, Vol. 5, No. 1, 2009
• “Why Do Information Technology Projects Fail?” Adam Alami, Conference on ENTERprise Information Systems / International Conference on Project MANagement / Conference on Health and Social Care Information Systems and Technologies, CENTERIS / ProjMAN / HCist 2016, October 5–7, 2016
• “The Root Cause of Failure in Complex IT Projects: Complexity Itself,” Kaitlynn M. Whitney and Charles B. Daniels, Complex Adaptive Systems, Procedia Computer Science, 20 (2013), pp. 315‒330.
• “Proposition 22: The Premortem Technique,” Olivier Serrat, Knowledge Solutions and publication of Asian Development Bank, March 2012/113.
• “The True Meaning of Root Cause and Root Cause Analysis (RCA),” Gary Jing, 2013 ASQ World Conference.
• “Automated Root Cause Isolation of Performance Regressions during Software Development,” Christopher Heger, Jens Happer, and Roozbeh Farahbod, ICPE ’13, April 21‒24, 2013.
• “Agile process Smell and Root Cause Analysis,” Dave Nicolette, International Conference on Agile Processes and Extreme Programming in Software Engineering, 2009. pp. 145‒195
• “The Analyzing Method of Root Causes for Software Problems,” Tomomi Kataoka, Ken Furuto and Tatsuji Matsumoto, SEI Technical Review, Number 73, October 2011.
• “A Case Study in Root Cause Defect Analysis,” Marek Leszak, Dewayne E. Perry, and Dieter Stoll, ICSE 2000.
• “What Are Problem Causes of Software Projects? Data of Root Cause Analysis at Four Software Companies,” Timo O. A. Lehtinen and Mika V. Mäntylä, 2011 International Symposium on Empirical Software Engineering and Measurement.
• “Root Cause Investigation Best Practices Guide,” Roland Duphily, TOR‒2014‒02202, The Aerospace Corporation, 30 May 2014.
• “Root Cause Investigation (RCI) Best Practices Guide Product Overview," Aerospace Report TOR‒2014‒02163, May 8, 2014
• “SCRAM: A Method for Assessing Risk of Schedule Compliance,” Adrian Pitman, Angela Tuffley, and Betsy Clark, DMO General Manager Systems, Australian Government, ASWEC 2013.
• Schedule Compliance Risk Assessment Methodology (SCRAM) Combined Process Reference Model and Process Assessment Model, Released Version 2.0, Australian Government, Department of Defence, Defence Material Organization, Version 2.0 29 May 2013.
• “Root Cause Investigation (RCI) Best Practices Guide Product Overview,” Aerospace Report TOR‒2014‒02163, May 8, 2014
• “Development and evaluation of a lightweight root cause analysis method (ARCA method) – Field studies at four software companies,” Timo O. A. Lehtinen, Mika V. Mäntylä, and Jari Vanhanen, Information and Software Technology, Volume 53, Issue 10, October 2011, Pages 1045–1061.
• “The Business Benefit of Root Cause Analysis,” Ben Linders,

Books on Root Cause Analysis for Software Development Projects

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• Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigations, 3^rd Edition, Lee N. Vanden Heuvel, Donald K. Lorenzo, Randal L. Montgomery, Walter E. Hanson, and James R. Rooney
• Root Cause Analysis: The Core of Problem Solving and Corrective Action, Duke Okes, ASQ Press.
• Root Cause Analysis: A Step‒by‒Step Guide to Using the Right Tool at the Right Time, 1^st Edition, Matthew Barsalou, Productivity Press.
• Root Cause Analysis: Simplified, Tools and Techniques, 2^nd Edition, Bjørn Andersen and Tom Fagerhaug, ASQ Quality Press.
• Apollo Root Cause Analysis: Effective Solutions to Everyday Problems Every Time, Dean Gano, 2003, Apollonian Publications
• Root Cause Analysis Handbook: A Guide to Efficient and Effective Incident Investigations, 3^rd Edition, Lee N. Vanden Heuvel, Donald K. Lorenzo, Randal L. Montgomery, Walter E. Hanson, and James R. Rooney
• Root Cause Analysis: The Core of Problem Solving and Corrective Action, Duke Okes, ASQ Press.
• Root Cause Analysis: A Step‒by‒Step Guide to Using the Right Tool at the Right Time, 1^st Edition, Matthew Barsalou, Productivity Press.
• Root Cause Analysis: Simplified, Tools and Techniques, 2^nd Edition, Bjørn Andersen and Tom Fagerhaug, ASQ Quality Press.