10/26/2020

Root Cause Analysis

Workshop
Explore, Prioritize, Validate

Facilitator:
Mr. Taresh Varshney
Deputy General Manager

“The problems that exist in the

world cannot be solved by the
level of thinking that created
them.”

- Albert Einstein

© Operational Excellence Consulting. All rights reserved.

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Why Root Cause Analysis?

How do I control?
Measure actual
performance

OK Establish control
Compare to
standards? standards

Not OK

Root Cause Analysis

Identify problem  Diagnose cause  remedy cause

Without root cause analysis, effective corrective action is impossible

Without corrective action, root cause analysis is a waste of time!

What we do in Root Cause Analysis?

• Define and document the problem
requiring RCA.
• Understand the problem.
• Collect and analyze data.
• Determine the root cause(s).
• Establish a corrective action plan.
• Implement the corrective action
plan.
• Evaluate the effects of
implementation to demonstrate
that the root cause of the problem
was eliminated.

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Applications of RCA
• Find the cause of accidents and health
incidents
• Find the cause of defects in a
manufacturing
• Find the cause of errors in engineering
• Find the cause of frequent breakdowns of
machines
• Find the cause of customer complaint-
Equipment deficiency
• Find the cause of waste in any
organization
• Find the cause of project execution delays

Principles of RCA

• Systems thinking approach

• Prevention of recurrence

• Employee involvement

• Problem
Solving/Continuous
improvement culture

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Root cause analysis is a key part of all problem solving approaches

PDCA Lean Six A3 G8D
Sigma
Plan:
Define Clarify the problem Create team & collect information
•Define the
problem
•Describe current Breakdown the problem Describe the problem
process Measure
Set a target Define interim containment actions

•Analyze and Identify & verify the root cause &

identify root cause Analyze Analyze the root cause
escape point
•Plan
Develop countermeasures Define possible corrective actions
countermeasures
Improve
Do – Implement
See countermeasures Implement & validate corrective actions
countermeasures
Check – Verify the Evaluate the results &
Define actions to avoid recurrence
results Control processes
Act - Standardize Standardize success Congratulate your team

What are the characteristics of a Cause?

• Producer of an effect
• A differentiator between having an effect & not having an effect
• Producer of a change
• It includes set of factors sufficient to drive a change
• It is any necessary component of a set of factors sufficient to drive a change
Y = f(X)
• Y • X1, X2,…….., Xn
• Dependent variable • Independent variable
• Output of the process • Input to the process
• Effect • Cause
• Symptom • Problem
• It is monitored • It is controlled

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Defining root cause – The “Evil at the Bottom” (1/2)

Although there is substantial debate on the definition of root cause, we use the
following:
• Root causes are specific & underlying
• Root causes are those that can reasonably be identified
• Root causes are those where management has control to fix
• Root causes are those for which effective recommendations for preventing
recurrences can be generated

Source: http://asq.org/quality-progress/2004/07/quality-tools/RCA

Defining root cause – The “Evil at the Bottom” (2/2)

The highest-level cause of a
The root cause is the “evil at the bottom” problem is called the root cause
that sets in motion the entire cause-and-
Visible
effect chain causing the problem(s) Symptom
Problem

First-level
For a particular product problem, Root cause
Cause is the factor that, when you fix it, Higher-level
the problem goes away and doesn’t cause
come back.

Root
Cause

In plain English a "root cause" is a "cause" (harmful factor) that is "root" (deep,
basic, fundamental, underlying, initial or the like).

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Root cause analysis is technique to understand the cause

• Root Cause Analysis (RCA) is a

technique that helps guide people to
discover and understand the initiating
cause(s) of a problem, with the goal
of determining missing or
inadequately applied controls that will
prevent recurrence.

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Root Cause Analysis approach

• Step One: Define the Problem

– What do you see happening?
– What are the specific symptoms?
• Step Two: Collect Data
– What proof do you have that the problem exists?
– How long has the problem existed?
– What is the impact of the problem?
• Step Three: Identify Possible Causal Factors
– 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?

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Root Cause Analysis approach

• Step Four: Identify the Root Cause(s)

– Why does the causal factor exist?
– What is the real reason the problem occurred?
• Step Five: Recommend and Implement
Solutions
– What can you do to prevent the problem from
happening again?
– How will the solution be implemented?
– Who will be responsible for it?
– What are the risks of implementing the solution?

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Root cause analysis has three key steps

1 Exploration 2 Prioritization 3 Validation

What: What: What:

In this step we try to find out
potential causes which could
lead to this problem
In this step we prioritize
various causes or various
problems as per their impact
or occurrence frequency
In this step we validate the
potential causes and confirm
the root cause(s) for the
problem and eliminate other
causes

Tools used: Tools used: Tools used:

1. Cause and effect
diagram (Fish bone)
2. Inter-relations diagram
3. Affinity diagram
1. Pareto charts
2. FMEA diagram
3. Prioritization matrix
1. Why-Why analysis
2. Gemba investigation
3. Hypothesis testing
4. DoE
5. Regression

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Exploration tool: Cause & Effect Diagram

• Definition

– Cause-and-effect diagram reveals relationships among different variables,

and the possible causes provide additional insight into process behaviour.

• Purpose

– To capture the causal relationship between cause and effect

– To stratify the causes into meaningful groups

• The Cause & Effect (C&E) diagram is also known as the ‘Fishbone diagram’ or
‘Ishikawa Diagram’

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Application and benefits of cause and effect diagram

Where - Applications Why - Benefits

• When investigating a problem, to • Helps to visually display the many

identify and select key problem
causes to address
• When effect of a problem is known,
but possible causes are unclear
• To find other causal relationships,
such as potential risks or causes of
desired effects
potential causes for a specific
problem or effect
• Useful in a group setting and for
situations in which little quantitative
data is available for analysis
• Helps to bring out a more thorough
exploration of the issues behind the
problem – which will lead to a more
robust solution

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Structure for creating Cause & Effect diagram in Manufacturing industry

Causes Effect

Man Methods Machines

cause

Problem
Statement

Environment Measurements Materials

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Structure for creating Cause & Effect diagram in Service industry

Causes Effect

Procedures People
cause

Problem
Statement

Technology Policies Environment

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Example: Cause and effect diagram

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Cause & Effect Diagram

Causal analysis
process
Potential
causes
exploration
using C&E
diagram
Cracks in
Root cause electrodes
validation by
hypothesis
testing of CTQs
(Xs) & Gemba
investigation

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Steps to create Cause & Effect Diagram

1. Develop and agree on a problem statement (effect)

2. Brainstorm a list of possible causes; remove symptoms and solutions related
to the stated effect
3. Identify major categories of causes (e.g. Man, Machines, Material, Method,
Measurement, Environment)
4. Place each cause in a category (same cause can occur in several category)
5. Ask “Why does this happen?” for each cause
6. Design data collection strategy to verify and prioritize main causes

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C&E Diagram: Practice Tips

• Get total agreement on ‘effect/problem’ before starting

• Think in negative terms when brainstorming
• Best used with team that has expertise to represent entire problem
• For each node, think what could be its causes and add them to the fishbone
• State causes, not symptoms or solutions
• Consider grafting relatively empty branches onto others
• Consider splitting up over-crowded branches
• Consider which root causes are likely to merit further investigation
• Test the most likely cause and verify with data

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Prioritization tool: Pareto chart

• Definition

– It is a focusing technique which uses Pareto charts based on Pareto

Principle – also known as the 80/20 Rule. It is the idea that 20 percent of
causes generate 80 percent of results

• Purpose

– To show relative significance of the identified root causes

– To prioritize high impact issues- where to focus
– To break big problems into smaller ones

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Application and benefits of Pareto charts

Where - Applications Why - Benefits

• Starter to problem solving – what to • 80% of the trouble comes from

solve? 20% of the problems – easy to
focus
• To break big problems into smaller
problems • Visual representation in form of
bar charts helps in identifying key
• When focus area is not clear – where
issues / pains.
to focus
• Easy to separate vital few from
• When resources are limited, to
trivial many
identify impact area
• Shows focus area to get most
gains

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Pareto charts can be used to prioritize effects and causes both

Effects: Causes:

• Quality: Defects, Faults , Failures, • Operator - Shift, Group,

Complaints, Repairs, Returned
items etc.
• Cost: Amount of loss, Expenses
• Delivery: stock, Shortages, Delay
in delivery, Default in payment.
• Safety: Accidents, Breakdowns,
mistakes.
Experience, Skill.
• Machine - Machines, Equipment,
Tools
• Raw material - Manufacturer, Lot
• Operational method - Conditions,
Order, method

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Steps to create a Pareto chart

1. Set the method and time period for the data collection. Collect the data and
classify them according to problems, causes or subject matter.

2. Arrange the data of the items in the order of the most data, and enter each item’s
data respectively. At the same time, add up the cumulative figure.

3. Create the framework for the horizontal and vertical axes. Horizontal axis is for
categories, problems or causes. The left vertical axis represents frequency
whereas the right vertical axis represents the percentage scale.

4. In the order of the most data, draw the bar graphs from the left. Using the
cumulative figure, draw the cumulative curve.

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Let us do an exercise for Pareto – no. of stoppages or duration?

Reasons for stoppages
Sr. no Duration A B C D E
1 2 *
2 1 *
3 5 *
4 2 *
5 2 *
6 10 *
7 1 *
8 2 *
9 1 *
10 14 *
11 3 *
12 7 *
13 6 *
14 1 *
15 2 *
16 2 *
17 12 *
18 2 *
19 3 *
20 1 *
21 5 *
22 2 *
23 11 *
24 2 *
25 3 *
26 6 *
Total 108 13 5 3 2 3
total no. of stops for each reason

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For effective usage of Pareto charts we should identify right

measurement parameter

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If problem is large split it into sub-themes

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If problem is large split it into sub-themes

Analysis: Cracks is the prominent defect category in selected families of electrodes.

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Practice tips: We should avoid some common mistakes while

preparing Pareto charts
This is a good Pareto chart Pareto wrong – too many/too few
Pareto wrong – Data inadequate
items
1 2 3

Pareto wrong: Scale improper 250 Pareto right: Proper scale Pareto wrong: Others bar is big

200
5
4
150
80
very tall
60 100

40
50
20

0
0
A B C D E F G A B C D E F G A B C D Others

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Validation tool: Why-Why analysis

• The Why-Why is a tool used in RCA. It is not a problem solving technique.

• By repeatedly asking the question “Why” (five is a good rule of thumb), you can
peel away the layers of symptoms which can lead to the root cause of a problem

• Very often the ostensible reason for a problem will lead you to another question

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Application and benefits of Why-Why

Where - Applications Why - Benefits

• When problems involve human • Help identify the root cause of a

factors or interactions problem

• In day-to-day business life problems; • Determine the relationship

can be used within or without a Six between different root causes of a
Sigma project problem

• One of the simplest tools; easy to

complete without statistical
analysis

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Steps to apply the Why-Why analysis:

1. Write down the specific problem. Writing the issue helps you formalize the
problem and describe it completely. It also helps a team focus on the same
problem.
2. Ask Why the problem happens and write the answer down below the
problem.
3. If the answer you just provided doesn’t identify the root cause of the problem
that you wrote down in Step 1, ask Why again and write that answer down.
4. Loop back to step 3 until the team is in agreement that the problem’s root
cause is identified. Again, this may take fewer or more times than five Whys.

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When do we stop asking why during analysis?

Must reach systems level

 Systems/Standards do not exist

 Inadequate systems/standards

 Lack of compliance to systems/standards

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Loss Causation Model explains that we should dig deeper to find root
cause which is generally system related

Inadequate There was a seal Floor was oily Operator slipped Operator hurt his
system for failure leading to and hit the edge leg while working
planned leakage of the machine on the machine
maintenance

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Why-Why – Practical tips

• Do not forget that the sought outcome of a Why-Why analysis is a root cause of
the defined problem, not the resolution of the problem itself; that will come later.
• Why-Why is not a standalone Problem Solving technique but more of a tool to
aid in this process.
• Do not worry about action plans and effectiveness verification yet as that will be
addressed in the problem solving process itself; but focus more on identifying
the reason that allowed the problem to happen and escape.
• If you can come up with a reasonable answer, the Why-Why exercise would be
successful. If it cannot be done, then quite probably more data needs to be
collected to get a better grasp of the problem and then the Why-Why process
can be re-started.

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Example of 5 Whys

Why no Accident on edge-grinding m/c. It stopped after making

production ? big noise. Work piece jammed in between 2 shafts,
cutting operator’s finger

It’s bearing mounting step Normal tendency -

Why jamming ?
diameter was found damaged Replace the Shaft

Why damaged ? Grease became thick slurry.

Refused to lubricate shaft.

Why it became thick slurry ? Good grease got contaminated with

grinding flakes and went into bearing

Why didn’t clean everyday ? ??? Inadequate

maintenance

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2- Leg Why-Why

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Why-Why Analysis : Wrong Consumables Used for

welding WHY-1 WHY-2 Validation
(Gemba Investigation)
Wrong
consumable Store/system data verified. Correct
request by consumable request by supervisor.
supervisor

Vanadium Consumable
detected mix up in the
while last layers Store keeper issued
doing PMI electrode from wrong
Wrong/mixed location
consumables
issued by store
keeper Mixing of few electrodes
while loading from baking
to holding oven

Old
consumables in
portable oven Vanadium job was not worked upon in shop
with welder in full week. No vanadium consumables
issued to shop in last ten days

29-Jan-2014 41

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Fault tree analysis (FTA)

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Proactive root cause analysis helps us in preventing the occurrence of defects

in first place

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Corrective Actions using Mistake-Proofing systems (Poka Yoke)

• Mistake-proofing refers to techniques

that make it impossible to make
mistakes

• Mistake-proofing helps people and

processes work right the first time

• Mistake-Proofing devices are failsafe

devices in machines and equipment that
can self-stop in the event of a problem

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Poka Yoke (mistake proofing systems)

Ten types of Human Errors

1) Forgetfulness (not concentrating)
2) Errors due to misunderstanding (jump to conclusions)
3) Errors in identification (view incorrectly...too far away)
4) Errors made by untrained workers
5) Wilful errors (ignore rules)
6) Inadvertent errors (distraction, fatigue)
7) Errors due to slowness (delay in judgment)
8) Errors due to lack of standards (written & visual)
9) Surprise errors (machine not capable, malfunctions)
10) Intentional errors (sabotage - least common)
Use Mistake Proofing to eliminate these Human Errors

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Poka Yoke: Effectiveness of Systems

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Levels of Root Cause Analysis

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Pitfalls to avoid while performing root cause analysis

(1/2)
• You don’t really know what problem it is that you’re solving.
• The use of RCA is focused only on analysis rather than eliminating
the problems.
• The use of RCA is focused on identifying who caused the problem,
i.e. placing blame, instead of finding out how the problem arises.
• A cause never stands alone, e.g. “Did not follow procedure” – RCA
process should adopt a systems thinking approach by exploring
other cause categories.
• RCA is biased or does not involve people or SMEs from other
functions or processes.
• If the cause is unknown to the person doing the problem solving,
using Why-Why may not lead to any meaningful answers.

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Pitfalls to avoid while performing root cause analysis

(2/2)
• The success of Why-Why is to some degree is contingent upon the skill
with which the method is applied; if even one Why has a bad or
meaningless answer, the whole procedure can be thrown off.
• The Why-Why method isn’t necessarily repeatable; three different people
applying Why-Why to the same problem may produce three totally
different answers.
• Too much energy is spent on speculating about potential causes in a
C&E diagram, many of which have no significant effect on the problem.
This approach can leave a team feeling frustrated and hopeless.
• C&E diagrams are typically based on opinion rather than evidence.

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Thank You

We can connect at:

Taresh.Varshney@Larsentoubro.com
+91-9820276569

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