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Determining the Root
Cause of a Problem

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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

 Focus is on systems and processes

 Focus is not on individuals

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When Should Root Cause Analysis be

 Significant or consequential events
 Repetitive human errors are occurring during a specific

 Repetitive equipment failures associated with a specific

 Performance is generally below desired standard

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How to Determine the Real Root
 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

Problem – Flat Tire

 Why? Nails on garage floor

 Why? Box of nails on shelf split open

 Why? Box got wet

 Why? Rain thru hole in garage roof

 Why? Roof shingles are missing

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Pareto Analysis

Vital Few
Supplier Material Rejections May 06 to May 07

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Cause and Effect Diagram
(Fishbone/Ishikawa Diagrams)


“Four M’s” Model


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Cause and Effect Diagram
Loading My Computer


Inserted CD Wrong
Cannot Answer Prompt
Question Not Following Instructions are Wrong


Brain Fade Cannot

Not Enough Softwar
Power Interruption CD Missing

Free Memory e on PC

Bad CD Wrong Type CD Inadequate System

Graphics Card Incompatible
Hard Disk Crashed


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Tree Diagram
Result Cause/Result Cause/Result Cause

Result Primary Secondary Tertiary
Causes Causes Causes

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Tree Diagram
Result Cause/Result Cause/Result Cause

Lack of Models/
Benchmarks No Money for Reference


No Outside Input

No Funds for Classes
Research Not Funded

No Performance
No Consequences

Poor Safety Inappropriate

Performance Infrequent Inspections
Behaviors No Special Subject

Inadequate Training

Lack of Regular Safety

No Publicity
Lack of Employee

Attention Zero Written Safety
Lack of Sr. Management Messages

No Injury Cost

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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
—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

and create Happy Campers!

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 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
1. Five Whys
2. Pareto Analysis
3. Cause and Effect Diagram
4. Tree Diagram
5. 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”,


 “The Quality Freeway”, Goodman, 1990

 “Potential Failure Modes & Effects Analysis: A Business Perspective”, Hatty & Owens,

 “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,

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