Root Cause Analysis
Thomas S. Arneson
3/19/2016
Focus Consulting
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Agenda
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Introductions and the index card.
It’s the process more than the tools that
matter.
A couple of tools
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Fishbone Diagram
Five Why’s Table
Conducting Root-Cause Analysis on a real
problem using the Five Why’s Table
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Introduction
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Root Cause Analysis: A process to systematically
identify and understand the causes of a non-conformity
or undesirable condition.
Root cause analysis process has 5 distinct steps;
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Defining the problem
Understanding the process
Identification of possible causes
Collecting the right data
Analyzing the data
We are going to examine two methods of conducting a
root-cause analysis
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Steps in addressing a problem
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Immediate, what are you going to do to contain the
problem(stop the bleeding)?
Remedial, how far back does to problem go?
Intermediate, what are we going to do to get in a
position to keep going until we find out what caused
the problem?
Root: What is the root cause of the problem
Permanent, Follow the Plan, Do, Check and Act
cycle to permanently eliminate the problem.
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Overview
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Two broad types of analysis
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Failures in a system (Common Cause)
Improvement Projects (Special Cause
There are many methods to develop theories on causes
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Brainstorming
Nominal group technique
Storyboarding
Tabular Arrangement
Cause and effect diagrams (fishbone charts)
Force field analysis
Affinity Diagrams
Structure Tree
Why-why diagram (5 Why’s)
Interrelationship digraph
Program decision process chart
Matrix
Check sheet
Pareto analysis
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Many approaches
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Events and causal factor analysis — Widely used for major, single-event problems, such
as a refinery explosion, this process uses evidence gathered quickly and methodically to establish
a timeline for the activities leading up to the accident. Once the timeline has been established, the
causal and contributing factors can be identified.
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Change analysis — This approach is applicable to situations where a system’s performance
has shifted significantly. It explores changes made in people, equipment, information, and more
that may have contributed to the change in performance.
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Barrier analysis — This technique focuses on what controls are in place in the process to
either prevent or detect a problem, and which might have failed.
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Management oversight and risk tree analysis — One aspect of this approach is the use
of a tree diagram to look at what occurred and why it might have occurred.
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Kepner-Tregoe Problem Solving and Decision Making — This model provides four
distinct phases for resolving problems:
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Situation analysis
Problem analysis
Solution analysis
Potential problem analysis
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Process is important
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When carrying out root cause analysis methods and processes, keep these hints in
mind:
Many root cause analysis tools can be used by a single person. Nevertheless, the
outcome generally is better when a group of people work together to find the problem
causes.
Those ultimately responsible for removing the identified root cause(s) should be
prominent members of the analysis team that sets out to uncover them.
Once the solution has been designed and the decision to implement has been taken,
it can take anywhere from a day to several months before the change is complete,
depending on what is involved in the implementation process.
A recent survey of ASQ members found that the most
important success factor in conducting a root cause analysis
was the use of a team.
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Form a Team
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A typical design of a root cause analysis in an
organization might follow these steps:
A small team is formed to conduct the root cause
analysis.
Team members are selected from the business
process/area of the organization that experiences the
problem. The team might be supplemented by:
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A line manager with decision authority to implement solutions
An internal customer from the process with problems
A quality improvement expert in the case where the other team
members have little experience with this kind of work
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Conduct the Analysis
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The analysis can last several months, relatively evenly
distributed between defining and understanding the problem,
brainstorming its possible causes, analyzing causes and
effects, and devising a solution to the problem.
During this period, the team meets at least weekly, sometimes
two or three times a week. The meetings are always kept
short, at maximum two hours, and since they are meant to be
creative in nature, the agenda is quite loose.
One person in the team is assigned the role of making sure
the analysis progresses, or tasks are assigned to various
members of the team.
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Define the Problem
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What happened or should have happened
Where specifically was the problem found,
Who was involved (this is important because
they need to be involved in the team, think
voc)
When did it occur, over what period of time
How much be specific
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Understand the Process
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Set the boundaries, it begins with this and
ends with that
Flow chart the process
Review any corresponding procedures, work
instructions, drawings, specifications etc..
Understand the process as perfectly as
possible.
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Identify possible causes
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Develop theories
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Each step of the flow charted process
Logic trees
Brainstorming
Cause and effect
Five why’s
Agree on a theory
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Collect data on the theory
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Know the cause and effect relationship to be tested,
key variables, form the data will be in,
Quantitative data
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Process data
Product data
Qualitative Data
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Descriptions of what was happening when the event
occurred, observing the process in operation.
Tip, interview people involved but prior to the interview ask
them to write down what they remember about the
situation.
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Analyze the data
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Pick the right tools
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Low frequency data
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High frequency tools
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Flowcharts
Compliance vs. results tables
Pareto Diagrams
Run charts
Affinity diagrams
Analyze the variation
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Fishbone Diagram
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Three step process
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Fill in the chart with process steps examining 5 M’s and 1
E
 Material
 Method
 Machinery
 Manpower
 Measurements
 Environment
Select top three for testing, develop action plan for those
selected (NGT or Multi-Voting)
Test the potential solutions
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Example
Root Cause Analysis, coating for Part 4005WF2X
Manpower
Methods
Washing Operator
Materials
Washed
Heated
Dipping Operator
Coated
Material Handler
Cleaning solution
Transported
Baking Operator
Polyethylene
Inspected
Inspector
Packaging
Baked
Shipping Manager
Inspected
Relief Operator
Part
Packaged
Shipped
Shipping packaging
Voids Coating
4005WF2X
Shipping Report
Baking Oven
Production and
Scrap Report
WIP Box
Dipping tray
Heating Oven
Machinery
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Plant Humidity
Speed Gage
Temperature gage
Measurement
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Plant Temp
Environment
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Five Why Method
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Four step process
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Create good understanding of what we know about the
problem and a list of “theories” of why problem happened,
ask why five times for each “theory”, select most likely
causes
Rank them in importance/most likely causes problem
Evaluate each of the potential causes
Test the theories selected to determine if solves the
problem
Exercise Why do we get such low attendance to
monthly meetings?
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Exercise
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Why do we get such low turnout to our
monthly ASQ section meetings?
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Defining the problem
Understanding the process
Identification of possible causes
Collecting the right data
Analyzing the data
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5 Whys Steps
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Develop Theories
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Rank the potential why’s
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Take time afterwards to combine as appropriate.
Ask why for each theory at least five times
Why’s that appear most frequently
Multi-voting (each participant gets the same number
of votes as there are team members, pile on one or
spread them out.
Evaluate the potential causes
Test the results PDCA
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Evaluation Matrix
Potential
Root Cause
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Root Cause
or
Symptom?
Causes
00% of
problem
Actionable
(dug deeply
enough to
lead to
corrective
action
yes/no
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How verify
System
related
yes/no
Other
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Summary
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We have taken a closer look at the 5 why’s
method
Follow the process use the tools, be careful
don’t jump to conclusions and remember to
keep you notes, if the problem comes back
you don’t want to start over from scratch
Thank you for the opportunity to work with
you
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Where to Get More Information
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WWW.ASQ.ORG
Juran’s Quality Control Handbook
The Core of Problem Solving and Corrective
Action by Duke Oakes
Focus Consulting
1622 48th Avenue
San Francisco, CA
270-860-8062
tarneson@gmail.com
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