Root Cause Analysis by Operational Excellence Consulting

© Operational Excellence Consulting. All rights reserved.
Root
Cause
Analysis
Identify, Eliminate, Prevent

© Operational Excellence Consulting. All rights reserved. 2
Objectives
1. Gain an overview of a problem solving process
2. Learn how to apply common Root Cause
Analysis tools such as 5 Whys and Cause &
Effect Diagram to identify root causes
3. Learn how to prioritize root causes with a
Pareto Chart
4. Understand the pitfalls in root cause analysis
NOTE: As this is a PREVIEW, only selected
slides are shown. To download the complete
presentation, please visit:
http://www.oeconsulting.com.sg

Program Outline
1. Introduction to Root Cause Analysis
2. Overview of a problem solving process
3. Root Cause Analysis using 5 Whys
4. Root Cause Analysis using Cause & Effect
Diagram
5. Root cause prioritization using Pareto Chart
6. Pitfalls to avoid

Introduction to
Root Cause
Analysis
1

“When we fail to
grasp the systemic
source of problems,
we are left to ‘push
on’ symptoms rather
than eliminate
underlying causes”.
- Peter Senge
The Fifth Discipline

What is Root Cause Analysis?
• Root Cause Analysis
(RCA) is a technique that
helps guide people to
discover and understand
the initiating cause(s) of a
problem, with the goal of
determining missing or
inadequately applied
controls that will prevent
recurrence.

Understanding Root Causes
Symptoms
 Result or outcome of the
problem
 What you see as a problem
(Obvious)
Causes
 “The Roots” – system below
the surface, bringing about
the problem (Not Obvious)
Symptoms
Causes
The Problem
 Gap from goal or standard
Problem
Infection
Fever
Achy, weak, tired

Why Root Cause Analysis?
• RCA helps to identify what, how, and why an
event or failure happened
• Root causes are underlying, are reasonably
identifiable, can be controlled by management
and allow for the generation of solutions
• Only when you are able to determine why an
event or failure occurred will you be able to
specify workable corrective and preventive
measures

Principles of Root Cause Analysis
• Systems thinking approach
• Prevention of recurrence
• Pareto principle
• Employee engagement
• Continuous improvement

Overview of
Problem Solving
Process
2

“The problems that
exist in the world
cannot be solved by
the level of thinking
that created them.”
- Albert Einstein

A Simple Problem Solving Process

Dealing with Root Causes
• Solutions must deal
with root causes, not
symptoms
• Ask “Why?” five times
to get to the root
cause
• Use the Cause and
Effect Diagram

5 Whys
3

“Every defect is a
treasure, if the
company can
uncover its cause
and work to prevent
it across the
corporation.”
- Kiichiro Toyoda,
Founder of Toyota

Benefits of the 5 Whys
• Help identify the root cause of a problem
• Determine the relationship between different
root causes of a problem
• One of the simplest tools; easy to complete
without statistical analysis

5 Whys Preparation
• It is said that a well defined
problem is a half resolved
problem; hence it is important to
state the problem as clearly as
possible.
• Whenever possible define the
problem in terms of the
requirements that are not being
met. This will add a reference to
the condition that should be and
is not.

5 Whys – Example 1
Why? Because…
1 Why is Tom injured? …he had a fall
2 Why did he fall? …the floor was wet
3 Why was the floor wet? …there was a leaking valve
4 Why was the valve leaking? …there was a seal failure
5 Why did the seal fail? …it was not maintained
1 3 4 52
A continuum of causes

Problem Evidence
Causes
Direct Indirect Root
Customers
complaining about
late deliveries.
On-time delivery
stands at 87%.
Packaging delays
creating a bottle-neck
of finished product.
Delivery of packaging
product is frequently
delayed from printer.
Films from art
department are being
held up waiting for
confirmations.
Need corporate
approvals for correct
usage of all company
logo marks.
Poor communication
between corporate
marketing and plants.
5 Whys – Example 2

Cause & Effect
Diagram
4

Cause & Effect Diagram
• Purpose
 To capture the causal relationship between cause and
effect
 To stratify the causes into meaningful groupings
• The Cause & Effect (C&E) diagram is also
known as the ‘Fishbone diagram’ or ‘Ishikawa
Diagram’

Cause & Effect Diagram (Manufacturing)
EffectCauses
cause
Machines
Measurements Materials
Methods
Mother Nature
Manpower
(Environment)
Problem
Statement

Manufacturing Example: Cause and effect diagram used in
solving the problem of “High Scrap of Barcode Labels”
MAN MACHINE
MATERIAL METHOD
Handling
Wrinkled
Torn
Improper
training
Machine
Breakdown
Ineffective
adhesive
Illegible
Smear
Printwheel Dirty
Worn Ribbon
Design of label
Damage
Poor printing
Improper storage
Wrong orientation
Process changes
Improper storage
Size of label
Process changes
High
Scrap of
Barcode
Labels

Combining 5 Whys and the Cause &
Effect Diagram
• The 5 Whys can be used individually or as a
part of the C&E diagram
• The C&E diagram helps you explore all potential
or real causes that result in a single defect or
failure
• Once all inputs are established on the fishbone,
you can use the 5 Whys technique to drill down
to the root causes

Pareto Chart
5

Pareto Chart
• Purpose
 To show relative significance of the identified root
causes
• When to use
 To differentiate the ‘vital few’ problems or causes from
the ‘trivial many’
 After improving a process, to show relative change in
the effect of the problem

Example: Pareto Chart
Wrong
Toppings
Pizza
Cold
Pizza
Late
Wrong
Crust
Tastes
Bad
Forgot
Breadstic
ks
Driver
Had No
Change
Smashed
in Box
Wrong
Price
Driver
Rude
All other
Quantity 29 25 22 13 10 7 4 3 2 1 2
Cum % 25% 46% 64% 75% 84% 90% 93% 96% 97% 98% 100%
% of Total 25% 21% 19% 11% 8% 6% 3% 3% 2% 1% 2%
0%
20%
40%
60%
80%
100%
120%
-
5
10
15
20
25
30
35
CumulativePercent
Occurences
Pizza Defects
Pareto Chart
January-02Time Period:

Pitfalls to Avoid
6

Pitfalls to Avoid
1. Not starting the RCA by looking at the impact
on the organization’s goals. This will help in
defining the problem to solve.
2. The use of RCA is focused only on analysis
rather than eliminating the problems.
3. The use of RCA is focused on identifying who
caused the problem, i.e. placing blame,
instead of finding out how the problem arises.

Pitfalls to Avoid
8. The success of 5 Whys is to some degree
contingent upon the skill with which the
method is applied; if even one Why has a bad
or meaningless answer, the whole procedure
can be thrown off.
9. The 5 Whys method isn’t necessarily
repeatable; three different people applying 5
Whys to the same problem may come up with
three totally different answers.

About
Operational
Excellence Consulting

About Operational Excellence
Consulting
• Operational Excellence Consulting is a management training and
consulting firm that assists organizations in improving business
performance and effectiveness.
• One of our unique strengths is going beyond a tools-focused
approach to seamlessly integrate people, processes, technology
and continuous improvement initiatives to suit the specific needs
and situations of our clients.
• We provide corporate learning programs and management advisory
services to assist our clients to achieve breakthrough in business
performance and effectiveness. Our aim is to support our clients in
designing, managing and executing lasting beneficial change.

To download this presentation,
please visit us at:
www.oeconsulting.com.sg
END OF PREVIEW

Root Cause Analysis by Operational Excellence Consulting

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