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To reach to the bottom of any issue, one needs to follow the below procedure:
1. Collect the full detail of the incident with the people involved in the process.
2. Break down the different phases of the process.
3. Analyse the whole incident and identify at what phase the problem occurred.
4. Identify what are the factors causes these problems and does this happened first time?
5. Once identified the root issues, suggest management with possible solutions and measures.
by standard's y5 and5y so this are the standards for identifying root cause analysis
Need to conduct Gap Analysis and then find out real problems
I would be using DMAIC (six sigma) approach for detailed analysis and it helps in improving the business process and designs.
1. Define the problem.
2. Take measurements.--Identify the parameters for performance.
3. Analyse all data including problem history analysis to eliminate the problem
4. Improve the design by finding solutions, test it and implement it in process.
5. Control-- update all documents, process and keep track of the change for sustained improvement.
