1. MODULE 3
Analysis
Running, like solving problems, is a natural process that everyone “just learns as they go.”
Becoming a good runner however, takes training and practice that does not come naturally. Doing a good job of analyzing problems also takes training and practice.
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2. The process requires complete honesty and no predetermined assumptions.
Eliminating preconceived notions is critical. Preconceived notions cause the team to side track the process. It leads the team to ignore data that points to the real problem.
Follow the Data!!!
Don’t try to lead it.
This process is a tool to be used to get a permanent fix. You won’t get it if you try to force the analysis into supporting a preconceived corrective action.
Remember: don’t get personal. It’s not a witch hunt. What we really want to know is: Why did it happen? Not who did it.
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3. “Operator Error”
Used too often.
Used as the easy way out.
Be careful when your analysis leads you to this cause. We’re all operators. We all have tasks to do. Blaming the operator is used much to often and usually means you stopped searching too early. Continue to look at why the operator may have done it that way. Ask yourself; if the operator was replaced with someone else, could the event still happen? If yes, then it wasn’t just operator error!
Why do people not perform?
Improper instructions
Improper tools
Improper training
Lost expectations
Were the instructions complete, clear, accurate, and were they understood by the user?
Were the right and necessary tools there?
Was the training proper and complete for the job?
Have the expectations been clearly stated and are they built into the working environment? Has the operator been given an expectation that can’t be taken seriously?
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4. Don’t limit the search! Remember the 80/20 Rule
Don’t be afraid to look at management systems and procedures as causes. A missing, incomplete, or improper system of doing business is found to be a major cause about 85% of the time!
Don’t be afraid to look beyond the areas you work in. Problems that come from other departments can and must be addressed.
Remember the 80/20 Rule
80% of the problems can be attributed to 20% of the causes. Be attentive to causes that show up frequently.
What role did management systems play?
Are you looking beyond your own back yard?
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5. Even the most serious or complex problems can be handled by using the Why-Why method coupled with cause chain diagrams.
Why Why-Why?
(Effect & Cause)
The “Why-Why” analysis method is used by everyone, everyday. It’s a natural, logical progression for thinking through a problem. You learned it as a child. Given a structure to apply it in makes it a powerful tool.
CHAINS ARE THE SECRET
Using cause chain diagrams allows you to handle large or complex problems that are impossible for the human brain to see as a whole. They also keep you honest!
Fast
Informal
Natural to use
Universal
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6. Take small steps! The best question is one that starts with “Why?”
Just keep asking “Why?”
Event: Didn’t get to work on time.
Eq:  Why were you late?
Car wouldn’t start
 Why didn’t it start?
Battery was dead.
 Why was the battery dead?
Dome light stayed on all night.
 Why was the light on?
Kids played in car, left door ajar.
Take small steps!
Work from an effect back to a cause, restate the cause as a problem (Why…?), and find the next cause. Repeat until you run into success!
Keeping it simple is the secret to the process. Asking complex or poorly focused questions will lead you off the correct path and waste time.
The best question is one that starts with
“Why?”
It will get you the most data!
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7. (The causes after the direct cause.)
So what does Why-Why do for you?
It gets answers for you, special answers called causes.
Direct Cause: The cause that directly resulted in
an event. (The first cause in the chain.)
This is the answer to your first question (your problem statement).
Contributing Cause: The cause that contributed
to an event but, by itself, would not have
caused the event.
(The causes after the direct cause.)
Note: For a simple problem, there may not be any contributing causes. For a complex problem there could be dozens.
Root Cause: The fundamental reason for
an event. (The last cause in the chain.)
Use the root cause definition to sort out contributing
causes at the end of a chain.
As will be shown, the root cause is not always the most significant cause in the chain and sometimes it can’t be corrected easily or well. Focus instead on the fact that it is just the last cause in the chain.
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8. Putting labels on the chain
Event: didn’t get to work on time.
EQ: Why were you late?
DC: Car wouldn’t start.
CC: Battery was dead.
CC: Dome light stayed on all night.
RC: Kids left door ajar.
Picking up the pieces
Event
Direct Cause
Contributing Cause
Contributing Cause
Contributing Cause
Contributing Cause
Root Cause
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9. How many Root Causes can you have?
Event
Problem One
Problem Two
Direct Cause
Direct Cause
Root Cause
Root Cause
Two, if your event leads to two problem statements. Each problem will have it’s own cause chain ending in a root cause.
Event
Direct Cause
Contributing Cause
Contributing Cause
Root Cause
Root Cause
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10. How many Root Causes can you have?
Event
Direct Cause
Contributing Cause
Contributing Cause
None, if the trail is lost! There are occasions when the chain stops because there is no more data. People retire, records are missing, the problem is very old, etc. In some cases the organization you may be responding to will request that you call the last available cause in this chain the root cause.
How many Contributing Causes can you have?
Event
Direct Cause
Contributing Cause
Root Cause
Many to none, depending on the size of the problem. For small problems your direct cause could lead straight to the root cause. For big problems you may have to ask “Why?” many times before reaching the root cause. Each time you ask “Why?” after the direct cause gets you another contributing cause.
Big Clue!
When a cause has two or more items inside of it, it may be time for a branch! Follow up on each part of that cause by asking different questions.
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11. How to keep things straight:
Write down each possible cause.
Use the Why-Why process to sort.
Start with the event question!
Start with the event question. Asking that question will get you the direct cause. Rephrase the direct cause as a question (“Why did…?”). It will lead you to a contributing cause. Rephrasing that into another question will lead you to more causes.
Take small steps
Remember that some causes can branch off and lead to other problems. Jumping ahead by leading your questions can cause you to miss causes. When the chain leads you to several contributing causes, use the root cause definition to sort out the most significant cause, i.e., the most fundamental reason for the event.
Solutions come later!
Stopping to consider solutions for each cause will mislead you. Not all causes have solutions, nor do they necessarily need them. Build the cause chain first, then go on to solutions!
Test the chain.
Not sure if the chain is correct? Try it backwards. Begin with the root cause and ask “Does it follow that the (last cause) leads to the (previous cause)?” In our example, does the kids leaving the radio on lead to the battery going dead? Yes, it does. Therefore, that step in the chain makes sense.
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12. Find the Direct, Contributing, and Root causes.
Use only what you’ve been given for causes!!!
Remember: Some causes may not be directly related to the event, but are still contributing causes, and may point out that there are other problems to be solved. Some problems may not have a contributing cause between the direct and root cause.
Event 1. Kid comes home with an “A” on a test.
Causes: __ Kid knew the material.
__ New girlfriend would not go out on late date unless kid
passed test.
__ Kid studied real hard.
Event 2. Car engine dies coming up the highway ramp.
Causes: __ Bought dirty gas at cheap filling station.
__ Fuel line filter was plugged with dirt.
__ Engine stopped getting fuel.
Event 3. Mary hurried to pick up daughter at school. Ended up causing an accident during a heavy rainstorm.
Causes: __ Did not yield right of way at stop sign.
__ Mary was in a hurry.
__ Heavy rain reduced vision.
__ Mary wasn’t paying attention.
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13. Find the Direct, Contributing, and Root causes.
Use only what you’ve been given for causes!!!
Remember: Some causes may not be directly related to the event, but are still contributing causes, and may point out that there are other problems to be solved.
Event 4. Couldn’t get automatic car door locks to operate.
Causes: __ Battery was dead
__ Kids were playing in the car and left the radio on all afternoon.
__ Car battery was six years old.
Event 5. Window in front room was found broken.
Causes: __ Daughter found gun and was showing it off to a friend.
__ Daughter dropped gun.
__ Gun discharged through window.
__ Father did not have gun locked up.
Event 6. In-laws overstayed husbands’ welcome.
Causes: __ In-laws just retired and had lots of time on hands.
__ In-laws wanted to spend time with daughter.
__ Wife enjoyed parents’ visits and never limited their time.
__ Husband wouldn’t communicate his feelings with wife.
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14. Find the Direct, Contributing, and Root causes.
Use only what you’ve been given for causes!!!
Event 7. Oak floor in bedroom was damaged.
Causes: __ Water soaked into the floor and warped the boards.
__ Water bed mattress and liner were leaking.
__ Short in bed heater burned through the mattress and liner.
Event 8. Parents find large hole in ceiling.
Causes: __ Kids hid in attic to smoke cigarettes.
__ Kids were walking in attic and slipped off one of the rafters.
__ Heavy smoke irritated eyes and made it difficult to see.
Event 9. Car exhaust makes loud noise during acceleration.
Causes: __ Daughter hit large pot hole.
__ Muffler was knocked loose from exhaust pipe.
__ Muffler was badly rusted.
__ Hard winter damaged roads, creating too many potholes to avoid.
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15. Let’s go back and expand on one of the problems.
Effect & Cause
Received ticket for safety violation.
Car exhaust too loud.
Muffler knocked loose from tail pipe.
Daughter hit pot hole.
Pot holes in road.
Winters damage roads.
Congress won’t approve extra
money for better roads.
Congress doesn’t have extra money.
Congress spent money on pork barrels.
Too many lawyers in Congress.
Solution? Drive car in Sweden where there are fewer lawyers.
Like answering questions from a four-year-old child, asking why can be taken too far.
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16. Normal progression of any analysis is to move from a point of not knowing enough about why the event occurred (first X) to a point where the problem becomes well understood and workable (bottom of curve). Past the point the problem picks up a “Silliness Factor” and quickly becomes unworkable. Knowing where to stop takes practice, experience, and some help in defining the limits of a root cause.
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17. Root cause: Do we own it? Did you go too far?
If the root cause lies within our facility, inside the company, or even inside a vendor we have ownership.
You must identify the root cause even though you may not have the resources in your team to solve it. Do not use these tests as an excuse to take the easy way out and not follow the process to the root cause. Just because you feel a problem is beyond your personal ownership or the ownership of the natural team does not mean it’s beyond the company’s ownership.
There are rare occasions when the root cause has been properly identified, but has no solution. It’s still the root cause and needs to be documented as such. (Module 4 will discuss what to do when the root cause has no solution.)
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18. INSTRUCTIONS FOR MILL FIRE EXERCISE
Using forms 2a & 2b:
Use the data to build cause chains for the fire and the burns
Use the why - why method and start with your event questions.
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19. WITHOUT THEM YOUR CORRECTIVE
THE CAUSES ARE
YOUR KEYSTONES
Building a bridge between an event and a solution requires finding the correct causes. If you don’t know what caused the problem, how are you going to fix it?
Still Worried?
You may not be comfortable with the cause chain you have created. After all, how can you know if you put every cause in it’s right place?
Don’t worry. The strength of this process is that as long as you have identified all the major causes, the corrective actions will follow nicely. Module 4 will show you that the corrective actions look at the problem as a whole and aren’t based on a single cause.
If you’ve done a good job of digging up the causes you are well on your way to getting good solutions.
ROOT
DIRECT
CONTRI-
BUTING
WITHOUT THEM YOUR CORRECTIVE
ACTION WON’T STAND UP
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