[5] Root Cause Analysis

Root Cause Analysis

one method that can help teams determine the cause of the a problem

Weed

symbolizes the problem; above the surface (obvious)

Root

represent the underlying causes; below the surface (not obvious)

Root Cause

the fundamental breakdown or failure of a process which, when resolved, prevents a recurrence of the problem; factor that, when you fixt it, the problem goes away and doesn’t come back

Root Cause Analysis (RCA)

the process of discovering the root causes of problems to identify appropriate solutions

Root Cause Analysis (RCA)

assumes that it is much more effective to systematically prevent and solve for underlying issues rather than just treating ad hoc symptoms ang putting our fires or applying temporary solutions that fail to recurring issues

Root Cause Analysis (RCA)

can be performed with a collection of principles, techniques, and methodologies that can all be leveraged to identify the root causes of an event or trend

• to discover the root cause of a problem or event

• to fully understand how to fix, compensate, or learn from any underlying issues within the root cause

• to apply what we learn from this analysis to systematically prevent future issues or to repeat successes

Goals of Root Cause Analysis (RCA)

• Focus on correcting and remedying root causes rather than just symptoms

• Don’t ignore the importance of treating symptoms for short term relief

• Realize there can be, and often are, multiple root causes

• Focus on HOW and WHY something happened, not WHO was responsible

• Be methodical and find concrete cause-effect evidence to back up root cause claims

• Provide enough information to inform a corrective course of action

• Consider how a root cause can be prevented (or replicated) in the future 

Core Principles of Root Cause Analysis (RCA)

actionable

Good analysis is ________ analysis

1. Physical

2. Human

3. Organizational

Three Basic Types of Causes

Physical Causes

tangible, material items failed in some way (e.g. production machine stopped working)

Human Causes

people did something wrong, or did not do something that was needed; typically lead to physical causes (e.g. no one filled the brake fluid, which led to the brakes failing)

Organizational Causes

a system, process, or policy that people use to make decisions or do their work is faulty (e.g. no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid)

1. Define the Problem

2. Collect Data

3. Identify Possible Causal Factors

4. Identify Root Causes

5. Recommend and Implement Solutions

Root Cause Analysis (RCA) Process

Define the Problem

Which step under the Root Cause Analysis (RCA) process does the following questions fall under?

• What do you see happening?

• What are the specific symptoms?

Collect Data

Which step under the Root Cause Analysis (RCA) process does the following questions fall under?

• What proof do you have that the problem exists?

• How long has the problem existed?

• What is the impact of the problem?

Identify Possible Causal Factors

Which step under the Root Cause Analysis (RCA) process does the following questions fall under?

• What sequence of events leads to the problem?

• What conditions allow the problem to occur?

• What other problems surround the occurrence of the central problem?

Identify Root Causes

Which step under the Root Cause Analysis (RCA) process does the following questions fall under?

• Why does the causal factor exist?

• What is the real reason the problem occurred?

Recommend and Implement Solutions

Which step under the Root Cause Analysis (RCA) process does the following questions fall under?

• What can you do to prevent the problem from happening again?

• How will be solution be implemented?

• Who will be responsible for it?

• What are the risks of implementing the solution?

• Define and Measure the Problem

• Analyze Cause-and-Effect Relationships

• Implement and Control the Best Solutions

DMAIC Problem Solving

Define and Measure the Problem

Which under the DMAIC Problem Solving does the following questions fall under?

• What does the company want to prevent from recurring?

• Where and when did it occur? What is the significance of the problem?

Define and Measure the Problem

done by comparing the expectation of the customer to what he/she currently receives; closing the gap between expectation or the voice of the customer (VOC) and reality or voice of the process (VOP)

Analyze Cause and Effect Relationships

Which under the DMAIC Problem Solving does the following descriptions fall under?

• once the problem is defined, it is important to uncover the root causes of the problem and to understand how they interact with one another

  • collect a sample of data related to the problem and conduct a root cause analysis to identify the reasons why the problem exist

• will form the basis for determining solutions that will prevent any recurrence of the causes, and ultimately, the problem

Implement and Control the Best Solutions

Which under the DMAIC Problem Solving does the following descriptions fall under?

• identify solutions based on the results of the root cause analysis

• solutions are specific actions that control root cause of the problem

• implementing the right solutions and controlling or monitoring the results

1. Brainstorming

2. Pareto Chart

3. Fishbone Diagram

4. Flow Chart

5. Run Chart

6. Histogram

7. Control Chart

8. 5 Why

9. Tree Diagram

10. Design of Experiments

Tools for Root Cause Analysis (RCA)

5 Whys

a simple, iterative problem-solving technique used to discover the root cause of a problem by repeatedly asking “Why"?” five times, with each answer forming the basis for the next question

Toyota Motor Corporation

where the 5 Whys originated from

5 Whys

helps to go beyond superficial symptoms and identify the fundamental reasons for an issue, preventing its recurrence by addressing the core problem rather than just its manifestations

Fishbone Diagram or Ishikawa Diagram or Cause-and-Effect Diagram

a visual tool used to identify the root causes of a problem by sorting potential causes into categories

Root Cause Analysis Template

a document that helps to explain the issue, detail any potential causes, and provide information about the solution

1. Description of the Issue

2. Timeline

3. People Involved

4. Root Cause

5. Methods

Components of a Root Cause Analysis

Description of the Issue

this part of the template describe the problem or incident in detail, including when it occurred, who discovered the problem and who the issue affected

Timeline

this section lists any events that occurred before, during, or after the incident; it’s important to be specific in this section to help identify potential underlying causes of the issue

People Involved

this section of the template identifies the team members who can help to analyze the issue, along with the methods they plan to use and the ways they plan to report their findings

Root Cause

in this section of the template, the team members can report their findings and explain their determination of the root cause, including any relevant data that supports their theory

Methods

the final part of the template allows teams to list solutions to the problem that can help prevent the issue from occurring again; these solutions usually include specific, actionable steps the business can take to minimize or eliminate the root cause of the problem