Determining the Root Cause of a Problem

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Determining Root Cause 1

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

Determining Root Cause

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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.
Determining Root Cause 4

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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

Determining Root Cause

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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

Determining Root Cause

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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
Vital Few
Supplier Material Rejections May 06 to May 07
180 160 140

Count

120 100 80 60 40 20

Trivial Many

60 % Defect of Material Rejections

g o n e r ns ng e d rial ip e r o n e d re ng rt s o n o n ria l e d ng ss ed e r n i k t i th io gi g e sh th t i d ilu gi a si ti e d ki e g t h a r nt a O e ns ka ma at an r O ura e e Fa ka g P e n nt a a t rro ar nlin ma O M e B ac a M m e ig xc st ac in im e M o M e a a e r um E Dim P r D e ct o rk ppli o nf e E Te P iss D um e c t d, C EB r Cl B D i l lie o rr W Su C Lif b SD r M EB o c o rr te pp oc ie E er i p l u D p c g lf L a E lie D nc us pl p S r u n n p p p S rI ro She lie r EB B I r R lie Su Su up p e i p e W E i l S l r p p r p pp Su lie plie Su up p p Su S p u Su S Count 162 139 34 20 19 19 15 15 14 14 11 9 7 7 3 3 3 3 2 2 1 5 Percent 32 27 7 4 4 4 3 3 3 3 2 2 1 1 1 1 1 1 0 0 0 1 Cum % 32 59 66 70 74 78 80 83 86 89 91 93 94 96 96 97 97 98 98 99 99 100

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Cause and Effect Diagram

(Fishbone/Ishikawa Diagrams)
CAUSES (METHODS) EFFECT (RESULTS)

Four Ms MAN/WOMAN Model METHODS

OTHER

EFFECT

MATERIALS

MACHINERY
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Cause and Effect Diagram

Loading My Computer
MAN/WOMAN Cannot Answer Prompt Question Brain Fade OTHER Power Interruption CD Missing Not Enough Free Memory Inadequate System

METHODS
Inserted CD Wrong Not Following Instructions Instructions are Wrong

Cannot Load Softwar e on PC

Bad CD

Wrong Type CD

MATERIALS

Graphics Card Incompatible Hard Disk Crashed MACHINERY

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Tree Diagram
Result Cause/Result Cause/Result Cause

Result

Primary Causes

Secondary Causes
Determining Root Cause

Tertiary Causes
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Tree Diagram
Result Cause/Result Cause/Result
Lack of Models/ Benchmarks Stale/Tired Approaches

Cause
No Money for Reference Materials No Funds for Classes No Performance Reviews No Special Subject Classes Lack of Regular Safety Meetings

No Outside Input Research Not Funded

No Consequences Infrequent Inspections Inadequate Training

Poor Safety Performance

Inappropriate Behaviors

Lack of Employee Attention

No Publicity Lack of Sr. Management Attention

Determining Root Cause

Zero Written Safety Messages No Injury Cost 16 Tracking

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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:

1. 2. 3. 4. 5.

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
Five Whys Pareto Analysis Cause and Effect Diagram Tree Diagram 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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