Root Cause Analysis

Root Cause Analysis
Superfactory Excellence Program™

www.superfactory.com
© 2004 Superfactory™. All Rights Reserved. 1

What is a root cause?
ROOT CAUSE =
 The causal or contributing factors that, if corrected, would prevent
recurrence of the identified problem
 The “factor” that caused a a problem or defect and should be permanently

eliminated through process improvement
 The factor that sets in motion the cause and effect chain that creates a
problem
 The “true” reason that contributed to the creation of a problem, defect or

nonconformance

What is root cause analysis?
 A standard process of:
 identifying a problem
 containing and analyzing the problem
 defining the root cause
 defining and implementing the actions required to
eliminate the root cause
 validating that the corrective action prevented
recurrence of problem

Benefits
By eliminating the root cause…

You save time and money!
 Problems are not repeated
 Reduce rework, retest, re-inspect, poor quality costs, etc…
 Problems are prevented in other areas
 Communication improves between groups and
 Process cycle times improve (no rework loops)
 Secure long term company performance and profits
$$ Less rework = Increased profits! $$

Importance of the root cause
Not knowing the root cause can lead to costly band aids.
 The Washington Monument was degrading

Why? Use of harsh chemicals
Why? To clean up after pigeons
Why so many pigeons? They eat spiders and there are a lot of spiders at the
monument
Why so many spiders? They eat gnats and lots of gnats at the monument
Why so many gnats? They are attracted to the light at dusk.
Solution: Turn on the lights at a later time.

How does it differ from what we do
now?
USUAL APPROACH
Firefighting! Problem
Problem
Immediate Containment reoccurs
Identified
Action Implemented elsewhere!
Find
someone to
blame!
PREFERRED APPROACH
Immediate Defined Solutions are
Solutions
Problem Containment Root Cause applied across
validated
Identified Action Analysis company and
with data
Implemented Process never return!

But who’s to blame?
 The “no blame” environment is critical

 Most human errors are due to a process error
 A sufficiently robust process can eliminate human errors
 Placing blame does not correct a root cause situation
 Is training appropriate and adequate?
 Is documentation available, correct, and clear?
 Are the right skillsets present?

Problem Solving Process
1
Identify
8 Problem 2
Validate Identify
Team
7 3
Problem
Follow Up
Plan Solving Immediate
Action
Process
Complete Root
Plan Cause
Action
6 Plan 4
5
Step #1
Identify the Problem

Very important!
 Clearly state the problem the team is to solve
 Teams should refer back to problem statement to avoid getting
off track
 Use 5W2H approach
 Who? What? Why? When? Where? How? How Many?

Step #1
5W2H
 Who? Individuals/customers associated with problem
 What? The problem statement or definition
 When? Date and time problem was identified
 Where? Location of complaints (area, facilities, customers)
 Why? Any previously known explanations

 How? How did the problem happen (root cause) and how will the problem
be corrected (corrective action)?
 How Many? Size and frequency of problem

Step #2
Identify Team
When a problem cannot be solved quickly by an individual, use a
team!
 Should consist of domain knowledge experts

 Small group of people (4-10) with process and product knowledge,
available time and authority to correct the problem
 Must be empowered to “change the rules”
 Should have a designated Champion
 Membership in team is always changing!

Step #2
Key Ideas for Team Success
 Define roles and responsibilities

 Identify external customer needs
 Identify internal customer needs
 Appropriate levels of organization present
 Clearly defined objectives and outputs
 Solicit input from everyone!
 Good meeting location
 near work area for easy access to info
 quiet for concentration and avoiding distractions

Step #2
Roles and Responsibilities
 Champion: Mentor, guide and direct teams, advocate to upper

management
 Leader: day-to-day authority, calls meetings, facilitation of team, reports
to Champion
 Record Keeper: Writes and publishes minutes
 Participants: Respect all ideas, keep an open mind, know their role
within team

Step #3
Immediate Action
 Must isolate effects of problem from customer

 Usually “Band-aid” fixes
 100% sorting of parts
 Re-inspection before shipping
 Rework
 Recall parts/documents from customer or from storage
 Only temporary until corrective action is implemented (very costly, but

necessary)
 Must also verify that immediate action is effective

Step #3
Verify Immediate Action
 Immediate action = activity implemented to screen, detect and/or

contain the problem

 Must verify that immediate action was effective
 Run Pilot Tests
 Make sure another problem does not arise from the temporary
solutions
 Ensure effective screens and detections are in place to prevent further

impact to customer until permanent solution is implemented.

Step #4
Root Cause
 Brainstorm possible causes of problem with team

 Organize causes with Cause and Effect Diagram
 “Pareto” the causes to identify those most likely or occurring most often
 Use 5 Why? method to further define the root cause of symptoms
 May involve additional research/analysis/investigation to get to each
“Why?”
 Must identify the process that caused the problem
 if root cause is company-wide, elevate these process issues (outside of
team control) to upper management to address

Step #4
Tools
 brainstorming  5 Why
 flowcharting  failure mode, effect & criticality
 cause & effect diagrams analysis
 pareto charts  fault tree analysis
 barrier analysis
 change analysis

Step #4
5 Why’s
 Ask “Why?” five times

 Stop when the corrective actions do not change
 Stop when the answers become less important
 Stop when the root cause condition is isolated

What is a Cause-Effect Diagram?
 A Cause-Effect (also called “Ishikawa” or “Fishbone”) Diagram is a

Data Analysis/Process Management Tool used to:
 Organize and sort ideas about causes contributing to a

particular problem or issue
 Gather and group ideas
 Encourage creativity
 Breakdown communication barriers
 Encourage “ownership” of ideas
 Overcome infighting

Cause-Effect Diagram
 A Cause-Effect Diagram is typically generated in a group

meeting
 It is a graphical method for presenting and sorting ideas
about the causes of issues or problems

 Steps used to create a Cause-Effect Diagram:

 Define the issue or problem clearly
 Decide on the root causes of the observed issue or problem
 Brainstorm each of the cause categories
 Write ideas on the cause-effect diagram. A generic example is shown
below:
Materials Methods
Environment Effect
Equipment People
NOTE: Causes are not limited to the 5 listed categories, but serve as a starting point

 Allow team members to specify where ideas fit into the diagram
 Clarify the meaning of each idea using the group to refine the ideas. For
example:
Materials Methods
Incorrect Quantity Late Dispatch

Spillage
Incorrect BOL Shipping Delay
Wrong Destination
Traffic Delays
Shipping
Environment
Wrong Equipment
Problems
Weather Driver
Dispatcher Attitude
Breakdown Dirty Equipment Wrong Directions
Equipment People

 After completing the Cause-Effect Diagram, take the following

actions:
 Rank the ideas from the most likely to the least likely cause cause
of the problem or issue
 Develop action plans for identifying the essential data, resources
and tools

Expected Outcome
• Individuals have become part of a problem solving team

 The sources of problems and other issues have been identified using
a systematic process
 Team members see issues from a similar perspective
 Ideas and solutions are documented
 Communication is improved
 Team members assume ownership

Step #5
Corrective Action Plan
 Must verify the solution will eliminate the problem

 Verification before implementation whenever possible
 Define exactly…
 What actions will be taken to eliminate the problem?
 Who is responsible?
 When will it be completed?
 Make certain customer is happy with actions

 Define how the effectiveness of the corrective action will be measured.

Step #5
Verification vs. Validation

(Before) (After)
 Verification
 Assures that at a point in time, the action taken will actually do what is
intended without causing another problem
 Validation
 Provides measurable evidence over time that the action taken worked
properly, and problem has not recurred

Step #6
Complete Action Plan
 Make certain all actions that are defined are completed as planned
 If one task is still open, verification and validation is pushed back
 If the plan is compromised, most likely the solution will not be as effective

Step #7
Follow Up Plan
 What actions will be completed in the future to ensure that the root cause
has been eliminated by this corrective action?
 Who will look at what data?
 How long after the action plan will this be done?
 What criteria in the data results will determine that the problem has not
recurred?

Step #8
Validate and Celebrate
 What were the results of the follow up?
 If problem did reoccur, go back to Step #4 and re-evaluate root cause,

then re-evaluate corrective action in Step #5
 If problem did not reoccur, celebrate team success!
 Document savings to publicize team effort, obtain customer satisfaction

and continued management support of teams

What does a good RCA look like?
 The Root Cause is

 Internally Consistent ,
 Thorough, and
 Credible

The Complete Root Cause Analysis is

• inter-disciplinary, involving experts from the frontline services
• involving of those who are the most familiar with the situation
• continually digging deeper by asking why, why, why at each level of
cause and effect.
• a process that identifies changes that need to be made to systems
• a process that is as impartial as possible

To be thorough a Root Cause Analysis must include:

• determination of human & other factors
• determination of related processes and systems
• analysis of underlying cause and effect systems through a series of
why questions
• identification of risks & their potential contributions
 determination of potential improvement in processes or systems

To be Credible a Root Cause Analysis must:

• include participation by the leadership of the organization &
those most closely involved in the processes & systems
• be internally consistent

Hints about root causes
 One problem may have more than one root cause

 One root cause may be contributing to many problems
 When the root cause is not addressed, expect the problem
to reoccur
 Prevention is the key!

Review
 You learned:
 How to identify the root cause
 Why it is important
 The process for proper root cause analysis
 How basic quality tools can be applied to examples

Six steps.......
• Explore the challenge - step 1-3
– Objective Finding (identify the goal, wish or challenge)
– Fact Finding (gather the relevant data)
– Problem Finding (clarify the problems that need to be solved
in order to achieve the goal)
• Generate ideas - step 4
– Idea Finding (generate ideas to solve the identified problem)
• Prepare for action - Step 5-6
– Solution Finding (move from idea to implementable solution)
– Acceptance Finding (plan for action)
5 Whys –gets to the root of the problem
Fishbone (Ishikawa) or cause and effect
diagram
Fishbone (Ishikawa) or cause and effect
diagram
• This technique can be used to:
– Discover the root cause of a problem.
– Uncover bottlenecks in your processes.
– Identify where and why a process isn't working.
• Steps:
1. Identify the problem
2. Identify the issues that contribute (use frameworks such as
McKinsey 7 S or 4Ps of marketing)
3. For each issue identify the possible causes
4. Analyse the diagram. What is it showing you about the issues
causing the problem
Structured problem solving
• Identify what the problem or worry is
– Step 1: “List all possible solutions even the bad ones”
– Step 2: “List advantages and disadvantages of each solution”
Two columns: one for advantages and one for disadvantages.
– Step 3: “Choose best or most practical solution or combination
– Step 4: “Plan how to carry out solution” Under this.. “How
will I achieve my goal?”
– Step 5: “Record progress and review plans. Feel good about
your efforts”
• Step 1 and 2 = problem solving
• Step 3 to 5 = decision-making and implementation
Introduction (FBD= fishbone diagram)
• FDB is a tool to find out relationships:
Cause Effect
• Use in QM especially in automotive industry

• On of the tool set used to create so called 8D report (8
disciplines=FBD+5WHYs+PA+QM)
• Another tool : 5 WHYs – will be cleared later Another tool :
PARETO=PA analysis will be shown later
Fishbone diagram
Mother Nature Men

Salary
To hot
Training
Terrible cold
Dissatisfied
worker
Incapable
Dangerous
Treacherous Obsolete
Management Machines
(Methods, Material, Manpower, Measurement, Machines, Mother Nature,Management)

Fishbone diagram-supportheart
of the
problem
a bad recruitment
HR have
Bad training
policy
Mother Nature Men
salary
Low
weather
Bad
weather
Good
Lower quality
of the consultants
Consultant takes
holiday Phlegmatic person reacts later
than expected
Consultant is on
sick leave
Dissatisfied
customer
Incapable
Bad communication
Interest in
golf only Bad SW
for support
(HELP DESK)
Management Machines
(Methods, Material, Manpower, Measurement, Machines)

Pareto analysis I
Pareto analysis II - data
Frequency Freq (%) Freq accum(%)
• Difficulty • 6 - (35,29 )- (35,29)

• Resignation • 5 - ( 29,41 )- (64,71)
• Underestimation • 4 - ( 23,53 )- (88,24)
• Low motivation • 2 - ( 11,76 )- (100,00)
Pareto analysis III

Root Cause Analysis

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Root Cause Analysis

Superfactory Excellence Program™

© 2004 Superfactory™. All Rights Reserved. 1

 The “factor” that caused a a problem or defect and should be permanently

 The “true” reason that contributed to the creation of a problem, defect or

© 2004 Superfactory™. All Rights Reserved. 2

 A standard process of:

© 2004 Superfactory™. All Rights Reserved. 3

By eliminating the root cause…

$$ Less rework = Increased profits! $$

 The Washington Monument was degrading

© 2004 Superfactory™. All Rights Reserved. 5

© 2004 Superfactory™. All Rights Reserved. 6

 The “no blame” environment is critical

 Is documentation available, correct, and clear?

 Are the right skillsets present?

© 2004 Superfactory™. All Rights Reserved. 7

Identify the Problem

© 2004 Superfactory™. All Rights Reserved. 9

 Why? Any previously known explanations

© 2004 Superfactory™. All Rights Reserved. 10

 Should consist of domain knowledge experts

© 2004 Superfactory™. All Rights Reserved. 11

Key Ideas for Team Success

 Define roles and responsibilities

© 2004 Superfactory™. All Rights Reserved. 12

Roles and Responsibilities

 Champion: Mentor, guide and direct teams, advocate to upper

© 2004 Superfactory™. All Rights Reserved. 13

 Must isolate effects of problem from customer

 Re-inspection before shipping

 Recall parts/documents from customer or from storage

 Only temporary until corrective action is implemented (very costly, but

© 2004 Superfactory™. All Rights Reserved. 14

Verify Immediate Action

 Immediate action = activity implemented to screen, detect and/or

 Ensure effective screens and detections are in place to prevent further

© 2004 Superfactory™. All Rights Reserved. 15

 Brainstorm possible causes of problem with team

© 2004 Superfactory™. All Rights Reserved. 16

© 2004 Superfactory™. All Rights Reserved. 17

 Ask “Why?” five times

© 2004 Superfactory™. All Rights Reserved. 18

 A Cause-Effect (also called “Ishikawa” or “Fishbone”) Diagram is a

 Organize and sort ideas about causes contributing to a

© 2004 Superfactory™. All Rights Reserved. 19

 A Cause-Effect Diagram is typically generated in a group

© 2004 Superfactory™. All Rights Reserved. 20

 Steps used to create a Cause-Effect Diagram:

© 2004 Superfactory™. All Rights Reserved. 21

Incorrect Quantity Late Dispatch

© 2004 Superfactory™. All Rights Reserved. 22

 After completing the Cause-Effect Diagram, take the following

© 2004 Superfactory™. All Rights Reserved. 23

• Individuals have become part of a problem solving team

© 2004 Superfactory™. All Rights Reserved. 24

Corrective Action Plan

 Must verify the solution will eliminate the problem

 When will it be completed?

 Make certain customer is happy with actions

© 2004 Superfactory™. All Rights Reserved. 25

Verification vs. Validation

© 2004 Superfactory™. All Rights Reserved. 26