DETERMINING THE ROOT

CAUSE OF A PROBLEM

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Why Determine Root Cause?

Prevent problems from recurring

Reduce possible injury to personnel

Reduce rework and scrap

Increase competitiveness

Promote happy customers and stockholders

Ultimately, reduce cost and save money

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Look Beyond the Obvious

Invariably, the root cause of a

problem is not the initial reaction or

response.

It is not just restating the Finding

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Often the Stated Root Cause

is the Quick, but Incorrect Answer

For example, a normal response is:

Equipment Failure

Human Error

Initial response is usually the symptom, not the root cause of the problem. This is why Root Cause Analysis is a very useful and productive tool.

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Most Times Root Cause Turns Out to

be Much More

Such as:

Process or program failure

System or organization failure

Poorly written work instructions

Lack of training

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What is Root Cause Analysis?

Root Cause Analysis is an in-depth process

or technique for identifying the most basic

factor(s) underlying a variation in

performance (problem).

Focus is on systems and processes

Focus is not on individuals

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When Should Root Cause Analysis be

Performed?

Significant or consequential events

Repetitive human errors are occurring during a specific process

Repetitive equipment failures associated with a specific process

Performance is generally below desired standard

May be SCAR or CPAR (NGNN) driven

Repetitive VIRs

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How to Determine the Real Root

Cause?

Assign the task to a person (team if necessary) knowledgeable of the systems and processes involved

Define the problem

Collect and analyze facts and data

Develop theories and possible causes - there may be multiple causes that are interrelated

Systematically reduce the possible theories and possible causes using the facts

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How to Determine the Real Root

Cause? (continued)

Develop possible solutions

Define and implement an action plan (e.g., improve communication, revise processes or procedures or work instructions, perform additional training, etc.)

Monitor and assess results of the action plan for appropriateness and effectiveness

Repeat analysis if problem persists- if it persists, did we get to the root cause?

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Useful Tools For Determining

Root Cause are: The 5 Whys

Pareto Analysis (Vital Few, Trivial Many)

Brainstorming

Flow Charts / Process Mapping

Cause and Effect Diagram

Tree Diagram

Benchmarking (after Root Cause is found)

Some tools are more complex than others

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Example of Five Whys for Root Cause

Analysis

Problem - Flat Tire

Why? Nails on garage floor

Why? Box of nails on shelf split open

Why? Box got wet

Why? Rain thru hole in garage roof

Why? Roof shingles are missing

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Pareto Analysis

Count 14 14 11 9 7 7 3 3 3 3162 2 2 1 513934 20 19 19 15 15

Percent 3 3 2 2 1 1 1 1 1 132 0 0 0 127 7 4 4 4 3 3

Cum % 86 89 91 93 94 96 96 97 97 9832 98 99 991005966 70 74 78 80 83

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Supplier Material Rejections May 06 to May 07

Vital Few

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60 % of

Material

Rejections

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Cause and Effect Diagram (Fishbone/Ishikawa Diagrams)

EFFECT

CAUSES (METHODS) EFFECT (RESULTS)

Four Ms Model MAN/WOMAN METHODS

MATERIALS MACHINERY

OTHER

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Cause and Effect Diagram Loading My Computer

MAN/WOMAN METHODS

MATERIALS MACHINERY

OTHER Cannot

Load

Softwar

e on PC

Inserted CD Wrong

Instructions are Wrong

Not Enough

Free Memory

Inadequate System

Graphics Card Incompatible

Hard Disk Crashed

Not Following

Instructions

Cannot Answer Prompt

Question

Brain Fade

CD Missing

Wrong Type CD Bad CD

Power Interruption

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Tree Diagram

Result Cause/Result Cause/Result Cause

Result Primary

Causes

Secondary

Causes Tertiary

Causes

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Tree Diagram

Poor Safety Performance

Stale/Tired Approaches

Inappropriate Behaviors

Lack of Employee Attention

Lack of Models/ Benchmarks

No Outside Input

Research Not Funded

No Money for Reference Materials

No Funds for Classes

No Consequences

Infrequent Inspections

Inadequate Training

No Publicity

Lack of Sr. Management Attention

No Performance Reviews

No Special Subject Classes

Lack of Regular Safety Meetings

Zero Written Safety Messages

No Injury Cost Tracking

Result Cause/Result Cause/Result Cause

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Bench Marking

Benchmarking: What is it?

"... benchmarking ...[is] ...'the process of identifying, understanding, and adapting outstanding practices and processes from organizations anywhere in the world to help your organization improve its performance.'" American Productivity & Quality Center

"... benchmarking ...[is]... an on-going outreach activity; the goal of the outreach is identification of best operating practices that, when implemented, produce superior performance." Bogan and English, Benchmarking for Best Practices

Benchmark refers to a measure of best practice performance. Benchmarking refers to the search for the best practices that yields the benchmark performance, with emphasis on how you can apply the process to achieve superior results.

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Bench Marking

All process improvement efforts require a sound methodology and implementation, and benchmarking is no different. You need to:

Identify benchmarking partners

Select a benchmarking approach

Gather information (research, surveys, benchmarking visits)

Distill the learning

Select ideas to implement

Pilot

Implement

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Common Errors of Root Cause

Looking for a single cause- often 2 or 3 which

contribute and may be interacting

Ending analysis at a symptomatic cause

Assigning as the cause of the problem the why

event that preceded the real cause

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Successful application of the

analysis and determination of the

Root Cause should result in

elimination of the problem

and create Happy Campers!

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Summary:

Why determine Root Cause?

What Is Root Cause Analysis?

When Should Root Cause Analysis be performed?

How to determine Root Cause

Useful Tools to Determine Root Cause 1. Five Whys

2. Pareto Analysis

3. Cause and Effect Diagram

4. Tree Diagram

5. Brainstorming

Common Errors of Root Cause

Where can I learn more?

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Where Can I Learn More?

Solving a Problem & Getting Along: Toward the Effective Root Cause Analysis, Khaimovich,1998.

The Quality Freeway, Goodman, 1990

Potential Failure Modes & Effects Analysis: A Business Perspective, Hatty & Owens, 1994

In Search of Root Cause, Dew, 1991

Solving Chronic Quality Problems, Meyer, 1990

The Tools of Quality, Part II: Cause and Effect Diagrams, Sarazen, 1990

Root Cause Analysis: A Tool for Total Quality Management, Wilson, Dell & Anderson, 1993

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