Comprehensive Guide to Root Cause Analysis: Understanding and Implementation

this course is intended to teach an individual or group with no prior knowledge of root cause analysis as well

as provide the knowledgeable individual an excellent review of the concepts we recommend that someone with prior

experience and training with root cause analysis teach the course if not being used as a course valuable information

can still be attained by following through the presentation if you have questions please visit

www. bis-pcbm we will review the definition of root cause the benefits of Performing

root cause analysis review a recommended problem solving process that contains root cause analysis steps provide

examples of problems addressed to root cause things to keep in mind when performing this analysis and finally a

summary review of the course upon completion of the course participants will be able to understand

the importance of Performing root cause analysis identify the root cause of a problem using the problem solving

process and understand the application of basic quality tools in the problem solving process here are some root cause

definitions 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 or the true reason that contributed to the creation

of a problem defect or non-conformance perhaps you have a your own example or

definition root cause analysis is part of a complete corrective action process getting to root cause is only half the

battle preventing the root cause requires many more additional steps such as identifying the problem containing

and analyzing the problem defining the root cause defining and implementing the actions required to eliminate the root

cause and validating that the corrective action prevented recurrence of the problem here are the benefits for why

your company should take the time on every problem to analyze down to the root cause you'll be saving time and

money because problems are not repeated problems are prevented in other areas communication improves between the

groups process cycle times improve since you've taken out the rework loops and the defects and you can secure long-term

company performance and profits with less rework and defects leads to increased

profits when should we perform root cause analysis well basically all the time

when you do not dig into a problem deep enough and and get into the details of the problems you should expect them to

continue to recur time and time again some of the reasons why problems occur include supplier defects scrap

problems audit findings safety issues budget problems machine defects excessive inventory computer issues and

human errors here is the usual versus preferred approach to problem solving in most

companies when a problem surfaces we firefight and try to put out the fire immediately this involves some kind of

quick fix or workaround to keep the process moving just as we find an acceptable Band-Aid fix that works

another fire starts somewhere else and we rush to fix it we never take the time to revisit these fires to figure out why

that they happened in the first place keep dealing with the same problems over and over again the preferred approach is

similar first we develop a quick fix for the problem however instead of rushing to the next issue of the day we take

some extra time to do root cause analysis so that same problem is not tomorrow's big fire or shows up again we

then implement the process change and check to see that it does not return and we inst institutionalize the solution so

other areas and groups do not have the same problem as well which one of these approaches will take longer to complete

obviously the preferred approach will take much longer so why should we take that extra time we must think in the

long term in 6 months or a year from now do we want to be dealing with the same number of problems as we are today or do

we want to have more time available to work on improving the process and other value added activities such as risk

mitigation and prevention if the problem is not stated in terms of money you will have a hard

time convincing management that is worth fixing ing it will also help you prioritize problems that have the

biggest impact financially typically we go after the most frequent problems and we may be missing those infrequent

problems that really hurt the company financially here's a basic example of how to attack a problem with the problem

solving process these are television sets with a defective screen that escapes to the

customer customers can be used as the internal customer such as another process area or the typical external

customer the one who pays for your product or service first we want to contain the problem we want to make

certain that the group or area and in this case it's our external customer that finds a problem does not

see it again so we put a containment around processes b c and d because we're not sure which one is actually driving

the issue but we're trying to keep the problem from getting to our customer once we better understand where

the problem originates we then isolate our containment around that process we allow the other processes to go back to

operating normally these processes should not see the problem return finally once root cause is

determined and prevented through process changes the containment effort should be lifted and the new process should no

longer create defects resulting from the same root cause there are three types of

corrective actions immediate is the action done to stop the immediate bleeding

permanent is typically done on a specific area or product to prevent the root cause from recurring this is where

most companies stop preventive is changing the process so the problem does not reoccur again in

that area or in any other area in the future this forces departments and groups to break down walls and

communicate for the good of the company here's an example of a transactional process showing the three

types of corrective actions if there's a documentation error the

immediate action is the reinspection of the paperwork for that specific error this might also include reworking the

document to get it back to an acceptable condition the permanent action is the changing of the form so that it cannot

proceed without the correct information going to the document in the future the preventive action is the

mistake proofing of all similar processes so that the error cannot be made again in the future in other

areas and if preventive action is not addressed problems will return here is another

example for the Meed action a part is removed and replaced in a product and it's

retested in the permanent action a product is redesigned to account for the part variability so it doesn't have a

problem in the future the preventive action is that we have a design process change so we require that variation

analysis testing on similar supplier Parts on future designs here's some more examples of the

difference between permanent versus preventive permanent would be trained employee on the proper machine use where

prevented would be made to training a requirement to new employees working in that

area permanent would be updating all customers with latest software revision to fix a problem and the preventive

would be checking for those same software bugs and making it into a checklist to perform prior to release of

the software permanent would be employees is fired for ethical

violation pre uh preventative would be ethics training developed and provided to all

employees here's a common simple and highly recommended eight-step problem solving process you may have another

process to use at your company and there often times there's a lot of overlap between problem solving

processes so hopefully the steps that we go through will be very similar the first and one of the most important

steps is to identify the problem to to address meetings can be drawn out and the teams can lose focus when the

problem is unclear it is very easy for teams to use meetings as opportunities to address other issues at the same time

which is taking them off track the five W's and 2 H's approach can help you get there simply answer the

who what where when and why and how and how many to help better Define the problem here's a description of the five

W and 2 questions for the who we want to know the individuals or the customers associated with the problem for the what

we want to know the problem statement or definition the when is the date and time when the problem was

identified where would be the location of the complaints whether that's an area facility or customer

segment why if there's any previously known explanations or ideas we'll get into the why as part of

our problem solving process the how how did the problem happen and how will the problem be

corrected and how many the size and frequency of the problem in most cases a team of affected

individuals should be brought together to discuss the issue problems can arise when the right people are not

involved try and keep the team between 4 to 10 people more than that can slow down the process it is recommended that

the team assigns a champion to oversee the problem until it is it is resolved they may play an active role in the

discussions or simply make certain the teams are meeting and that the progress is being made they may also be

responsible for taking issues up to leadership as the problems become more defined and Analysis starts to drive the

team in One Direction it is normal for the team members to change initially step one will have the most team members

and towards the end of the process maybe only one or two people are still actively working the issue during the

root cause analysis step new members may be asked to participate based on their expertise in a certain area the

following are keys to success for working in a group first one is defining roles and

responsibilities each member must know what they're expected to bring to the table this assures the team that all

needed areas are adequately covered before beginning second note is to identify

external customer needs what outputs and results are expected from the customer and how will they be communicated at the

end of the project during only when needed those are the questions that need to be decided

upon identify internal needs what processes and procedures need to be followed and what systems are available

or required this may include corrective action process without the appropriate levels

of management supporting the effort the team will have a hard time implementing any actions or activities that will

result from the team's efforts clearly defined objectives and outputs are essential otherwise the team

May try to attack issues outside the scope of the analysis or get sidetracked by other problems that each group may

want resolved if all members are not involved in that in the discussions there will be

less Buy in to the resolution identify members who are not participating and ask for their opinions try to prevent

certain individuals from dominating the discussion good meeting location may not make the team perform any better but it

will prevent other distractions and issues that can really impact the team success here here are some other roles

and responsibilities the champion should be the mentor who can guide and direct the

teams and be an advocate to upper management the leader should be in charge of the day-to-day Authority

calling the meetings facilitating the team and Reporting up to the champion a Record Keeper or scribe is

the one who writes and publishes the meeting minutes and the participants need to have all their ideas respected

keep an open mind and know their roles within the team the third step is to address the immediate action needed to

keep the problem from spreading any further often times this involves some sort of Band-Aid or containment effort

such as sorting of parts or paperwork reinspection rework or recall whatever immediate action is done

it should only be temporary and not stay in place after the root cause has been corrected a check should also be made to

to see that the containment and immediate action actually kept the problem from spreading any further don't

just assume when we verify the immediate action we want to make sure that the

activity implemented to screen detect or Andor contain the problem was was effective we must verify that it was

through running pilot tests and making sure that another problem does not arise from our temporary

solutions we also need to ensure effective screens and detections are in place so that we do not further impact

the customer and it gives us time until the permanent solution is implemented step four is defining the

root cause first of all we want to brainstorm the possible causes of the problem with the team we recommend the

use of the cause and effect or fishbone diagram after brainstorming use the paral principle to determine which

causes to focus on or some sort of voting with the team members after selecting the most

probable cause there is still more analysis to perform use the five wise methodology until you get to the root

cause the root cause will be a process that initially caused the problem to occur people departments groups or

machines are not the root cause try to take the try to take the root cause one more step to make sure the team

addresses the same problem as the company at the companywide level or outside of their own department or group

here's an example of a five wise with the Washington Monument first while the Washington Monument was deterior

deteriorating we first asked why and we determined that it's due to the use of harsh

chemicals the second why we figure out that they're cleaning it with the chemicals to get rid of the residue left

from the pigeons after that after the next why we find out that the pigeons were hanging

around to eat all the spiders which is why they were there making the mess when we ask why again find out that

the pigeons were there because there's a lot of spiders who were there eating the gats that were near the

monument we ask why again and we find out that the gats were there because they were attracted to the lights at

dusk so we go down to a six Y and ask why are there so many gats there attracted to the lights and we find out

that the lighting the timing of the lights didn't change with the seasons and so therefore it was

offset so as you ask why after each cause you can start to appreciate how complex the

problem might be if you were to stop after the first y you might try and change chemicals but that wouldn't get

the monument clean and you might have to increase the frequency of the cleanings which would incur additional costs if

you stopped a after asking the second why you might try and remove the pigeons from the area which might also be

costly if you never get to the true root cause you will often stop short of the best solution which is to develop a

system that self self adjusts the lights throughout the year anything prior to that solution will probably not be

sufficient and most likely will incur additional costs such as Exterminating the the spiders and the gats turning

lights off too early which it might cause security issues ETC in step five verification involves

testing of the proposed solution to make sure it will do what the team thinks it will prior to a full scale

implementation often times the solution solution can create additional problems if the solution will not work it is

better to find out in a beta or Pilot test environment rather than under normal operating conditions let's

discuss the difference between verification and validation verification assures that at

a point in time the action taken will actually do what is intended without causing another problem validation

provides a measurable evidence over time that the action taken worked properly and that problem has not returned

instead step six we are simply making sure to complete the action plans defined in step five you cannot verify

or validate until all actions have been completed if the actions are not fully completed or they're only partially done

the effectiveness of the solution will be jeopardized step seven involves

preparing the team for Action once the data analysis of the solution is complete who should be collecting the

data and for how long what type of data results will be deemed acceptable finally in Step eight the

team should review the data results to conclude whether the root cause was adequately

defin or that the corrective action put in place was effective if the problem still exists go back to either step four

and redefine the root cause or step five readdress the corrective actions put in place the problem went away formally

Clos the problem and celebrate success is extremely beneficial official of a financial savings impact of resolving

the problem is calculated many companies will redistribute a percentage of the cost savings back to the team members to

further support the importance of solving problems here's a first example we will go through we're going to walk

through this example using the quality tools in the problem solving process second example would be transactional

process step one identifying the problem a part polarity has been reversed on a circuit

board this may have been one incident or recurring problem identified from a Paro chart we next identify the correct team

members based on their roles in the company and how they can contribute to the problem solving effort the immediate

corrective action is that we'll have additional inspection added after this assembly process step to check for

reverse part defects we also have the last 10 lots of printed circuit boards reinspected to

check for similar errors to see if they got out we place our problem statement in the first box then we asked the first

why why was the part reversed the team determines that the factory worker was unsure of the correct

part orientation when performing the task often times teams will stop and assume that the problem is due to human

error this is not an acceptable root cause errors will always be made so teams must dig deeper to find a way of

making the process easier or find a better way of catching the problem sooner we again ask why why was the

worker unsure of the correct orientation when we answer the question on this y we find out that the part is not marked

properly the five y's implies asking why five times but it could be more than five asking at least five times forces

the team to dig beyond their own knowledge of the process and make certain that they don't stop short of

the root cause which is usually only two or three times in this step we ask again and we

find out that engineering ordered it that way from the vendor without any part markings

so now the team determines that the Engineering Process does not adequately account for manufacturing issues during

the selection or specification process notice that they did not put the blame on the individual engineer here are the

permanent and preventive actions the permanent solution will change the part for that particular problem the

preventive solution truly addresses the larger issue of selecting the parts correctly first time with orientation

markings instead of afterward when the problem is found here's a second example this one geared towards transactional or

office related processes the problem is the department didn't complete their project on

time here are the team members in step three we appli immediate action the team applies additional resources to get the

team back on schedule and no new projects were started until the root cause solution of this project was

completed why didn't the team complete the project on time the team decided to use the cause and

effect diagram to identify possible causes of the Project's delay each cause is placed in the appropriate

category we use four different categories for this cause and effect diagram Personnel procedures materials

and Equipment under the Personnel we identified three possible causes lack of

worker knowledge lack of resources or poor project management skills under equipment we identify inadequate

computer system in the material section we identified inadequate computer programs or poor documentation and under

procedures we identify a poor project plan the team decides based on experience and available data to focus

on the lack of resources as a major reason for the delay so the team determines that the

appropriate resources were not available when they're most needed to keep the project on

schedule that is only answering the first why in our five y exercise in the next why the team determines that the

project manner was not hired in time which had a huge impact on the project schedule the team keeps asking why this

time determining that the specifics for the project manager position were not clear and caused the human resources

department to contact and interview some candidates who were not fully qualified instead of stopping and

blaming the the HR department the team brings a representative from HR into the team to dig further after some

discussion the team determines that there are some problems with the internal job posting process which

allows the job specifics for this position to be overlooked or not clearly defined during the corrective action

phase the permanent action involves adding an additional full-time support person to the project the preventive

action addresses the process issue so that the problem does not happen again which is to develop a checklist form

with HR for submitting job openings in the future here are some hints about root causes and things to keep in mind

when doing per Performing root cause analysis remember just as one problem may have multiple root cause

possibilities one root cause may be causing multiple problems when you do root cause analysis

on a problem you will have one root cause however if you look at all the possible ways in which it could go wrong

you will find multiple things that need to be improved when you don't get to root

cause the process that creates it continues to send more problems and the problems will eventually return many

times a short period of time without recurrence does not mean the root cause has gone

away when at all possible brainstorm what possible root causes might be so you don't have to wait for a problem to

arise before it is fixed prevention is the key so let's review what we talked about you learned how to identify the

root cause why it is important a process for proper root cause analysis and how basic quality tools like five wise and

cause and effect diagram can be applied to examples if you have any questions about our root cause analysis training

or like to check out other courses we offer visit our site at bis-pcbm