Root Cause Problem Solving

The fire
May 5, 2006
This report is solely for the use of client personnel. No part of it may be circulated, quoted, or
reproduced for distribution outside the client organization without prior written approval from McKinsey &
Company. This material was used by McKinsey & Company during an oral presentation; it is not a
complete record of the discussion.
CONFIDENTIAL
OPI Module #8
1
2
3
4
Two hours later
5
6
7
Fire
Fuel
Heat

O
2
8
9
Fire
Fuel
Heat

O
2
10
Fire
Fuel
Heat

O
2
11
Two days later
12
13
Fire
Fuel
Heat

O
2
?
14
Fire
Fuel
Heat

O
2
15
16
17
Fire
Fuel
Heat

O
2
18
Two months later
19
20
Fire
Fuel
Heat

O
2
?
21
Fire
Fuel
Heat

O
2
22
23
24
25
Fire
Fuel
Heat

O
2
26
Root cause problem solving 5 Why?
Why
was
there
a
fire?
Why was
there
oxygen?
Oxygen
cannot be
removed.
Why were
people
smoking?
Put non
smoking
sign!

Why
was
there
a
leak?
Why did
they keep
falling on
the pipe-
line?
Cut tree,
eliminate
the root
cause!

Why did
coco-
nuts fall
on the
pipeline?
27
Results of root
cause analysis
5 Why? - Root
cause analysis
revealed falling
objects (coconuts)
as root cause for
the pipeline leak
and thus the fire

Implication
To prevent this from
happening again:
1) Cut tree
2) Check for other
falling objects
3) Incorporate
learning in SOP
Root Cause Problem Solving

The fire
May 5, 2006
This report is solely for the use of client personnel. No part of it may be circulated, quoted, or
reproduced for distribution outside the client organization without prior written approval from McKinsey &
Company. This material was used by McKinsey & Company during an oral presentation; it is not a
complete record of the discussion.
CONFIDENTIAL
OPI Module #8