U

nexpected problems can occur in any type

Nuts & Bolts | Talking Tools of business operation. To resolve these
problems, the root cause must be identified
so proper corrective and preventive actions can be
implemented.

A Comprehensive View Perhaps the most common method of root

cause analysis (RCA) is five whys. It is an iterative
method in which the root cause is determined by
asking “why” repeatedly. The number five is arbi-
trary—depending on the complexity of the problem,
the root cause can be determined by asking “why”
fewer than or more than five times.
Improve root cause The problem with five whys is, in many scenar-

analysis by combining ios, the first-level cause has multiple second-level

causes. When the causes continue to branch out, it
five whys and fault can become difficult to keep track of all the causes

tree analysis at all the levels. For this reason, it is beneficial to

combine five whys with fault tree analysis.
Fault tree analysis is a top-down RCA graphical
tool used to investigate the causes of an identified
problem. At the top of the tree is the problem,
and directly below are the first-level causes. The
higher-level causes are drawn into the tree until
the root causes are identified.
There are three fundamental gates in fault
tree analysis:
Topic
1. The “and” gate is used if all inputs are
Root cause analysis
required for the event to occur.
Author 2. The “or” gate is used if any one of the inputs
Matthew C. Mateos can cause the event to occur.
3. The “vote or” gate is used if a specified num-
Email
ber of the inputs are needed for the event
mcmateos@ymail.com
to occur.
Figure 1 depicts a situation in which the problem
is that the process yield of a polymer extrusion
line is below target. After asking “why” once, the
first-level causes are identified as overuse of raw
materials, high amount of product rejected by qual-
ity assurance and losses from the material transfer
system. The “or” gate between the problem and
the first-level causes indicates that the occurrence
of any one of these inputs can cause the problem.
The higher-level causes are revealed by repeatedly
asking “why.”
Following the first-level cause “overuse of raw
materials,” one of the third-level causes is incor-
rect calibration of feeder scales. The “and” gate
underneath indicates that for the calibration to
be incorrect, the fourth-level causes “uncertified
weight used to calibrate feeders” and “calibration
not validated” both must occur.
Following the first-level cause “high amount of
product rejected by quality assurance,” the fifth-
level cause is “high extruder barrel temperature.”

28 May 2021 | LEAN & SIX SIGMA REVIEW

Figure 1 FIVE WHYS AND FAULT TREE ANALYSIS EXAMPLE Process yield
below target

or

Overuse of raw High amount of product Losses from material

1st level: Why? materials rejected by quality assurance transfer system

or

Material
Inaccurate High quantity of out-of- High occurrences of transfer line
feeder rates specification product product lot contamination
2nd level: Why? leaks

or

Incorrect calibration Incorrect feeder Weak tensile Erratic product

3rd level: Why? of feeder scales controller set points strength changeovers

and or

Uncertified weights used Calibration not Lack of knowledge in Degraded No Equipment

4th level: Why? to calibrate feeder scales validated feeder controllers product standard Disorganized cleaning
changeover work area procedures
process lack detail

Standard Standard High extruder barrel

operating operating Maintenance temperature
procedure doesn’t procedure doesn’t
5 level: Why?
th
specifically require specifically require
technicians
not trained
certified weights calibrations to be
for calibration validated
Vote
3/5

Thermocouple 1 Thermocouple 2 Thermocouple 3 Thermocouple 4 Thermocouple 5

6th level: Why? false reading false reading false reading false reading false reading

Problem
Thermocouple Thermocouple Thermocouple Thermocouple Thermocouple
1 incorrectly 2 incorrectly 3 incorrectly 4 incorrectly 5 incorrectly
7 level: Why?
th
positioned positioned positioned positioned positioned
Level cause

Root cause

The “vote or” gate underneath indicates a high extruder barrel
temperature can occur if three out of the five thermocouples give
false readings. The red circles at the bottom of each branch depict
the root causes.
Better together
Five whys is a common and conceptually simple tool to use when
conducting RCA. Using it in conjunction with fault tree analysis
allows situations to be depicted in which a cause is the result of
multiple events. By keeping track of all root causes at all levels,
in theory, a comprehensive and effective corrective and preventive
action strategy can be developed.
BIBLIOGRAPHY
Kubiak, T.M., and Donald W. Benbow, The Certified Six Sigma Black Belt
Handbook, second edition, Quality Press, 2009.
MATTHEW C. MATEOS is vice president,
process engineer at Wells Fargo in Las Vegas.
He received an MBA and bachelor’s degree
in chemical engineering from the University
of Toledo in Ohio. In addition, he has a certif-
icate in circuits and industrial controls from
Edison Community College in Ohio. A senior
member of ASQ, Mateos is an ASQ-certified quality improve-
ment associate, quality process analyst, inspector, technician,
calibration technician, process analyst, auditor, hazard analysis
and critical control point auditor, biomedical auditor, supplier
quality professional, Six Sigma Green Belt, Six Sigma Black
Belt and Master Black Belt. Mateos has completed OSHA-10
training in General and Construction Industry Safety and Health.
He also is a nationally certified pharmacy technician through
the Pharmacy Technician Certification Board and a registered
pharmaceutical technician through the Nevada State Board
of Pharmacy.

LEAN & SIX SIGMA REVIEW | asq.org/pub/sixsigma 29