Determining the Root

Cause of a Problem

Determining Root Cause 1

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 Why Determine Root Cause?

• Prevent problems from recurring

• Reduce possible injury to personnel

• Reduce rework and scrap

• Increase competitiveness

• Promote happy customers and stockholders

• Ultimately, reduce cost and save money

Determining Root Cause 2
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 Look Beyond the Obvious

• Invariably, the root cause of a

problem is not the initial reaction
or response.
• It is not just restating the Finding

Determining Root Cause 3

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 Often the Stated Root Cause
is the Quick, but Incorrect Answer
For example, a normal response is:
•Equipment Failure
•Human Error

Initial response is usually the symptom, not

the root cause of the problem. This is why
Root Cause Analysis is a very useful and
productive tool.
Determining Root Cause 4
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 Most Times Root Cause
Turns Out to be Much More
Such as:

• Process or program failure

• System or organization failure
• Poorly written work instructions
• Lack of training

Determining Root Cause 5

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What is Root Cause Analysis?

Root Cause Analysis is an in-depth

process or technique for identifying the
most basic factor(s) underlying a
variation in performance (problem).

• Focus is on systems and processes

• Focus is not on individuals

Determining Root Cause 6

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 When Should Root Cause
Analysis be Performed?
• Significant or consequential events
• Repetitive human errors are occurring
during a specific process
• Repetitive equipment failures associated
with a specific process
• Performance is generally below desired
standard
• May be SCAR or CPAR (NGNN) driven
• Repetitive VIRs
Determining Root Cause 7
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 How to Determine the Real
Root Cause?
• Assign the task to a person (team if necessary)
knowledgeable of the systems and processes involved

• Define the problem

• Collect and analyze facts and data

• Develop theories and possible causes - there may be

multiple causes that are interrelated

• Systematically reduce the possible theories and possible

causes using the facts

Determining Root Cause 8

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 How to Determine the Real
Root Cause? (continued)
• Develop possible solutions

• Define and implement an action plan (e.g., improve

communication, revise processes or procedures or work
instructions, perform additional training, etc.)

• Monitor and assess results of the action plan for

appropriateness and effectiveness

• Repeat analysis if problem persists- if it persists, did we

get to the root cause?

Determining Root Cause 9

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Useful Tools For Determining
Root Cause are:
• The “5 Whys”
• Pareto Analysis (Vital Few, Trivial Many)
• Brainstorming
• Flow Charts / Process Mapping
• Cause and Effect Diagram
• Tree Diagram
• Benchmarking (after Root Cause is found)

Some tools are more complex than others

Determining Root Cause 10

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Example of Five Whys for Root
Cause Analysis
Problem - Flat Tire

• Why? Nails on garage floor

• Why? Box of nails on shelf split open
• Why? Box got wet
• Why? Rain thru hole in garage roof
• Why? Roof shingles are missing

Determining Root Cause 11

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 Pareto Analysis
Vital Few
Supplier Material Rejections May 06 to May 07
180
160
140
120

Trivial Many
Count

100
80
60
40
20
0
r l r l r
60 % Defect
of ing t ion he io ns ing ge d e ria ship he t io n de d lure ing a rt s sio n tio n e ria de d ing e ss ged he
k t g t i g k t
a r t a O ns a a at n O ra e a a P n t a a t ro ar lin a O
Material M e n B e ac k am M ma e r igu xce st F ac k ing ime e n M o r M e a n am
r E im P D ct rk pli nf E e P ss D m c t , C B Cl D
lie cum rD
r o i E r B
Rejections p
p o ie p lie o rre W up Co Life b T SD r M EB o cu o rre te d lie E
u D p l p c S g f L a E i e D c s p
S r n l l n u
lie
p Su r In ro She lie r pp EB B I r R up
p Su i e W p u E lie S
p pl r lie r up S
pp
Su u p
p li e p S u
S p up S
Su S
Count 162139 34 20 19 19 15 15 14 14 11 9 7 7 3 3 3 3 2 2 1 5
Percent 32 27 7 4 4 4 3 3 3 3 2 2 1 1 1 1 1 1 0 0 0 1
Cum % 32 59 66 70 74 78 80 83 86 89 91 93 94 96 96 97 97 98 98 99 99 100

Determining Root Cause 12

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 Cause and Effect Diagram
(Fishbone/Ishikawa Diagrams)
CAUSES (METHODS) EFFECT (RESULTS)

“Four M’s” Model

MAN/WOMAN METHODS

OTHER EFFECT

MATERIALS MACHINERY
Determining Root Cause 13
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 Cause and Effect Diagram
Loading My Computer
MAN/WOMAN METHODS

Inserted CD Wrong
Cannot Answer Prompt
Question Not Following Instructions are Wrong
Instructions
Brain Fade Cannot
OTHER Load
Not Enough Softwar
Power Interruption CD Missing e on PC
Free Memory

Bad CD Wrong Type CD Inadequate System

Graphics Card Incompatible

Hard Disk Crashed
MATERIALS MACHINERY
Determining Root Cause 14
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 Tree Diagram
Result Cause/Result Cause/Result Cause

Result Primary Secondary Tertiary

Causes Causes Causes
Determining Root Cause 15
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 Tree Diagram
Result Cause/Result Cause/Result Cause
Lack of Models/
Benchmarks No Money for Reference
Materials
Stale/Tired No Outside Input
Approaches
Research Not No Funds for
Funded Classes

No Consequences No Performance
Reviews
Poor Safety Inappropriate Infrequent
Performance Behaviors Inspections No Special Subject
Classes
Inadequate
Training Lack of Regular
Safety Meetings
No Publicity
Lack of
Employee
Attention Zero Written Safety
Lack of Sr. Messages
Management Attention
Determining Root Cause No Injury Cost16
Tracking
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 Bench Marking
Benchmarking: What is it?

• "... benchmarking ...[is] ...'the process of identifying, understanding, and

adapting outstanding practices and processes from organizations
anywhere in the world to help your organization improve its
performance.'"
—American Productivity & Quality Center

• "... benchmarking ...[is]... an on-going outreach activity; the goal of the

outreach is identification of best operating practices that, when
implemented, produce superior performance."
—Bogan and English, Benchmarking for Best Practices

• Benchmark refers to a measure of best practice performance.

Benchmarking refers to the search for the best practices that yields the
benchmark performance, with emphasis on how you can apply the
process to achieve superior results.

Determining Root Cause 17

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 Bench Marking
All process improvement efforts require a sound
methodology and implementation, and benchmarking
is no different. You need to:

• Identify benchmarking partners

• Select a benchmarking approach
• Gather information (research, surveys, benchmarking
visits)
• Distill the learning
• Select ideas to implement
• Pilot
• Implement
Determining Root Cause 18
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Common Errors of Root Cause

• Looking for a single cause- often 2 or 3

which contribute and may be interacting
• Ending analysis at a symptomatic cause
• Assigning as the cause of the problem the
“why” event that preceded the real cause

Determining Root Cause 19

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Successful application of the
analysis and determination of
the Root Cause should result
in elimination of the problem

and create Happy Campers!

Determining Root Cause 20
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 Summary:
• Why determine Root Cause?
• What Is Root Cause Analysis?
• When Should Root Cause Analysis be
performed?
• How to determine Root Cause
• Useful Tools to Determine Root Cause
1. Five Whys
2. Pareto Analysis
3. Cause and Effect Diagram
4. Tree Diagram
5. Brainstorming
• Common Errors of Root Cause
• Where can I learn more?
Determining Root Cause 21
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 Where Can I Learn More?
• “Solving a Problem & Getting Along: Toward the Effective Root Cause
Analysis”, Khaimovich,1998.

• “The Quality Freeway”, Goodman, 1990

• “Potential Failure Modes & Effects Analysis: A Business Perspective”, Hatty

& Owens, 1994

• “In Search of Root Cause”, Dew, 1991

• “Solving Chronic Quality Problems”, Meyer, 1990

• “The Tools of Quality, Part II: Cause and Effect Diagrams”, Sarazen, 1990

• “Root Cause Analysis: A Tool for Total Quality Management”, Wilson, Dell &
Anderson, 1993

Determining Root Cause 22

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