Root Cause Analysis

In many situations, problem-solving team members are faced with deciding whether or not they
should focus on the immediate elimination of the issue and then move on to other projects or invest
the additional time and effort required to identify and eliminate root causes permanently, generating a
process with increased capability.
 
Using an unstructured approach for a high-level investigation of the problem can generate a good
cross-section of ideas and energize team members. In some cases, this approach may provide a
sufficiently positive result, but it generally does not validate the actual root causes of the problem and
prevent their recurrence. All too often, these unstructured investigations point to superficial symptoms
- ones that really exist - rather than actual root causes- ones that can be eliminated under robust
operating conditions. 

Until the team finishes a structured investigation, it cannot be sure that it has found the root cause
and, therefore, cannot establish reliable methods that will solve the problem permanently.  The
remedy may address obvious process issues and restore the operation to its required performance
and at first glance, this remedy appears to deal with root causes, but the reality is that the issues
resolved by the remedy continue to occur on a long-term basis. Additional investigation can be
expected to reduce the potential for recurrence of the incident and the associated consequences of
the failure. A structured or systematic approach to incident investigation allows for a deeper look into
management systems and work processes to determine the underlying causes of incidents.

Under these circumstances, the results will seem to improve, and the team may be tempted to stop
investigating the root cause in a more structured manner. This is a poor decision, however, because
quickly implemented remedies rarely provide permanent solutions to problems. To maintain the
quality improvement that was obtained with a remedy, the team needs to make sure it has identified
the actual root cause—otherwise that cause will reassert itself and the problem will recur. The
company has not identified a root cause whose prevention will generate long-term process
improvement. Unstructured analysis may make sense, but it does not probe deeply enough to
determine if there are root causes present whose elimination would reduce the organization’s risks
better and improve future results more broadly.

The root cause analysis process involves examining an event along with any and all component parts
involved in it, in an effort to identify its fundamental cause. Finding the cause isn't an end in itself, the
process is meant to be a "springboard," and the critical next step involves identifying and making the
changes necessary to reduce the likelihood of recurrence and can be used proactively as a loss
prevention tool.

Flowcharts and Logic trees can be particularly useful in analysing events and once an issue has been
analysed, there is never one root cause. Focus on the systems and processes, not individuals and
ask why and why and why again. Anyone who wants to go on an improvement journey, really, needs
to be using root cause analysis.

Because you are almost relying on your own knowledge, every time you ask why, you're looking at
your own knowledge or the knowledge of the team that's there. The five- to ten-member analytical
team should be drawn from a wide range of the disciplines and departments involved. Outside experts
can offer insight team members might be unaware of. To eliminate latent roots, a champion is needed
to follow up with management and effect change in the way the site is operated. Management support
to embark on behavioural change to focus on establishing cause of failures, rather than treatment of
symptoms is required.

You need to have support from the top management. Inappropriate procedures can be used routinely
and it can be that management tolerates them. The first thing that is absolutely required is
management support that is committed and lasting. Results will need to be carried through, and with
management behind that activity.

It's about understanding what the problem is, containing and analysing that problem, defining the root
cause, and then define and implement an action plan that's going to eliminate that root cause. Then
the most important step, which most people forget - which is the validation stage, at some point in the

Page 1 of 23
future, as to whether that action plan has eliminated the root cause, or if the cause is still there. So ,
you didn't find the root cause; you found a false cause.

Sometimes people find that hard. Often, it requires a fundamental shift in attitude and mind-set of the
workers, the people who are involved in the process, especially established organisations. You can
get stages where people think that they know what the problem is, and they don't need to go through
any kind of analysis process, because they've worked here for so many years and they know what the
problem is. 

Sometimes, when you challenge people to actually sit down and investigate a failure in a structured
manner, that can actually cause problems. Organisations are sometimes bad at using root cause in
the wrong way, so they find people to blame, and that's not what root cause is about.

The thing about RCA is that the desired outcome is to prevent the problem from occurring again. It is
very easy to get caught up in chasing for the root cause when, in reality, in all likelihood there will be
multiple causes. There is a common tendency to solve the physical root of the problem and then
wonder why the failure recurs.

Comparable to rotating slices of Swiss cheese—the pieces represent errors and when the holes line
up, there is an incident. Errors eventually will link and cause failures, but we don’t know exactly when
or how often. Sometimes there is no incident using the same process and not having a failure yet,
probably due to luck. Remaining unrecognized and uncorrected roots will come back to cause another
breakdown.

There are always multiple root causes — physical, human and latent. Finding and eliminating those
human and latent causes has a far greater financial return. If the people doing the analyses don’t
recognize there are always multiple causes, they will never reach an accurate conclusion. The
number of roots typically depends on the complexity of the problem, and usually a problem has
between four and seven roots. The number of root causes found also might depend on the depth of
the analysis. A good root cause failure analysis program can reduce errors and improve savings. Fit
for purpose tools need to be determined.

There are three main types of root causes that build upon each other:
 
Physical roots. - The actual physical mechanism of the failure.

Human roots - The human practices that allowed the physical roots to exist.

Latent roots - The way the site is managed and/or designed that creates the human roots.

Human roots -There are multiple roots of this type: → design errors account for 60% of human roots.

A true root cause failure analysis that goes into the human and latent roots can eliminate whole
categories of failures. It also hits the bottom line: putting the findings from a root cause failure analysis
into practice often results in more than a thousandfold return on the cost of  the analysis. 

There are lots of methods out there, but the reality is that most of the reasons why things don't work
the way they should do is down to finger trouble. That's often down to there not being a sort of
standard way of doing things. More fundamental causes and aspects of organizational operations,
including controls for tasks and processes and management systems and the organization’s culture
can be analysed.

In seeking out a countermeasure, consider the fire service advice on preventing fires. A fire needs
fuel, heat and oxygen. Remove one of these and a fire will be prevented. The equivalent for
manufacturing organisations the three generic countermeasures. To prevent a failure, you need three
things: 

1. A standard (when this happens, do that)

2. Formal best practice for the activity that is easy to do right, difficult to do wrong and simple to learn
3. Process control cause/effect limits

Page 2 of 23
Important aspects of RCA include:

 Management support to embark on behavioural change to focus on establishing cause of failures,

rather than treatment of symptoms
 Determine fit for purpose tools
 Establish levels of competency, roles and responsibilities and train staff in process and tools
Assess effectiveness of process, resources and quality of documentation and content

Reference Diagrams

At the top, equipment performance gaps (EPGs) and frontline personnel performance gaps (FLPPGs)
are analysed. Performance gaps are differences between the desired and actual performance of
equipment or personnel. These two gaps often become the focus of unstructured incident
investigations and the development of remedies. Although they provide worthwhile information,
they do not go far enough to create long-term preventive solutions.

Farther down in the triangle are more fundamental causes and aspects of organizational operations,
including controls for tasks and processes. The bottom two areas are where management systems
and the organization’s culture can be analysed. Probing more deeply into the triangle’s levels makes
it possible for organizations to increase their learning about how the organization as well as the
problematic process function, which encourages the development of corrective and preventive
actions that are more fundamental in nature and broader in scope. Thus, deep analysis of incidents
leads to more robust changes that allow problems to be solved once, instead of recurring
repetitively.

At the bottom levels, different activities have more in common with each other. All activities share
the same organizational culture. The different tasks have many management systems in common. As
the analysis moves to higher levels, there is less and less in common among the tasks. An
unstructured analysis would focus on trying to correct the situation at the EPG or FLPPG level. The
problems at the top of the task triangle (EPGs and FLPPGs) often can be identified with limited
investigation effort. To follow that approach, however, results in solving the problem multiple times
—whenever an error is committed during performance of any of the involved tasks. When trying to

Page 3 of 23
solve a problem at the bottom of the triangle (at the management-system level), additional
investigative work is required. The symptom (an issue) can be seen at the top of the task triangles,
but the root causes are buried within deeper levels of the triangle.

Only investigating the effort to dig deeper into the task triangles and solve the problem at the
management-system level will generate a solution that works over the long term and for all related
situations. This approach requires solving the problem just once, which is much more efficient than
solving it several times (once for each of the tasks). In addition, by solving the management system
issue, many future failures can be avoided.

The question, “What is it about the way we operate our business that caused or allowed this to
occur?” must be answered. If an answer to that question can be determined, the investigation will
have dug deeply into the task triangle. This will allow the issue to be addressed only once so that
other failures can be prevented.

So, the trade off is this. Do more work now to understand the underlying causes and address them.
In return, there is only one problem to solve instead of many, and future failures can be averted.
Avoiding failures allows operations to run more smoothly and personnel to plan with more
confidence. Furthermore, it reduces the stress associated with always “fighting the latest fire.”

Root cause analysis transforms an old culture that reacts to problems to a new culture that solves
problems before they escalate, creating a variability reduction and risk avoidance mindset. Aiming
performance improvement measures at root causes is more effective than merely treating the
symptoms of a problem.

By the time many team members have completed the task of developing hypotheses regarding the
root causes of a problem and collecting supporting data on the as-is performance of those factors, a
sense of frustration—and possibly even exhaustion—may appear. Many team members would
rather skip over the analysis and head straight into creating solutions. The phrase “analysis paralysis”

Page 4 of 23
is used to criticize teams that don’t make quick and deliberate progress toward solving the
problems. Many teams still prefer to use the age-old trial-and-error method of quickly guessing the
root causes and investing the bulk of their efforts on trying popular solutions

Corrective Action: Eliminate the designated Root Cause(s)

Preventative Action: Implementation of actions to prevent recurrence of the root, contributing or

direct cause conditions.

There is usually more than one potential root cause for any given problem. To be effective the
analysis must establish all known causal relationships between the root causes and the defined
problem.

The basic elements of RCA may include the following. However, this list is just a starting point.

• Materials

o Defective raw material

o Wrong type of material for the job
o Lack of raw material

• Machine / Equipment

o Incorrect tool selection

o Poor maintenance or design
o Poor equipment or tool placement
o Defective equipment or tool

• Environment (Milieu)

o Orderly workplace
o Job design or layout of work
o Surfaces poorly maintained
o Physical demands of the task
o Forces of nature

• Management

o None or poor management involvement

o Not paying attention to the task
o Task hazards not guarded properly
o Other (horseplay, inattention....)
o Stress demands
o Lack of Process

• Methods

o Practices are not the same as written procedures

o Poor communication
o Management system
o Training or education lacking
o Poor employee involvement
o Poor recognition of hazard

Page 5 of 23
o Previously identified hazards were not eliminated

Page 6 of 23
Find the Root Cause and Verification

o Prepare a ‘Cause and Effect’ Diagram

o Review and update the Process Flow Diagram (if necessary)
o Repeated 5 Whys
o Develop Theories
o Record ideas of what could have happened using the brainstorming method
o Test and eliminate potential root causes
o Verify the selected root causes

ROOT CAUSE QUESTIONS

o Is there a relationship between the problem and the process?

o Is this a unique situation or is it the root cause?
o Is it similar to previous cases?

BARRIERS TO ROOT CAUSE ANALYSIS

• Not using a system

o Leads to incorrect root causes

o Unverified corrective actions
o Lack in customer satisfaction

• Using the incorrect tool

o Not following the corrective action format

o Over-reliance on experience
o Keep the guesswork out of the process
o Keep an open mind

• Resistance to change

o We have always done it this way

PREVENT RECURRING SYSTEM PROBLEMS QUESTIONS

• Can we use our improvement on another existing process?

• What allowed this problem to occur?

• Was it a failed procedure?

• Was it a system breakdown or failure?

• Did we use our best practices?

• What practices do we need to standardize?

• Have you written the plans to coordinate the preventive actions?

o Who is responsible?
o What are the action items to be completed?

Page 7 of 23
Webster’s dictionary defines a symptom as “a sign or token; that which indicates the existence of
something else.” Indeed, the “something else” is the cause, which is defined as “that which produces
or affects a result; that from which anything proceeds, and without which it would not exist.

A team may not always have the capability or authority to address the true root cause of a problem
and, therefore, may be forced to address symptoms in the system. For most teams, the analyses
phase involves determining the deepest cause that can be resolved practically and reliably.

The tendency for team members to have preconceived solutions in mind and, therefore, to want to
rush through the root cause analysis step so they can design creative fixes exacerbates this issue.

Striking the right balance between the selection of the appropriate tools and the tendency for the
team to be trying to push forward is the key to success, and that balance is best guided by an
understanding of the risks associated with an incorrect identification of the root cause.

No matter how much the team wants to skip the root cause analysis process, it is absolutely
essential that an orderly determination of the root cause occurs. Even if the team does an intensive
analysis of the potential root causes using the tools, the analyse and improve phases still require
that the root cause and proposed solutions be verified.

Unless the project champion and other key stakeholders are experienced, they are unlikely to
support having the team invest much effort in exploration. The pressure— sometimes enormous
pressure—will be on rushing to implement change and make the problem magically disappear.

As always is the case when seeking high team member engagement and overall team performance—
and at the same time conforming to the process—the greatest success is attained when the issues
are openly expressed and discussed.

Page 8 of 23
The regulations for the United States and the European Union require investigations to be
performed when deviations occur in the manufacturing process. The ultimate goal of these
investigations is to determine why something went wrong, what caused it to go wrong, and how to
address the issue and prevent its recurrence. Root-cause analysis is simply a systematic problem-
solving approach used for determining the cause of a deviation that occurred during processing and
identifying solutions to prevent recurrence.

The following are a few general considerations to keep in mind while conducting investigations:

 One size investigation doesn’t fit all situations. Simple errors require simple documentation
while more serious deviations require broader investigations.
 The best tool to have is inquisitiveness. Ask yourself how far this deviation could extend.
 Widen your perspective. Look for ways to relate, not separate, similar issues.
 Human error is rarely a sufficient root cause.
 Always verify information or your instincts and never assume you are correct without proper
data to support your instincts.

Page 9 of 23
Choosing the right root-cause analysis tool is crucial in assuring the process is effective and ensuring
the true root cause has been identified. Some of the available tools include brainstorming, the 5
Whys, flowcharting, and fishbone diagrams. Using some or all of these tools in combination during
an investigation is practical and necessary.

Root cause analysis tools can be detrimental to the outcome of an investigation if they are
improperly used, so it is important to train people in their proper use. The information needed to
determine the root cause for any investigation should be appropriately documented.

To make sure the true root cause is identified, each investigation must address the following
elements:

 Historical evaluation; have we seen this before on this or other products? Have we seen this
before on this line? Have we seen this before with these operators?
 An evaluation of the process/methods used during the operation
 An evaluation of the materials used during the operation
 An evaluation of the equipment/instruments used during the operation
 An evaluation of the personnel involved
 An evaluation of the laboratory analysis associated with the operation
 A review of the validation information for the operation

The investigation should be broad so that all possible causes of the deviation can be captured and
evaluated as the possible root cause. Avoid jumping to conclusions and investigate all possible
causes so they can be properly eliminated, thus exposing the true root cause.

Also, remember that there could be more than one possible root cause to a deviation. Whatever
tool/tools you use to identify the root cause of an issue, they need to be supported by a robust, well-
documented investigation.

Problem solving is finding the root cause of a problem and preventing it from ever happening again.
Problem solving is not putting a Band-Aid on the problem.

Without the ability to anticipate and prepare, organisations fall into traps that are usually
predictable and avoidable. Organisations may be confronted with the following most common traps:

 Insufficient preparation time

 Incorrect communication lines
 Profits matters, not people

Many times, workers cannot adapt to a new business model or use new tools and processes in the
old way. The attitude 'well, because that is how we have always done it' is the main reason why
many of the changes have failed.

Traditional approaches to management place emphasis on a wide range of training and provide
individual employees with the new skills they need to fulfil their new responsibilities. These
measures, although necessary, are not sufficient.

The traditional approach should also take into account the fact that not every employee can be
properly trained and not everyone can learn the skills that his superiors have just wanted. There are
people who are unable to think analytically or who lack the technical knowledge to such an extent
that they are in no way able to master new ways of acting. Such employees often feel very
uncomfortable at work and their incompetence irritates their superiors.

Page 10 of 23
The Supply Chain means the flows of raw materials, materials, semi-finished products, finished
products and information. Building and managing supply chains is not a simple task, during which
there are many barriers and challenges.

To systematize these problems, the Deming cycle (Plan, Do, Check, Act) can be used and challenges
assigned to the stages: Plan, Do, Check, Act. This allows a schematic approach to problem solving.
There can be advantages of this methodology to analyse the root causes for errors occurring in each
stage.

The basic principle of the Deming Cycle is iteration - once the hypothesis has been confirmed, it
contributes to the further expansion of knowledge after the cycle has been repeated. Repeating the
Deming cycle can bring you closer to your goal, usually improving your performance and result. The
PDCA model should be implemented in an iterative way, spirally expanding the knowledge of the
system, while approaching the target with each subsequent cycle. This can be imagined as open-
ended spiral springs, where each loop is one cycle of the method and each cycle brings an increase in
our knowledge of the system under examination.

This approach is based on the belief that our knowledge and skills are limited, but there is room for
improvement. Especially at the beginning of the project, the key information may not be known; the
Deming approach provides feedback to support our assumptions and increases our knowledge. By
broadening our knowledge, we can choose to improve.

The pace of change and adaptation to customer needs is a key factor in competitiveness. PDCA
allows improvements to be made and is typically associated with projects, involving both time and
people. The Deming cycle in the PDCA version consists of the following steps:

PLAN - planning, which means determining the activities that are necessary to achieve the goal

DO – execution according to all points of the intended plan

CHECK – analysing the results, which means checking whether the plan has been effective and what
can be done to improve the process

ACT – an action that consists of improving the process and integrating ideas into the next plan

--------------------------------------------------------------------------------------------------------------------------------------

P – Plan

D – Do

C – Check

A – Act

The last phase, i.e., the act, has the highest total risk level and the most frequent challenge is to
properly understand the concern for one's own interests and the interests of all participants of the
supply chain.

Experienced practitioners who are aware of the rich variety of tools and the need to choose and use
one proper theorem that there is no tool that is best for your application. A method for selecting and
using quality management instruments to improve production processes in the form of a matrix of
criteria that supports the selection of the most useful quality tool can be used. Each quality tool can
be described by its selection criteria as well as the states of these characteristics.

Page 11 of 23
It is possible to select an appropriate tool for analysing the causes of problems for the PDCA phase in
which the problem was diagnosed. For problems with the planning phase the most effective tools
are the Ishikawa diagram and the systematics diagram. In the Do phase it can be a block diagram,
control card, histogram and 5 Why? Analysis.

Most tools can be used in the Check phase, such as Ishikawa Diagrams, Pareto Diagram, Block
Diagram, Matrix Diagram, Relations Diagram, and Histogram. The phase for which there is the least
number of tools is the Act phase and the corresponding tool for analyzing the source causes for this
phase is the Diagram of Dispersion.

Based on the principle of continuous improvement of management processes using the Deming
Cycle, the problems have been sorted and make it possible to select appropriate methods and tools
for particular stages of management. It also allows you to identify where the root of the problem is
in the management phase. Locating the source of the problem allows you to eliminate it at the point
of its creation and focus on the causes rather than consequences.

After analysing the information available in the literature and systematising the problems
encountered, it appears that serious problems are emerging at every stage of the supply chain
management. But by using the Deming wheel you can systematize these problems and adapt the
solutions and tools to the different stages of management. Additionally, knowing what problems can
wait at each stage you can prepare for and minimize the costs of eliminating them. This gives a
simple tool to respond to problems that occur during supply chain management.

Page 12 of 23
RCA methods are different from each other in terms of the reasoning method. A deductive reasoning
is applied in the Ishikawa diagram, Conflict Resolution Diagram, Why-Why diagram (5 Why?) but
induction is applicable to the Current Reality Tree, Why-Why diagram, case study, ABCD method, the
Six Thinking Hats technique and the scenario method. The brainstorming and 8D’s methods are
characterised by both the inductive and deductive reasoning.

RCA can help to implement design for quality if the relationship between cause and effect is known .
RCA methods can be placed into two broad categories - identification of the potential causes and
validation to root cause. In order to validate the causes, it needs to be supported by evidence. The
FMEA (Failure Mode and Effect Analysis) method determines the risk of occurring potential
problems but it does not aim at determining them.

Brainstorming

This method makes it possible to express ideas that would not be normally revealed for fear for
being suspected of nor seriousness or competency. The method essence is to search for ideas,
concepts, solutions and information in order to achieve the intended state i.e., to collect as many
ideas as possible and to select the most beneficial one out of them in the possibly shortest period of
time. Therefore, the brainstorm aims at:  forming the wealth of ideas about the considered
problem which leads to achieving the set goal  improving the ability to cooperate in a team which
facilitates the formation of creative atmosphere and encouraging enthusiasm. The team should
consist of approximately 12 people. 1/3 of these people should be laymen. In the team there should
not be people in superior-subordinate relationships.

The team members intelligence level and communications skills should be ensured to be identical. A
session should not last longer than an hour, a creative session is usually divided into several (e.g., 3)
stages separated by breaks. In the second session there are 3 participants who are not excessively
conservative and know the enterprise strategy and industry potential. The problem should be
presented in such a way that it will get criticised. The list with ideas should be returned to the
participants in order to be completed. During the second session the ideas are divided into the hot
ones (to be applied within a week), the ones dependent on additional research and analyses (1
month) and the useless ones (over 6 months). The results should be announced.

‘Why-Why diagram’ (5 Why?)

The why-why diagram is a tree-type diagram and its basis is the assumption that each consecutive
statement is specified by asking the question “why”. The diagram is used to assess the network of
problem causes and the relations between the problems. The ‘Why-Why’ diagram implementation
results in the possibility to find problem sources with their graphic representation and to develop
short- and long-term solutions to the investigated problems.

The “Why-why” diagram variation is a problem analysis by the “5 Why’s” method and relies on
asking the “why” question 5 times as indicated by its own name. The method objective is to
diagnose the “fundamental cause”. In Taiichi Ohno’s view “it is necessary by the real problem
solution to find a fundamental cause, not only its root. The fundamental cause is hidden deeper than
the root”.

For this reason, it is justified to ask a question about why a given problem occurred. This makes it
possible to indicate the primal malfunctioning with a number of further consequences. As
presented, the “5 Why’s” method is applied to analyse a 7-stage “practical problem solving” process.
The “5 Why’s” method is merely a constituent part of the tool for identifying and solving problems.

Page 13 of 23
As it might be observed, a key solution aspect is to identify the fundamental cause. Due to that it is
feasible to take effective preventive actions. The “5 Why’s method” belongs to a group of methods
to identify fundamental causes.

Ishikawa Diagram

Another name for the Ishikawa diagram is the “fishbone diagram” or “herringbone diagram” The
Ishikawa diagram is an image of mutual correlations between process influencing factors and effects
caused by them. The work on developing the chart takes place among numerous employees in the
form of brainstorming. Each participant has an opportunity to speak freely as each remark is a step
towards the intended objective fulfillment.

The diagram formation process relies on specifying the process result that will give rise to making
further considerations. The mentioned process result is written on right side of the main horizontal
axis. The next work stage relies on indicating main (major) causes. The application of the 5M cause-
classification appears to be helpful in this case - Man or Manpower, Method, Machines, Material and
Measurement. Other sources also mention another 6th M as “environment and management”.
Nevertheless, the above-described groups of causes are not required to form the Ishikawa diagram.
One might specify one’s own essential groups every time an individual problem is considered. Such
determined main factors are put on the branching directly connecting the main horizontal axis.

Conflict Resolution Diagram

A conflict resolution diagram is another thinking process used in the Theory of Constraints. The
diagram is used to analyse the reasons for forming a system limitation and the attempts to solve it
by eliminating a preliminary conflict between the previously chosen assumptions. The Conflict
Resolution Diagram structure is very simple. To fulfil the objective at least two situations (needed to
achieve the objective – Needs) must occur. Nevertheless, it is necessary to take appropriate actions
to make the situations be possible to occur. It might turn out that one cannot perform the actions as
they oppose to each other and their simultaneous performance might create a conflict. Such a
conflict might be exemplified by: Prerequisite 1 – increase in investment expenditure, Prerequisite 2
– decrease in the enterprise expenditure. The Conflict Resolution Diagram is a frequently used
problem identification and solving tool. Its popularity is mainly implied by its application simplicity
and transparency. This causes that the diagram might be executed in numerous groups by means of
the brainstorming method.

Current Reality Tree

The Current Reality Tree comes from the Theory of Constraints. In the enterprise activity
improvement the Theory of Constraints is focused on the enterprise internal process and system
constraints. A constraint is a resource which makes it infeasible to fulfil the system design objective
at a better level. The enterprise functioning improvement might occur at 3 levels. There are
processes in the entire organisation and their correlations at the highest level. There are 5 basic
organisation improvement steps according to TOC presented below:

1. Identify a constraint in the system

2. Define how to use the constraint in the system

3. Subordinate everything to the above decision.

4. Raise the constraint in the system.

Page 14 of 23
5. Go back to step 1.

One searches for real reasons for the newly occurred problems by analysing the symptoms observed
in the organisation activity. According to this logic one might find traces of making a diagnosis in
medicine. While identifying the reasons for biliousness a doctor makes a diagnosis based on
symptoms and examination results. Such an action is also applied in enterprises. The right diagnosis
makes it possible to focus the activity on the area in which it is the most efficient.

ABCD Method

Another name for the ABCD method is the Suzuki method. It makes it possible to specify the
significance and rank of particular problem causes. This method is very simple and widely used and
needs active participation of a carefully selected team of employees. They are experts on their own
fields and are knowledgeable about the problem from their own experience. This method might be
used in all enterprises regardless of their activity profile and size. The ABCD (Suzuki) method might
be applied if it is unknown which causes from their group have the smallest or even minimal
influence on the analysed problem. Thereby, the method makes it possible to confine the scope of
action by specifying the most significant causes that influence the analysed problem. Once the
problem is defined and the work team is selected, the procedure is included in 4 stages. Ordering
the significance indicators from the smallest to the biggest value which makes it feasible for the
work team to state which causes have the largest or an average or minimal influence on a given
problem.

Scenario method

The scenario method might be applied to consider relations between events and the influence of an
object on the environment. This method is used to form long-term quantitative or qualificative or
material or non-material forecasts. The scenario should include such information as: the
specification of hypothetical situations and their sequential future occurrence and the presentation
of existing variants in the case of each event. The variants might facilitate the event occurrence or
prevent from it. The classification of the scenario methods into 4 groups is as follows: scenarios of
possible events, simulation scenarios, scenarios of environment states and scenarios of environment
processes:

1. The essence of scenarios of possible events is to make lists of events to be taken place in the
future and the enterprise capacity to adjust to the above changes. The formation of a scenario
related to the development of the situation in the environment is possible due to the design of an
appropriate enterprise reaction.

2. Simulation scenarios make it feasible to make an advance value assessment in the case of
particular strategic decisions dependent on the environment influence.

3. What the scenarios of environmental states provide is a generalised environment image and are
qualitative by nature. The scenarios specify the influence of particular environment process on the
enterprise and estimate the probability of their occurrence in the future.

4. The scenarios of processes in the environment are an extension of the environment state scenario
method by focusing on the processes with a potentially large impact force on the enterprise.

Six Thinking Hats

The author of the Six Thinking Hats technique is Edward de Bono and the technique is one of the
creative thinking methods. Managers of contemporary enterprises encounter situations and

Page 15 of 23
problems which need to be solved by going beyond standard thinking frames. Therefore, modern
management may be compared to “creative management” that needs not only creative thinking,
imagination and analytical capabilities but also intuition. At the beginning it is required by the
application of such techniques to appropriately formulate a problem that will undergo further
analysis. It recommended to formulate problems by means of open questions (e.g., “How?” “Why?”)
Edward de Bono distinguished 6 styles which people use in the thinking process. As regards to this
method, all participants think in a parallel way which means that “all thinkers think in the same
direction”. The participants simultaneously adopt the thinking style assigned to each hat and express
loudly their thoughts related to the ruling colour when the deliberation meeting is in progress.
Therefore, each hat executes a different task.

8D Report

8D (8 Disciplines) is a methodology of solving problems related to the possibilities of improving

products or goods. This method has 8 stages presented below. Every step taken within 8D ‘s is
significant and the next step efficiency is conditioned by its execution precision. The 8D’s method is a
combination of 3 elements: problem solving process, standardisation and the unified form of
reporting results. The method is intended to identify, correct and eliminate repeating problems with
goods quality. 8D is applied to analyse and solve both internal and external problems with the
enterprise functioning. Their causes are unknown or their significance was not previously
determined.

To successfully implement the 8D methodology the persons involved should receive an appropriate
training. It is crucial to use the 8D method as a complex tool for highly urgent and highly important
problems.

Page 16 of 23
There were three main weaknesses expected:

 Insufficient and shallow root cause investigation, and intuitive conclusions not based on
facts.
 The application of 8D to non-systematic random errors.
 The omission of the motivation factor.

The phenomenon of quick findings is usually related to the problem of a lack of time for 8D process
management. 8D teams are intended to make the 8D problem solving process shorter, having used
quick (often not fact based and incorrect) findings.

A lack of time for the accurate solving of systematic and significant problems is often induced by the
phenomenon of there being a huge number of problems at the customers’ site and a big amount of
opened 8D reports. In fact, most of the problems which pass multiple-level control are random
mistakes, caused by the human factor.

The lack of motivation is seen as critical in the 8D process. However, the omission of the motivation
factor has to be analysed in the broader context of non-competent team leaders, who are not
competent in allocating resources as well as a lack of management support.

The purpose of the effective problem-solving process is not that the report is accepted by the
customer. The level of its implementation is a matter not only of the company itself and its culture,

Page 17 of 23
but must be seen in the broader context of the 8D teams’ members and their involvement in the
problem-solving process.

Page 18 of 23
There are a number of different methods to specify the root causes. The brainstorming method is
the popular and is used by many. Another 3 popular methods are the analysis of case studies, “Why
Why” diagram and Ishikawa diagram. Methods as the conflict resolution diagram and the Six
Thinking Hat technique are rarely used and the 8D’s report is considered efficient.

D4: Root Cause Analysis

Finding the root cause is the most difficult part of the 8D process. If this problem was simple and
easily solved, it would be resolved already. Two types of variability exist that should be considered—
special cause and random cause. Naturally, we are interested in finding the special cause that is
deeply hidden in the process. The main reason teams with subject-matter experts are formed is to
find the special cause. Problem-solving tools are sometimes categorized as soft or hard. The term
“hard” here refers to those using statistical analysis. In this book, we concentrate on the following
soft tools:

 Team brainstorming events

 Five whys process
 Flowcharts
 Checklists and check sheets
 Fishbone diagrams

A common flaw during the root-cause analysis stage is to make assumptions and jump to conclusions
without evaluating all factors.

The most commonly used 8D process indication is the average time from receiving the customer
complaint until the full submission of the 8D report, including the application of the permanent
corrective action and the evaluation of its efficiency. There is no doubt that it is important to
monitor the duration of the problem-solving procedure. However, following only the procedure
duration may directly negatively influence the efficiency of the 8D method.

Page 19 of 23
D7: Preventive Plans

The objective of preventive plans is to proactively address items identified during the root-cause
analysis stage that could possibly be issues in the future. It is up to the team to determine the
validity of a proposed preventive action plan before it is drafted in the 8D plan.

D8: Recognition and Lessons Learned

 This section is necessary to confirm that an 8D CAPA has successfully been completed and to
conduct a “lessons learned” review to see what went well and challenges encountered
during this corrective action. CAPAs bring a wealth of information to the organization, and
this section of the CAPA allows for the team to summarize accomplishments. It is important
to recognize team members during management review meetings once CAPAs have
successfully been completed. These projects bring value to the organizations that receive
these 8D CAPA reports, as well as the customers who receive them.
 There is a set of tools that we can use to improve the results of each of the phases that
continuous improvement projects must go through (8D, PDCA, DMAIC, Double diamond).
These methods use divergent techniques, which help generate multiple alternatives, and
convergent techniques that help analyse and filter the generated options. However, the
tools used in all those frameworks are often very similar

Page 20 of 23
There is no doubt that problem-solving is one of the key aspects by which efficiency critically
influences customer satisfaction and loyalty. Actually, modern business use, different methods for
problem-solving, the usage of which lead to effective problem-solving process management and the
elimination of problems in the future. A structured method of problem-solving helps in
communication with customer and supports the development of partnership between the customer
and supplier.

The feeling of urgency emerges at the hierarchy top and needs to be constantly confirmed and
supported by managers to make the employees wake up every morning with a firm intention to act,
execute tasks on the work day in order to approach the strategic objectives. Teams might also use all
the information to make decisions for the benefit of the entire enterprise. Top management have to
present the vision and strategy in such a way that they command the employees’ involvement. T he
team can establish cooperation with additional departments that have appropriate information from
each domain related to each topic. Although people are not too patient, they need to keep
constantly learning based on experience and not only focusing on their own work.

To strengthen strategic changes in the enterprise culture. No strategic initiative – neither the big, nor
the small one – will be complete until it is anchored in the enterprise everyday activities. A new
direction of actions or a newly conceived method needs to sink into the enterprise culture. This will
happen, if the initiative starts bringing visible effects and make the enterprise get closer to a
strategically better future.

One of the best definitions is provided by the FDA in its summary description of CAPA:

“The purpose of the corrective and preventive action subsystem is to collect information, analyse
information, identify and investigate product and quality problems, and take appropriate and
effective corrective and/or preventive action to prevent their recurrence. Verifying or validating
corrective and preventive actions, communicating corrective and preventive action activities to

Page 21 of 23
responsible people, providing relevant information for management review, and documenting these
activities are essential in dealing effectively with product and quality problems, preventing their
recurrence, and preventing or minimizing device failures. One of the most important quality system
elements is the corrective and preventive action subsystem.”

An example of a scoring system:

Page 22 of 23
Page 23 of 23