Root Cause Root Cause AnalysisAnalysis

Problem Solving MethodProblem Solving Method

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Root cause analysisRoot cause analysis ((RCARCA) is a ) is a class of class of problem solvingproblem solving methodsmethods aimed at identifying the aimed at identifying the root root causescauses of problems or events. of problems or events. Proponents belief that problems Proponents belief that problems are best solved by attempting to are best solved by attempting to correct or eliminate root causes, correct or eliminate root causes, than by treating the immediately than by treating the immediately obvious symptoms. obvious symptoms.

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By directing corrective measures By directing corrective measures at root causes, it is hoped that the at root causes, it is hoped that the likelihood of problem recurrence likelihood of problem recurrence will be minimized. will be minimized.

-- WikipediaWikipedia

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General Principles of Root General Principles of Root Cause Analysis Cause Analysis

Aiming corrective measures at root Aiming corrective measures at root causes is more effective than merely causes is more effective than merely treating the symptoms of a problem. treating the symptoms of a problem. To be effective, RCA must be To be effective, RCA must be performed systematically, and performed systematically, and conclusions must be backed up by conclusions must be backed up by evidence. evidence. There is usually more than one root There is usually more than one root cause for any given problem.cause for any given problem.

-- WikipediaWikipedia

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Example: Treating Example: Treating SymptomsSymptoms

Organizations have a well defined process for Organizations have a well defined process for accepting, processing, and shipping customer accepting, processing, and shipping customer orders. orders. However, when a customer complains about However, when a customer complains about not getting their order the most normal not getting their order the most normal response is to expedite. response is to expedite. This means that someone personally tracks This means that someone personally tracks down this customer's order, assigns it a #1 down this customer's order, assigns it a #1 priority, and ensures it gets shipped ahead of priority, and ensures it gets shipped ahead of everything else. everything else.

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Few people realize that in Few people realize that in expediting this order one or more expediting this order one or more other orders were delayed other orders were delayed because the process was because the process was disrupted to get this customer's disrupted to get this customer's order out the door. order out the door. Expediting orders simply ensures Expediting orders simply ensures that more orders will have to be that more orders will have to be expedited later. expedited later.

-- Gene Gene BellingerBellinger

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Finding Root CausesFinding Root CausesTo find root causes there is one To find root causes there is one really only one question that's really only one question that's relevant, "What can we learn from relevant, "What can we learn from this situation?" this situation?" Research has repeatedly proven Research has repeatedly proven that unwanted situations within that unwanted situations within organizations are about organizations are about 95% 95% related to process problemsrelated to process problems and and only 5% related to personnel only 5% related to personnel problems. problems.

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So organizations should spend far more So organizations should spend far more time and effort looking for causes time and effort looking for causes (rather than trying to find culprits). (rather than trying to find culprits). Then they can gain from understanding Then they can gain from understanding the foundation of the unwanted the foundation of the unwanted situation.situation.

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Scenario # 1Scenario # 1The Plant Manager walked into The Plant Manager walked into the plant and found oil on the the plant and found oil on the floor. floor. He called the Foreman over and He called the Foreman over and told him to have maintenance told him to have maintenance clean up the oil. clean up the oil. The next day while the Plant The next day while the Plant Manager was in the same area of Manager was in the same area of the plant. the plant. He found oil on the floor again.He found oil on the floor again.

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He rebuked the Foreman for not He rebuked the Foreman for not following his directions from the day following his directions from the day before. before.

Get the oil cleaned up Get the oil cleaned up or I’ll find someone or I’ll find someone

who would!who would!

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Scenario # 2Scenario # 2The Plant Manager walked into the The Plant Manager walked into the plant and found oil on the floor. plant and found oil on the floor. He saidHe said “Foreman, why is there oil on “Foreman, why is there oil on the floor?”. the floor?”. ForemanForeman “It is due to a “It is due to a leaky gasket in the pipe joint above”. leaky gasket in the pipe joint above”. Plant ManagerPlant Manager “When was the gasket “When was the gasket last replaced?”. last replaced?”. ForemanForeman “Maintenance had installed 4 “Maintenance had installed 4 gaskets over the past few weeks and gaskets over the past few weeks and they all seem to leak”. they all seem to leak”.

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ForemanForeman “Maintenance had been “Maintenance had been talking to Purchase Dept. about the talking to Purchase Dept. about the gaskets because it seemed they were gaskets because it seemed they were all bad”. Plant Manager then speaks to all bad”. Plant Manager then speaks to Purchase Dept.Purchase Dept.Purchase ManagerPurchase Manager “We have received a “We have received a bad batch of gaskets. We have been bad batch of gaskets. We have been asking the supplier for the past 2 asking the supplier for the past 2 months to replace 5,000 bad gaskets”. months to replace 5,000 bad gaskets”. Plant ManagerPlant Manager “ Why are we “ Why are we purchasing from this supplier?”. purchasing from this supplier?”. Purchase ManagerPurchase Manager “Because they were “Because they were the lowest bidder”.the lowest bidder”.

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Plant ManagerPlant Manager “ Why are we going with “ Why are we going with the lowest bidder”. the lowest bidder”. Purchase ManagerPurchase Manager “ Direction has come from the VP of “ Direction has come from the VP of Finance”. Finance”. The Plant Manager then talks to the VP The Plant Manager then talks to the VP of Finance. of Finance. VP of FinanceVP of Finance “Purchase had been “Purchase had been directed to always select lowest bidder directed to always select lowest bidder because you indicated that we had to because you indicated that we had to be as cost conscious as possible!" be as cost conscious as possible!" The Plant Manager was horrified when The Plant Manager was horrified when he realized that he was the reason he realized that he was the reason there was oil on the plant floor. there was oil on the plant floor. Bingo!Bingo!

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You may find scenario # 2 somewhat You may find scenario # 2 somewhat funny. However this is often true in funny. However this is often true in numerous variations on the same numerous variations on the same theme.theme.Everyone in the organization doing Everyone in the organization doing their best to do the right things, and their best to do the right things, and everything ends screwed up.everything ends screwed up.The root cause of this whole situation The root cause of this whole situation is is local optimization with no global local optimization with no global thought involvedthought involved. .

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To Resolve or Not To To Resolve or Not To Resolve?Resolve?

Once the root cause is Once the root cause is determined then it has to be determined then it has to be determined whether it costs more determined whether it costs more to remove the root cause or to remove the root cause or simply continue to treat the simply continue to treat the symptoms. symptoms. This is often not an easy This is often not an easy determination. determination.

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ExampleExampleSuppose it requires Rs.10,00,000 to Suppose it requires Rs.10,00,000 to remove the root cause of a problem remove the root cause of a problem and only 5 minutes for someone to and only 5 minutes for someone to resolve the situation when the resolve the situation when the customer calls with the problem. customer calls with the problem. Initially one might perceive that the Initially one might perceive that the cost of removing the root cause is far cost of removing the root cause is far larger than the cost of treating the larger than the cost of treating the symptom. symptom.

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Yet suppose that this symptom is Yet suppose that this symptom is such that when it arises it so such that when it arises it so infuriates the customer that they infuriates the customer that they swear they will never buy another swear they will never buy another product from you. product from you. And also And also advise everyoneadvise everyone they they meetmeet what a terrible company you what a terrible company you are to do business with. are to do business with.

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How do you estimate lost business How do you estimate lost business cost associated with this situation?cost associated with this situation?

I will never buy from you…. and

advise everybody not to buy from

you!

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Finding Root Causes: Finding Root Causes: DifficultiesDifficulties

In normal chaotic organizational In normal chaotic organizational environments it is often quite difficult environments it is often quite difficult to find candidates for root cause to find candidates for root cause analysis because the situations which analysis because the situations which repeat are either repeat are either distributed over time.distributed over time.So one doesn't realize they are actually So one doesn't realize they are actually recurring.recurring.Or the Or the situationsituation happens to different happens to different peoplepeople so there isn't an awareness of so there isn't an awareness of the recurring nature of the situation. the recurring nature of the situation.

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SoftwareSoftwareSome organizations use automated problem Some organizations use automated problem resolution support system like resolution support system like Solution Solution BuilderBuilder. It makes it easy to determine which . It makes it easy to determine which situations are recurring with what frequency. situations are recurring with what frequency. Every time a solution is used its frequency Every time a solution is used its frequency counter gets updated.counter gets updated.So all one has to do is run reports against the So all one has to do is run reports against the system to determine which solutions are system to determine which solutions are being used with what frequency. being used with what frequency.

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Those situations which are Those situations which are recurring with the greatestrecurring with the greatest frequencyfrequency and consume the and consume the greatest amount of resourcegreatest amount of resource to to rectifyrectify are the candidates for root are the candidates for root cause analysis. cause analysis.

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CriticismCriticismIs "Root Cause Analysis" really an Is "Root Cause Analysis" really an appropriate phrase? appropriate phrase? In this apparently endlessly In this apparently endlessly interconnected world, everything interconnected world, everything seems to influence so many other seems to influence so many other things. things. Seeking the "Root Cause" is an endless Seeking the "Root Cause" is an endless exercise because no matter how deep exercise because no matter how deep you go there's always at least one you go there's always at least one more cause you can look for. more cause you can look for.

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Might "Actionable Cause Analysis" Might "Actionable Cause Analysis" be more appropriate? be more appropriate? I think I'm looking for a cause that I think I'm looking for a cause that I can act on that will provide long I can act on that will provide long term relief from the symptoms, term relief from the symptoms, without causing more problems without causing more problems that I have to deal with tomorrow. that I have to deal with tomorrow.

-- Gene Gene BellingerBellinger

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END of Part IEND of Part I

5 Whys5 Whys

A Method for Root Cause A Method for Root Cause AnalysisAnalysis

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5 Whys5 WhysThe The five whysfive whys is a question asking is a question asking method used to explore the method used to explore the cause/effect relationships cause/effect relationships underlying a particular problem. underlying a particular problem. Ultimately, the goal of applying Ultimately, the goal of applying the 5 Whys method is to the 5 Whys method is to determine a determine a root causeroot cause of a of a defectdefect or problem. or problem. The following example The following example demonstrates the basic process.demonstrates the basic process.

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My car will not start. (the problem) My car will not start. (the problem) Why?Why? -- The battery is dead. (first why) The battery is dead. (first why) Why?Why? -- The alternator is not The alternator is not functioning. (second why) functioning. (second why) Why?Why? -- The alternator has broken The alternator has broken beyond repair. (third why) beyond repair. (third why) Why?Why? -- The alternator is well beyond its The alternator is well beyond its useful service life and has never been useful service life and has never been replaced. (fourth why) replaced. (fourth why)

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Why?Why?Why?Why? -- I have not been maintaining my I have not been maintaining my car according to the recommended car according to the recommended service schedule. (fifth why, root service schedule. (fifth why, root cause) cause) The five iterations The five iterations are not gospelare not gospel; ; rather, it is postulated that five rather, it is postulated that five iterationsiterations of asking why is generally of asking why is generally sufficient to get to a root cause. sufficient to get to a root cause.

-- WikipediaWikipedia

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The real key is to encourage the The real key is to encourage the troubleshooter to troubleshooter to avoid assumptionsavoid assumptions and logic traps and instead to and logic traps and instead to trace the trace the chain of causalitychain of causality in direct increments in direct increments from the effect through any layers of from the effect through any layers of abstraction to the first or root cause. abstraction to the first or root cause. The technique was originally The technique was originally developed by developed by SakichiSakichi ToyodaToyoda and was and was later used within later used within ToyotaToyota Motor Motor CorporationCorporation during the evolution of during the evolution of their manufacturing methodologies. their manufacturing methodologies.

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