4. What is Root Cause Analysis?
DEFINE
MEASURE
ANALYZE
-Structured approach
-To identify and change
IMPROVE
-To prevent recurrence
-To identify Lessons to be learned
-To achieve better consequences
CONTROL
5. Fixing the symptoms
Problem Logged by Pilot Ground Crew Action
• Left, inside,Looseon undermain landing
NoiseVolume is unbelievably
DME coming from
Evidence of leak in right the
Somethingmissingtire almost loud
#3 Engine main cockpit • Almost found set left, inside,brief
Evidence removed more midget
Something tightened in cockpit
Took hammer on wing after
Engine replaced to from
DME volume away
instrument panel. Sounds like a midget
gear
needs replacement believable level
main tire
search
with a hammer.
9. Example
Pareto
Environment Methods Manpower
Chart
Loose
Wires
Machine Material
10. Investigate the Root Cause
Method of “throwing out” any
Brainstorming possible idea that anyone on the
team thinks could be the cause.
Guidelines: Rules:
• Record all ideas One thought at a time
• No Judgment (there are no Don’t interrupt
“bad” ideas.
Don’t criticize
• Combine like ideas
Don’t discuss / analyze
• Rank in order of likelihood
Build on ideas
Record the ideas
Note: Say the first thing you
Collect as many ideas as you
think of.
can
11. Investigate the Root Cause
Method of “throwing out” any
Brainstorming possible idea that anyone on the
team thinks could be the cause.
Guidelines: Rules:
• Record all ideas One thought at a time
• No Judgment (there are no Don’t interrupt
“bad” ideas.
Don’t criticize
• Combine like ideas
Don’t discuss / analyze
• Rank in order of likelihood
Build on ideas
Record the ideas
Note: Say the first thing you
Collect as many ideas as you
think of.
can
15. The Titanic: a simple example
CAUSE
Why did the The
Titanic sink? Titanic
Sinks
EFFECT
March 7, 2012 15
16. CAUSE
Why did the Bulkheads Fill The
bulkheads fill w/Water, ship Titanic
with water? loses buoyancy Sinks
EFFECT
March 7, 2012 16
17. CAUSE
Why did
the seams
open up?
Bulkheads
Fill The
Seams of the
w/Water, sh Titanic
ship open up
ip loses Sinks
buoyancy
EFFECT
March 7, 2012 17
18. CAUSE
Bulkheads
Fill The
Rivet Heads Seams of the
w/Water, shi Titanic
Shear ship open up
p loses Sinks
buoyancy
Why did
the rivets
shear?
EFFECT
March 7, 2012 18
19. CAUSE
Side Impacts
Why did the
Iceberg; shear
titanic hit the
force applied
iceberg?
along side of
ship
Bulkheads Fill
Rivet Seams of The
w/Water, shi
Heads the ship Titanic
p loses
Shear open up Sinks
buoyancy
March 7, 2012
EFFECT 19
20. CAUSE
Systemic Causes Dark & overcast
Lookouts See
conditions reduce
Iceberg too late; Captain
swerve to avoid visibility
ignores
iceberg
Titanic sailing White Star pushes
warnings
too fast for for record crossing
conditions time
Side Impacts
Bulkheads Fill
Iceberg; shear Rivet Seams of The
w/Water, shi
force applied Heads the ship Titanic
p loses
along side of Shear open up Sinks
buoyancy
ship
March 7, 2012
EFFECT 20
21. Applying the 5 Whys
A Machine is leaking coolant
Why? Because the seal has broken
Why? Because the machine is overheating
Why? Because the air filter is clogged
Why? Because there isn’t a maintenance
check
Why? Because a procedure wasn’t
developed
22. Applying the 5 Whys to the
Loose Wires scenario
Group Exercise
23. Applying the 5 Whys to the
Loose Wires scenario
Group Exercise
24. Applying the 5 Whys to the
Loose Wires scenario
Group Exercise
Introduction – There are hundreds of problems that come up in the course of doing our business: A report is routinely late. Wires coming loose inside our cranes. A work process doesn’t achieve the right results. Customers are receiving the product as it was ordered, but the specs had errors. Or, even worse, the Customer is not receiving the product as it was ordered.And so sometimes, we find ourselves fixing the same problem repeatedly – for whatever reason, it’s not staying fixed. And if that’s the case, then the problems aren’t the real problems – they’re symptoms of a bigger problem. Root Cause Analysis can help you to dig down beyond the surface of a problem – past the symptoms. For example – When you’re sick, you experience a lot of different problems: Runny nose congested breathing headache sneezing coughing sore throat We often treat these symptom with some kind of over the counter medication – Dayquil, Tylenol Cold, throat lozenges. But the problem is that the symptoms return after the quick fix wears off. If we took the time to go to a doctor, he’d work with us to determine what the illness is, and he might even do some tests to verify his diagnosis, and then he’d prescribe an antibiotic to cure the illness. He investigates to determine the Root Cause of our illness.Click
And so we need to try to do the same thing.Solving problems effectively and efficiently means we need to have a process that is followed so that we can make sure we identify the problem, we understand it’s impact, find the root cause, implement an effective solution, and prevent the problem from returning. In today’s training I’m focusing on finding the Root Cause – so my objectives are to teach you how to make the best use of the data related to a problem in a process, and conducting a cause and effect analysis
In a perfect world suppliers would ship materials to us on time, our cranes would come out of the factory without any defects, on time, and the customers would always be happy. In a perfect world, things never go wrong.In the Real World things do go wrong in Business processes regularly.Either the product doesn’t work like it’s supposed to, or it isn’t shipped to the customer on timeOr suppliers don’t get materials delivered on time; or they create problems by supplying defective materialBecause problems hurt the customer – which in turn, hurts our business – they have to be addressed.To find out the best way to fix a problem, you have to drill down to its real cause
So what is Root Cause Analysis?Root Cause Analysis is a problem solving technique that is one part of Process Improvement Methodology – and there are many (8 D, Lean Six Sigma, etc.), But they have some common steps:Define – Define what the Problem is and how it affects the processMeasure – Gather Data that relates to the problemAnalyze – Review the Data and find the Root CauseImprove – Implement the correction to the processControl – Put controls in place to monitor and ensure there isn’t a return to what caused the problemRoot Cause Analysis a structured approachto identify and change the factors that resulted in harmful outcomes to prevent recurrence of similar harmful outcomes and to identify the lessons to be learned for the achievement of better consequences.The benefit of using Root Cause analysis is that it:Saves time and moneyEstablishes the cause of a business problemIt’s relatively simple to doIt’s empowering for the employees involvedFlexible methodOnce the Source of a problem is found – then possible solutions can be determined.
And so, what we really want is to not focus on the just the symptoms of a problem – And to do that it’s very important to Define the problem. To illustrate the importance finding the root causes of problems by sharing a little story.Apparently, after every Qantas Airlines flight the pilots fill out a form that lists any faults or problems they encounter – it’s known as a 'gripe sheet', And it basically is used to tell the ground crew engineers about any mechanical problems on the aircraft during the flight. The engineer is supposed to read the form, correct the problem, fill-in the details about what action taken, and return it for the pilot to review before the next flight.So here we see the pilot identifies a problem. It’s a little vague, but I think he makes it clear that a Tire should be replaced. But does the action of the Ground Crew solve the problem?Next (click) 1. Something loose in cockpit. 2. Something tightened in cockpit. (click) Evidence of leak on right main landing gear. Evidence removed. (click)1. DME volume unbelievably loud. 2. DME volume set to more believable level. (click)1. Number 3 engine missing. 2. Engine found on right wing after brief search. (click)1. Noise coming from under instrument panel. Sounds like a midget pounding on something with a hammer. 2. Took hammer away from midget.
When Analyzing a problem – it’s helpful to use some kind of visual representation to show the details in the process.Click If you had car wreck, and the insurance company asked for pictures, you’d probably take pictures of the part of your car that was damaged, the intersection it occurred at (making sure you showed road signs or signals that control traffic), and if possible, pictures of the other vehicles involved and their damage. You wouldn’t pose your family in front of the car and have everyone smiling – right?It’s the same for RCA - By using visual tools we can make it easier to see patterns. When we see patterns we can more easily identify and define the problem.In root cause analysis – we start off with Pareto Charts, Run charts, or Histograms to try and narrow the scope of our problem.ClickThis is one of our tools that most of you are familiar with. Here we’re using a Pareto Chart and a Run chart. And you can see from the high bars on the Pareto chart that we’ve identified a couple problems. But responding only to the issues on a Pareto chart isn’t how to get to the root cause.
Now – Pareto charts are very effective tools for a reason. The Pareto principle (also known as the 80–20 rule, and the law of the vital few) states that, for many events, roughly (CLICK) 80% of the effects come from (CLICK)20% of the causes. It isn’t always 80/20, but the effect us generally the same.The2 main benefits of using a Pareto Chart are:First – it breaks problems down into the “vital few” causes: The 20% of causes, that account for 80% of the problemsAnd Second – it puts the data into categories that are easier to analyzeClickIn this example, the tracking of various events over the course of a week shows us that “loose wires” is the biggest problem. The damaged motor is more likely an anomaly, and Oversized pins and the New Operator are the not as significant, but might be another cause worth investigating later if they worsen. So after identifying Loose Wires as the Problem, we now need to dig deeper to find the root cause.
So now we build a Cause and Effect Diagram – often known as a Fishbone Diagram or the Ishikawa Diagram. We use a Fishbone diagram in order to narrow our focus on what is causing the problem. There are 4 steps to building a Fishbone Diagram:ClickStep 1 – identify the problem (Head) and major categories (the Major categories can be steps in a process, or as I’m using, basic general categories – it’s up to you)Step 2 – Brainstorm – as a team or as an individual, take time to brainstorm all of the possible causes to the problemStep 3 – Enter Probable Causes – putting them under the applicable categoriesStep 4 – Prioritize 2 – 3 causes to investigate – pick a couple causes to further investigateAnd so we see that the finding from our Pareto chart (or any other tool we use) becomes the “Head” or the problem statement on our Fishbone Diagram. Our Major Categories, or big bones – are Manpower, Methods, Material, Machine and Environment. All those little bones are possible causes and contributors to causes, and they’re grouped under those major categories to keep you organized.One thing to be careful of when doing a Fishbone Diagram is when it starts to turn in to a Whalebone Diagram – which means it keeps growing to the point it covers all the walls in the conference room. That usually means you didn’t narrow your focus enough when you defined the problem, or the team has started to broaden the focus. Organizations that don’t know how to break a problem down into specific cause and effect relationships tend to only address the symptoms of the problem.
So, let follow an example of using this model. We’ve narrowed our focus using a Pareto Chart, Histogram, or Control chart which leads you to your problem statement – in this case Why are there loose wires?We then build the “big bones” of our fish bone diagram – and these are the major categories you chose to dig into, but for this example I’m using the standard for manufacturing: Material, Machine, Manpower, Methods, and Environment.We have identified Loose Wires as our problem statement, and we have the categories of Manpower, Methods, Material, Machine, and Environment under which we’ll list some possible causes.
At this time, within your groups – take 20 minutes to brainstorm possible causes amongst yourselves. Use the butcher-boards at your areas to build your Cause and Effect Diagram and build and record your ideas. I want you to avoid limiting yourself to any preconceived causes you might deal with normally. Instead, use the major categories to guide your brain-storming. In case you don’t know – Brainstorming is a method of a team throwing out any possible idea as it relates to the problem statement.I have some basic Guidelines and Rules posted to guide you in this process,And if you get stuck, don’t worry a small deck of cards with possible causes is provided - As you Brainstorm you are allowed to flip one card from the deck on your table, but only when the buzzer sounds – this represents the research you do to find possible causes – It might end up being something you already thought of or it might be something new. You may only flip a card when the buzzer sounds.
At this time, within your groups – take 20 minutes to brainstorm possible causes amongst yourselves. Use the butcher-boards at your areas to build your Cause and Effect Diagram and build and record your ideas. I want you to avoid limiting yourself to any preconceived causes you might deal with normally. Instead, use the major categories to guide your brain-storming. In case you don’t know – Brainstorming is a method of a team throwing out any possible idea as it relates to the problem statement.I have some basic Guidelines and Rules posted to guide you in this process,And if you get stuck, don’t worry a small deck of cards with possible causes is provided - As you Brainstorm you are allowed to flip one card from the deck on your table, but only when the buzzer sounds – this represents the research you do to find possible causes – It might end up being something you already thought of or it might be something new. You may only flip a card when the buzzer sounds.
So, you can see that in the course of our Brainstorming – we have several possible causes – and these are the issues that we’re going to dig deeper on.And so this takes us into doing the 5-Why analysisClick
How many of you have Children? Ok – then you’re already familiar with the 5 Whys Method! Why do birds have feathers? So they can fly Why do they fly? So they can catch bugs Why do they need to catch bugs? That’s what they eat Why do they eat bugs? And eventually, we as parents get to the answer we hope will end the questions: Because that’s how god made them.The 5 Whys is a questions-asking method used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the 5 Whys method is to determine a root cause of a defect or problem.So – as an example, I’m reminded about an article I read about the CEO of Amazon.com. Apparently, he had a tradition of visiting the Amazon.com Fulfillment Centers, spending time with the associates, and also physically working on the floor alongside everyone else. Anyway, during one visit, there had just been a safety incident where an associate had injured his fingers. When the CEO was told about this during a meeting, he was pretty upset and got very emotional — at first he was mad, but then felt really bad for this associate and his family. And so he got up, walked to the whiteboard and began to ask the 5-why’s:Why did the associates fingers get hurt? Because his fingers got caught in the conveyor.Why did his thumb get caught in the conveyor? Because he was chasing his bag, which was on a running conveyor.Why did he chase his bag? Because he placed his bag on the conveyor, but it then turned-on by surprise.Why was his bag on the conveyor? Because he used the conveyor as a table.Why was he using the conveyor as a Table? Because he didn’t have an area to keep some personal items.And so, the likely root cause of the associate’s damaged thumb is that he simply needed a table, there wasn’t one around, so he used a conveyor as a table. To eliminate further safety incidences, Amazon only neededto provide tables at the appropriate stations for the associates to use and also update and a greater focus on safety training. Also, look into preventative maintenance standard work.So – at this time take a 10 minutes to read the scenario about the Titanic in your handouts. After that we’ll use the 5 Why’s to show how we dig to the root of the problem.
So let’s conduct an exercise using the 5 Whys to examine why the Titanic Sank. (Click)We begin the 5 why with questioning the effect, and therefore:Beginning with the obvious question (click) – Why did the Titanic Sink?
Even though it’s an obvious answer – it is a fact, and a starting point. This is often why many times we are tempted to jump to a conclusion without seeing the process through. But this is a step that has to be made in the process of getting to the root, so don’t skip the ‘obvious’, or stop at at this point.
The open seams in the ship caused the bulkheads to fill with water, But (Click) Why did the seams open?
Rivets recovered in the debris field were found in great numbers to have been sheared at the rivet head. Sheared rivets allowed the seams of the ship to open, and water to fill the bulkheads.Witness accounts reported hearing ‘popping’ noises like ball bearings or marbles hitting the floor at the time of the impact.Click So, the next question is Why did the rivets shear
So at the 4th Why we get to the “causal mechanism”. A Causal Mechanism can best be described as the actual “physical cause” – in this case the force of the ship against the iceberg causing the rivet head to shear.We could go further and indentify why slag was in the rivets – but this was a scientific/manufacturing constraint at the time. In this case there is no action to prevent against the failure of the rivets. Any sideswipe can cause the rivets to shear – and that was well known by maritime officials of the time. So now we need to know (click)Why did the Titanic hit the iceberg?
And so now we come to a point with multiple systemic failures: the push for a record crossing, resulted in the Titanic was sailing too fast; The captain ignoring the iceberg warnings, and the reduced visibility; and the lookouts seeing the iceberg too late for the ship to swerve away, are all systemic causes for the ship colliding with the Iceberg. Now, this is a relatively simple example, but it does show the basic flow of causal mechanisms and the separation of systemic, enabling and physical causes.
So now lets look an one more example, This time we have a piece of equipment that’s leaking coolant. A group leader see’s the coolant on the floor, and it’s been a reoccurring problem. He’s completed a Fishbone Diagram, determined that a broken seal may be the likely cause, so now he’s ready to use the 5 Why analysis to get to the root of the problem. Why has the seal broken? The seal broke because the machine is overheating, and the heat weakened the seal.Why is the machine overheating? Because the air filter for the machine has become clogged with dust and debrisWhy is the Air Filter clogged with Dust and debris? Because maintenance isn’t checking to replace the filters.Why isn’t Maintenance checking? Because a preventative maintenance procedure wasn’t developed when the machine was installed.
So as a group now – take 20 minutes to use the 5 whys on the Cause and Effect Diagrams you developed for the Loose Wires problem. Pick one of the probable causes and try to follow the problem to a root cause.
Music slide only
Music slide only
So, what I hope you’ve learned about 5 Why is that the goal is to continue building on each answer until you come to the root. “5 Why’s” isn’t a number set in stone – sometimes it will take fewer, sometimes more – the point is not to stop until you reach a root cause.There are some pitfalls to be cautious of however – these include: Losing focus - not staying with the defined problem or starting another causal chain. Blaming – trying to pin cause to an individual (if it is, then ask Why? Follow the answers to the root). 5 Why is often not repeatable because different teams/individuals come up with different results
So in conclusion, using The Fishbone Diagram and the 5 Whys can be powerful tools for resolving problems. We’ve discussed methods for presenting data, such as the pareto chart, and how to conduct Cause and Effect Analysis using the Fishbone Diagram and 5 Why Analysis.These tools provide the benefit of: - A Structured Approach - That Addresses more than the symptoms of a problem - And provides Permanent SolutionAre there any questions?Please remember to complete a training evaluation sheet.
So in conclusion, using The Fishbone Diagram and the 5 Whys can be powerful tools for resolving problems. We’ve discussed methods for presenting data, such as the pareto chart, and how to conduct Cause and Effect Analysis using the Fishbone Diagram and 5 Why Analysis.These tools provide the benefit of: - A Structured Approach - That Addresses more than the symptoms of a problem - And provides Permanent SolutionAre there any questions?Please remember to complete a training evaluation sheet.
The first thing I want to talk about then is the Cause and Effect Diagram, also known as the Fishbone Diagram or the Ishikawa Diagram.
Here we have a Pareto Chart and a Run Chart paired up to measure problems with schedule adherence.
