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Root Cause Analysis - Overview

Root Cause Analysis

Corrective Action
RCCA - Learning Objectives

The purpose of this module is to:

Apply the 5-why technique in

problem solving analysis.

Identify and understand the direct,

contributing and root cause of a
Learn the 2 types of corrective action.
Utilize a Corrective Action Matrix form
to track and drive action item
Root Cause Analysis - An Overview

Root Cause Analysis and Corrective

Action (RCCA) is a process for :

Finding the true cause(s) of an event

Identifying and implementing
corrective actions
Assessing the effectiveness of
corrective actions
Preventing recurrence of the events
Why Root Cause Analysis ?
Integral part of Continuous
If we do not take action on problems,
we will be wasting our time and all involved
will lose interest.

Our Customers expect it !

ISO 9001-2000 requirement
Makes good Business sense
Keeps us from passing on
problems to
internal and external
DMAIC process applied to RCCA

Control Form Team
Scope project

Analyze (Customer complaints,
Investigate Audit findings,
Root Cause Production, Inspection Data, Product returns, Warranty etc)
Understand and State the Problem

Understand the Problem

From the event, what is the problem to
be solved,
what is the customers concern?

More than one Problem?

An event could have more than one problem,
with a root cause for each problem.

If you cannot say it simply, you do not

understand the problem!
A Cause . . .

Is a set of circumstances or conditions


Allows a condition to exist or an event

to happen,


Makes a condition exist or an event

The Critical Five

Direct Cause: The cause that directly resulted in

the event.
(The first cause in the chain.)

Contributing Cause: The cause(s) that

contributed to an
event but, by itself, would not have caused the
(The cause after the direct cause.)

Root Cause: The fundamental reason for an

which if corrected, would prevent recurrence.
The Critical Five

Specific Corrective Action: Action(s) taken to

correct or
improve conditions noted in the event, by changing
direct cause
The direct cause and the effect.

Preventative Corrective Action: Action(s) taken

prevent recurrence of the condition noted in the
Root Cause/ Corrective Action
The process requires complete honesty
and no
predetermined assumptions.

Follow the Data! Dont try to lead it.

A common cop-out: Operator error

Why do people not comply?
Improper instructions
Worn-out tools
Improper training
Lost expectations
Root Cause/ Corrective Action

Dont limit the search !

What role did management systems play?

Are you looking beyond your own backyard?
Remember the 80/20 rule.

Be attentive to causes that show

up frequently!
Root Cause/ Corrective Action

Utilize 5 Whys technique for

determination of cause and effect
Ask Why? 5 times.
Most problems, even the most serious or complex,
can be handled by using the 5 Why technique when
coupled with cause chain diagrams.

So, why use the 5 Why technique?
Root Cause/ Corrective Action

Just keep asking

Why did it happen?

Didnt get to work on time.

Car wouldnt start. Why?
Battery was dead. Why?
Dome light stayed on all night. Why?

Kids played in car, left door ajar.

Root Cause/ Corrective Action
The 5 Whys another example
Problem: Customers complain about waiting too long to get
connected to staff during lunch hours.
Why does the problem happen?
Backup operators take longer to connect callers.
Why does it take backup operators longer?
Backup operators dont know the job as well as the regular
operator/ receptionist do.
Why dont backup operators know the job as well?
There is no special training, no job aids to make up for the
gap in experience and on-the-job learning for back-ups.
Why dont they have special training or job aids?
In the past, the organization has not recognized this need.
Why hasnt the organization recognized the need?
The organization has no system to identify training
Decomposition Diagram
What it is: Poor
control of Don't know
Involves the use of manuf. how to Didn't
control the understand
tree structures to process
process implications of
break down the spec.
area/process under Didn't
study achieve
spec. first
A tree diagram time
where all items are
included Large volume of The designs
(comprehensively rework in PCB Boards been through
exhaustive) and not manufacture difficult several
repeated (mutually to make They're iterations
exclusive) designed
like that

When to use it:

Can be used as an Operations
analysis structure take no
Benefits: their work
Depicts a single make They rely
dimension of lots of upon
hierarchy mistakes Operators poorly
Why - Why (5 Whys) Analysis
Problem Why? Why? Why? Why? Why?
Poor control of
manufacturing Don't know how to
process control the process

Didn't understand
Large volume of Didn't achieve spec. implications of spec.
rework in PCB Boards difficult to The designs have first time
They're designed
manufacture make been through several
like that

Operators take no
responsibility for their
Operators make work They rely upon
lots of mistakes Operators poorly 100% inspection

suited to both Repetitive and Non-Repetitive Processes
Why - Why (5 Whys) Analysis

What it is:
A combination of a decomposition diagram and cause and effect diagram in tree
diagram format that shows the linkages between an effect and its root cause
When to use it:
When a cause and effect diagram has been built and the primary causes have
been identified, the 5 whys is used to delineate the causal linkages between the
final effect and the originating root cause. ** Dont be limited to only 5 whys:
the end point is the root cause
Establishes the evidence chain (or the hypothesis thereof) so that confirming
facts and data can be collected to substantiate the sequence and the critical
dependencies between relationships and time sequences
Disciplines the problem solving team to critically examine assumptions and
evidence in order to support the relationships between each link. How do you
Case of a Broken
Why - Why Diagram
Waiting too long
Impatience Too slow
Wrong machine
No budget
Not trained No plan
No trainer

No plan to replace
MACHINE No budget No perceived need
BROKEN Age No one responsible
"Old reliable"
WHY? Non-business
Too many copies Wrong type machine

WHY? Not obvious needed

No limits
No one responsible
Root Cause/ Corrective Action
Direct Cause: The cause that directly resulted in the
(The first cause in the chain.)

Contributing Cause: The cause(s) that contributed to

event but, by itself, would not have caused the event.
(The cause after the direct cause.)
Note: For a simple problem there may not be any contributing causes.

Root Cause: The fundamental reason for an event,

which if corrected, would prevent recurrence.
(Last cause in the chain.)
The Cause Chain

Root Cause Analysis
Lets expand on a problem Cause and Effect
Received ticket for safety violation
- Car exhaust too loud
- Muffler knocked loose from tailpipe
- Daughter hit pot hole
- Pot holes in road
- Winters damage roads
- Congress wont approve extra
money for better roads
- Congress doesnt have extra money
- Congress spend money on pork barrels
- Too many lawyers in Congress

Drive in Sweden, where there are fewer Lawyers.
Root Cause Analysis

Utilize appropriate toolset with the

team. Uncover the root cause. Test
and formulate corrective action.
Brainstorming, Pareto analysis, Cause and Effect
analysis, X-Y matrix
Process audit, Benchmarking
Consensus, mistake proofing (poka-yoke)
Statistical analysis, quality function deployment
Opportunity for simplification - Integration and
standardization (refer to VE & VA module)
Root Cause/ Corrective Action

Corrective Action:

A set of planned activities (actions)

implemented for the sole purpose of
permanently resolving the problem.
Root Cause/ Corrective Action

Two types of Corrective Action:


These two types of corrective action are

quite different in how they are applied and
what they do. Not understanding this leads
to serious mistakes in fixing problems.
Root Cause/ Corrective Action

Specific Corrective Action:

Action(s) taken to correct the direct cause.
(Corrects, or improves the condition noted
in the
event, by changing the direct cause, or the
cause and effect.)

Sometimes called containment

Only used to correct the DIRECT cause
Does not prevent recurrence !
Root Cause/ Corrective Action

Preventive Corrective Action:

Preventive corrective actions focus on
the root cause and any contributing

You probably wont get a 100% effective

fix at just one point (the root cause).

You often have to consider two or more

contributing causes to ensure the chain
is broken.
Root Cause/ Corrective Action

Preventive Corrective Action:

Action(s) taken prevent recurrence of the
condition noted in the event. (Preventive
actions must directly address the root
and contributing causes to be effective.)
Preventive Corrective Action



Root Cause/ Corrective Action

Test the specific solutions to

ensure they are valid:
Do the corrective actions eliminate or
control the direct cause?

Are the results desirable?
Root Cause/ Corrective Action

Example (ask Team)
Root Cause/ Corrective Action

Preventive Action Test:

If these preventive corrective actions
were in place, would the event have

Are there adverse effects caused by

implementing the corrective actions that
make them undesirable?

Do the preventive corrective actions

lower the risk factor of the event to an
Root Cause/ Corrective Action

Basic elements of reporting:

Restatement of the problem/ event/
Data (who, what, where, why, how, etc.)
Team (natural work group, qualified)
Causes (root, direct, contributing)
Corrective Actions (specific, preventive,
Milestone dates (Analysis complete, C/A
initiated, C/A implemented, Corrective
Action Report closed)
Tracking Form - example

Basic tracking form

Corrective Action Matrix (CAM)

Refer to - webpage (tools)
Tracking Form - example
NOTE: Blank form located on free lean site
Watson - Weekly Update Date Entered Start
Location Actions Resp
For w/e - FRIDAY 4/22/2005 into Matrix Date

Teach 2 Yellow Belt Training Sessions Schedule. Plan and

1 1/31/2005 LC JW 01/15/05
(usually offer 3 a year for new Dallas based employees) conduct YB training class

Set up
Dallas JW 01/15/05

Sent out invitations to

Dallas JW 01/29/05

1a Dallas CONDUCT 1st CLASS JW 02/10/05

1b Dallas CONDUCT 2nd CLASS JW 02/24/05

Assembly list, review to

BEGAN assembly of YB MASTER LISTING at Corporate 16-Feb Dallas JW 02/18/05
existing database

Set up
28-Feb Dallas JW 02/28/05

Sent out invitations to

28-Feb Dallas JW 02/28/05

1c 25-Feb Dallas CONDUCT 3rd CLASS JW 02/28/05

4-Mar Dallas Evaluate Performance JW 02/28/05

1d 4-Mar Dallas CONDUCT 4th CLASS JW 02/28/05
4-Mar Dallas Evaluate Performance JW 02/28/05
Root Cause/ Corrective Action


A review must be conducted in sufficient

detail to assess whether the corrective
actions that have been implemented are
effective as implemented and are truly
preventing recurrence of the event.
Root Cause/ Corrective Action

Effectiveness Measures
The criteria used to evaluate if the corrective
actions achieved the desired outcome.
Scrap quantities significantly reduced
Print was not manufactured to print tolerance. After
corrective action, part meets print.
Design could not be manufactured with current technology.
After corrective action, part can be manufactured with
current technology.
Parts would not assemble properly. After corrective action,
parts would assemble properly.
Root Cause/ Corrective Action

Did corrective actions work?

Some additional things to consider:
If corrective action implemented differs from proposed,
find out why.
If better or alternate corrective actions were implemented,
document the changes.
Periodic checks may be necessary to be sure the corrective
actions are still in place.
Document using the proper forms.
Root Cause Analysis - Overview

Root Cause Analysis

Corrective Action