Training on Root cause

analysis /
Problem solving techniques

Dinesh Sharma
 Training Content
• Training Objectives
• What is Root Cause?
• Benefits
• The Problem Solving Process
• Examples and Exercises
 Training Objectives
Upon completion of this Training, participants
should be able to:

• Understand the importance of performing root cause analysis

• Identify the root cause of a problem using the problem solving process
• Understand the application of basic quality tools in the problem solving process

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 Definitions
Cause (causal factor): a condition or event that results in an
effect
Direct Cause: cause that directly resulted in the occurrence
Contributing Cause: a cause that contributed to the
occurrence, but by itself would not have caused the
occurrence
Root Cause: cause that, if corrected, would prevent
recurrence of this and similar Problems occurrences
 What is a root cause?
ROOT CAUSE =
• The causal or contributing factors that, if corrected, would prevent recurrence of the
identified problem

• The “factor” that caused a problem or defect and should be permanently eliminated through
process improvement

• The factor that sets in motion the cause and effect chain that creates a problem

• The “true” reason that contributed to the creation of a problem, defect or nonconformance

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 What is root cause analysis?
• A standard process of:

 identifying a problem
 containing and analyzing the problem
 defining the root cause
 defining and implementing the actions required
to eliminate the root cause
 validating that the corrective action prevented
recurrence of problem
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 Benefits
By eliminating the root cause…
You save time and money!
• Problems are not repeated
– Reduce rework, retest, re-inspect, poor quality costs, etc…
• Problems are prevented in other areas
• Communication improves between groups and
• Process cycle times improve (no rework loops)
• Secure long term company performance and profits

Less rework = Increased profits!

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 Importance of the root cause
Not knowing the root cause can lead to costly band aids.

• The Monument was degrading

Why? Use of harsh chemicals
Why? To clean up after pigeons
Why so many pigeons? They eat spiders and there are a lot of spiders at
the monument
Why so many spiders? They eat gnats and lots of gnats at the monument
Why so many gnats? They are attracted to the light at dusk.
Solution: Turn on the lights at a later time.

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When should root cause analysis
be performed?
When PROBLEMS occur !!

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 How does it differ from what we do now?

USUAL APPROACH
Firefighting! Problem
Problem
Immediate Containment reoccurs
Identified
Action Implemented elsewhere!

Find
someone to
blame!

PREFERRED APPROACH
Immediate Defined Solutions are
Solutions
Problem Containment Root Cause applied across
validated
Identified Action Analysis company and
with data
Implemented Process never return!

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 How does it work?

Defect found at “Customer”…

PROCESS PROCESS PROCESS PROCESS
A B C D

CUSTOMER

“Customer” can be
Internal or External

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 How does it work?

Contain the problem…

PROCESS PROCESS PROCESS PROCESS
A B C D

CUSTOMER

Nothing is allowed to further

escape to the customer

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 How does it work?

Contain the root process…

PROCESS PROCESS PROCESS PROCESS
A B C D

CUSTOMER

Nothing is allowed to further

escape to the next process

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 How does it work?

Prevent the problem…

PROCESS PROCESS PROCESS PROCESS
A B C D

CUSTOMER

Corrective action implemented

so root cause of problem does
not occur again!

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 But who’s to blame?
• The “no blame” environment is critical
• Most human errors are due to a process error
• A sufficiently robust process can eliminate human errors
• Placing blame does not correct a root cause situation
– Is training appropriate and adequate?
– Is documentation available, correct, and clear?
– Are the right skill sets present?

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 Corrective Actions
3 types of Action:

• Immediate action ( Correction)

– The action taken to quickly fix the impact of the problem so the “customer” is
not further impacted

• Permanent root cause corrective action ( Corrective action )

– The action taken to eliminate the root cause on the affected process or
product that prevents re occurrence of the problem with Systematic
Approach.

• Preventive action

– The action taken to Prevent the root cause of potential non conformity /
problem from any process or product with systematic Approach

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 Examples of Corrective Actions
Immediate (step #3)
All current batch of paperwork re-inspected by another
worker for same type of problem
Permanent (step #5)
Form changed to mandate completion of certain fields

Preventive (step #5)

Similar forms with same fields used all over in
company are changed to “mandatory”

If preventive not addressed, problem will return!!

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 Examples of Corrective Actions
Immediate (step #3)
Part removed and replaced in product, retested

Permanent (step #5)

Product redesigned to account for part variability

Preventive (step #5)

Design process changed to require variation
analysis testing on similar supplier parts

If preventive not addressed, problem will return!!

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 The Difference between
Permanent vs. Preventive Corrective Actions
Permanent
• Trained employee on proper machine use
• Changed product design to make parts easier to
assemble manually
• Specific customer document critical to project is
identified with red folder
• Update all customers with latest software revision
to fix problem
• Fallen patient given full-time assistant to provide
help moving around hospital
• Employee fired for ethical violation
Preventive
 Made training a requirement to new
employees working in that area
 Changed design guidelines to not allow
for use of part in full scale production
 All documents that are critical to project
are identified with red folders
 Check for those software bugs added to
checklist and performed prior to release
of software
 Process developed to identify “at risk”
patients for falls who require assistant
 Ethics training developed and provided
to all employees
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 Problem Solving Process
1

Identify
8 Problem 2

Validate Identify
Team
7 3
Problem
Follow Up
Plan Solving Immediate
Action

Process
Complete Root
Plan Cause

Action
6 Plan 4

5
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 Step #1
Identify the Problem
Very important!

• Clearly state the problem the team is to solve

– Teams should refer back to problem statement to avoid
getting off track
• Use 5W2H approach
– Who? What? Why? When? Where? How? How Many?

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 Step #1
5W2H
• Who? Individuals/customers associated with problem
• What? The problem statement or definition
• When? Date and time problem was identified
• Where? Location of complaints (area, facilities, customers)
• Why? Any previously known explanations
• How? How did the problem happen (root cause) and how will the problem
be corrected (corrective action)?
• How Many? Size and frequency of problem

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 Step #2
Identify Team
When a problem cannot be solved quickly by an individual, use a team!

• Should consist of domain knowledge experts

• Small group of people (4-10) with process and product knowledge,
available time and authority to correct the problem
• Must be empowered to “change the rules”
• Should have a designated Champion
• Membership in team is always changing!

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 Step #2
Key Ideas for Team Success

• Define roles and responsibilities

• Identify external customer needs
• Identify internal customer needs
• Appropriate levels of organization present
• Clearly defined objectives and outputs
• Solicit input from everyone!
• Good meeting location
– near work area for easy access to info
– quiet for concentration and avoiding distractions

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 Step #2
Roles and Responsibilities

• Champion: Mentor, guide and direct teams, advocate to upper

management
• Leader: day-to-day authority, calls meetings, facilitation of team, reports
to Champion
• Record Keeper: Writes and publishes minutes
• Participants: Respect all ideas, keep an open mind, know their role within
team

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 Step #3
Immediate Action

• Must isolate effects of problem from customer

• Usually “Band-aid” fixes
– 100% sorting of parts
– Re-inspection before shipping
– Rework
– Recall parts/documents from customer or from storage
• Only temporary until corrective action is implemented (very costly, but
necessary)
• Must also verify that immediate action is effective

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 Step #3
Verify Immediate Action

• Immediate action = activity implemented to screen, detect and/or contain the problem
•
• Must verify that immediate action was effective
– Run Pilot Tests
– Make sure another problem does not arise from the temporary solutions

• Ensure effective screens and detections are in place to prevent further impact to customer
until permanent solution is implemented.

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 Step #4
Root Cause
• Brainstorm possible causes of problem with team
• Organize causes with Cause and Effect Diagram
• “Pareto” the causes to identify those most likely or occurring
most often
• Use 5 Why? method to further define the root cause of
symptoms
– May involve additional research/analysis/investigation to
get to each “Why?”
• Must identify the process that caused the problem
– if root cause is company-wide, elevate these process issues
(outside of team control) to upper management to address
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 Step #4
Tools used

 brainstorming
 flowcharting
 cause & effect diagrams
 pareto charts
 barrier analysis
 change analysis
 5 Why
 failure mode, effect &
criticality analysis
 fault tree analysis

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 Step #4
5 Why’s
• Ask “Why?” five times
• Stop when the corrective actions do not change
• Stop when the answers become less important
• Stop when the root cause condition is isolated

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 What is a Cause-Effect Diagram?

• A Cause-Effect (also called “Ishikawa” or “Fishbone”)

Diagram is a Data Analysis/Process Management Tool
used to:

– Organize and sort ideas about causes contributing to

a particular problem or issue
– Gather and group ideas
– Encourage creativity
– Breakdown communication barriers
– Encourage “ownership” of ideas
– Overcome infighting

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 Cause-Effect Diagram

• A Cause-Effect Diagram is typically generated in a group

meeting
• It is a graphical method for presenting and sorting ideas
about the causes of issues or problems

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 Cause-Effect Diagram
• Steps used to create a Cause-Effect Diagram:
– Define the issue or problem clearly
– Decide on the root causes of the observed issue or problem
– Brainstorm each of the cause categories
– Write ideas on the cause-effect diagram. A generic example is shown
below:

Materials Methods

Environment Effect
Equipment People

NOTE: Causes are not limited to the 5 listed categories, but serve as a starting point

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 Cause-Effect Diagram

– Allow team members to specify where ideas fit into the diagram
– Clarify the meaning of each idea using the group to refine the ideas. For example:

Materials Methods

Incorrect Quantity Late Dispatch

Spillage
Incorrect BOL Shipping Delay
Wrong Destination

Traffic Delays

Shipping
Environment
Wrong Equipment
Problems
Weather Driver
Dispatcher Attitude
Breakdown Dirty Equipment Wrong Directions

Equipment People

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 Cause-Effect Diagram
• After completing the Cause-Effect Diagram, take the
following actions:
– Rank the ideas from the most likely to the least likely cause of the
problem or issue
– Validate all possible causes on genba w.r.t. defined requirements.
– Do why - why analysis to find out root causes for the problem.
– Develop action plans for identifying the essential data, resources
and tools

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 Expected Outcome

• Individuals have become part of a problem

solving team
• The sources of problems and other issues have
been identified using a systematic process
• Team members see issues from a similar
perspective
• Ideas and solutions are documented
• Communication is improved
• Team members assume ownership

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 Step #5
Corrective Action Plan

• Must verify the solution will eliminate the problem

– Verification before implementation whenever possible
• Define exactly…
– What actions will be taken to eliminate the problem?
– Who is responsible?
– When will it be completed?
• Make certain customer is happy with actions
• Define how the effectiveness of the corrective action will be measured.

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 Step #5
Verification vs. Validation
(Before) (After)

• Verification
– Assures that at a point in time, the action taken will actually do what is
intended without causing another problem

• Validation
– Provides measurable evidence over time that the action taken worked
properly, and problem has not recurred

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 Step #6
Complete Action Plan

• Make certain all actions that are defined are completed as

planned

• If one task is still open, verification and validation is pushed

back

• If the plan is compromised, most likely the solution will not

be as effective

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 Step #7
Follow Up Plan

• What actions will be completed in the future to ensure that

the root cause has been eliminated by this corrective action?
• Who will look at what data?
• How long after the action plan will this be done?
• What criteria in the data results will determine that the
problem has not recurred?

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 Step #8
Validate and Celebrate

• What were the results of the follow up?

• If problem did reoccur, go back to Step #4 and re-evaluate

root cause, then re-evaluate corrective action in Step #5
• If problem did not reoccur, celebrate team success!

• Document savings to publicize team effort, obtain customer

satisfaction and continued management support of teams

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 Hints about root causes
• One problem may have more than one root
cause
• One root cause may be contributing to many
problems
• When the root cause is not addressed, expect
the problem to reoccur
• Prevention is the key!

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 Specific Problem
What if root cause
is?
Operator did
not follow
instructions

Do we stop here?
 Specific Problem
Operator did not follow
instructions

Do standard work Create a

instructions exist? standard
instruction

Or do we Is the operator
trained?
Train operator

attempt to find
the root cause? Were work
Create a system
to assure
instructions correctly
conformity to
followed?
instructions

Are work Modify

instructions instructions &
effective? check
effectiveness

Do you have the

right person for this
job/task?
 Review
• You learned:
• How to identify the root cause
• Why it is important
• The process for proper root cause analysis
• How basic quality tools can be applied

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Manufacturing

Root Cause Analysis

Example #

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 Example

Identify Problem

A manager walks past the assembly line and notices a

puddle of water on the floor. Knowing that the water
is a safety hazard, she asks the supervisor to have
someone get a mop and clean up the puddle. The
manager is proud of herself for “fixing” a potential
safety problem.

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 But What is the Root Cause?

The supervisor looks for a root cause by asking

'why?’

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 Immediate Action
Knowing that the water is a safety hazard, the manager
asks the supervisor to have someone get a mop and
clean up the puddle.

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 Root Cause
Puddle of water on the floor

Why?

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 Root Cause
Puddle of water on the floor

Leak in overhead pipe

Why?

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 Root Cause
Puddle of water on the floor

Leak in overhead pipe

Water pressure is set too high

Why?

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 Root Cause
Puddle of water on the floor

Leak in overhead pipe

Water pressure is set too high

Water pressure valve is faulty

Why?

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 Root Cause
Puddle of water on the floor

Leak in overhead pipe

Water pressure is set too high

Water pressure valve is faulty

Valve not in preventative maintenance program

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 Corrective Action
• Permanent – Water pressure valves placed in
preventative maintenance program.

• Preventive - Developed checklist form to

ensure new equipment is reviewed for
possible inclusion in preventative
maintenance program.

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 Example

Identify Problem

Department didn’t complete their project on

time

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 Determine Team
• Team members:
1. Boss –
2. Worker –
3. Worker -
4. Project Mgr –
5. Admin –

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 Immediate Action
• Additional resources applied to help get the
project team back on schedule

• No new projects started until Root Cause

Analysis completed

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 Root Cause
Didn’t complete project on time

Why?

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 Cause and Effect
Procedures Personnel
Lack of worker
knowledge
Poor project plan
Poor project
mgmt skills Lack of resources

Didn’t complete
project on time

Inadequate
Poor Inadequate
computer
documentation computer system
programs

Materials Equipment

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 Cause and Effect
Procedures Personnel
Lack of worker
knowledge
Poor project plan
Poor project
mgmt skills Lack of resources

Didn’t complete
project on time

Inadequate
Poor Inadequate
computer
documentation computer system
programs

Materials Equipment

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 Root Cause
Didn’t complete project on time

Resources unavailable when needed

Why?

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 Root Cause
Didn’t complete project on time

Resources unavailable when needed

Took too long to hire Project Manager

Why?

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 Root Cause
Didn’t complete project on time

Resources unavailable when needed

Took too long to hire Project Manager

Lack of specifics given to

Human Resources Dept
Why?

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 Root Cause
Didn’t complete project on time

Resources unavailable when needed

Took too long to hire Project Manager

Lack of specifics given to

Human Resources Dept

No formal process for submitting job opening

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 Corrective Action
• Permanent – Hired another worker to meet
needs of next project team

• Systematic - Developed checklist form with

HR for submitting job openings in the future

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