DETERMINING THE ROOT

CAUSE OF A PROBLEM

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

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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

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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.

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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

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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

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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

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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
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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?
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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

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Example of Five Whys for Root Cause

Analysis
Problem - Flat Tire

Why?
Why?
Why?
Why?
Why?

Nails on garage floor

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

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

Count

120
100
80

Trivial Many

60
40
20

Defect
of

60 %
Material
Rejections

g o n e r ns ng e d rial ip e r on e d re ng rt s o n on ria l e d ng ss ed e r
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rk t at Oth nsio ag a g at e ns O th rat e d a ilu ag Pa ns t at a te ro d ark lin a g Ot h
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M e n B e ac a M m e r ig xc st ac in im e n M o M e a n am
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Count
Percent
Cum %

162139 34 20 19 19 15 15 14 14 11 9 7 7 3 3 3 3 2 2 1 5
32 27 7 4 4 4 3 3 3 3 2 2 1 1 1 1 1 1 0 0 0 1
32 59 66 70 74 78 80 83 86 89 91 93 94 96 96 97 97 98 98 99 99 100

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Cause and Effect Diagram

(Fishbone/Ishikawa Diagrams)
EFFECT (RESULTS)

CAUSES (METHODS)

Four Ms Model
MAN/WOMAN

METHODS

EFFECT

OTHER

MATERIALS

MACHINERY
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Cause and Effect Diagram

Loading My Computer
METHODS

MAN/WOMAN
Cannot Answer Prompt
Question

Inserted CD Wrong

Not Following
Instructions

Instructions are Wrong

Brain Fade

OTHER
Power Interruption
Bad CD

CD Missing
Wrong Type CD

MATERIALS

Not Enough
Free Memory

Cannot
Load
Softwar
e on PC

Inadequate System

Graphics Card Incompatible

Hard Disk Crashed
MACHINERY
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Tree Diagram
Result

Result

Cause/Result

Primary
Causes

Cause/Result

Secondary
Causes

Cause

Tertiary
Causes
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Tree Diagram
Result

Cause/Result

Cause/Result
Lack of Models/
Benchmarks

Stale/Tired
Approaches

Poor Safety
Performance

Inappropriate
Behaviors

No Outside Input
Research Not
Funded
No Consequences
Infrequent
Inspections
Inadequate
Training

Lack of
Employee
Attention

Cause
No Money for Reference
Materials
No Funds for
Classes
No Performance
Reviews
No Special Subject
Classes
Lack of Regular
Safety Meetings

No Publicity
Lack of Sr.
Management Attention

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Zero Written Safety

Messages
No Injury Cost16
Tracking

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.

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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
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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

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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!
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Summary:

1.
2.
3.

4.
5.

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
Five Whys
Pareto Analysis
Cause and Effect Diagram
Tree Diagram
Brainstorming

Common Errors of Root Cause

Where can I learn more?
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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
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