1. Root Cause Analysis
Thomas S. Arneson
12/26/2018
Focus Consulting

2. Agenda Introductions and the index card.
It’s the process more than the tools that matter.
A couple of tools
Fishbone Diagram
Five Why’s Table
Conducting Root-Cause Analysis on a real problem using the Five Why’s Table
12/26/2018
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3. Introduction
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;
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
12/26/2018
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4. Steps in addressing a problem
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.
12/26/2018
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5. Overview Two broad types of analysis
Failures in a system (Common Cause)
Improvement Projects (Special Cause
There are many methods to develop theories on causes
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
12/26/2018
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6. Many approaches
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.
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.
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.
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.
Kepner-Tregoe Problem Solving and Decision Making — This model provides four distinct phases for resolving problems:
Situation analysis
Problem analysis
Solution analysis
Potential problem analysis
12/26/2018
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7. Process is important
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.
12/26/2018
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8. Form a Team
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:
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
12/26/2018
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9. Conduct the Analysis
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.
12/26/2018
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10. Define the Problem 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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11. Understand the Process
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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12. Identify possible causes
Develop theories
Each step of the flow charted process
Logic trees
Brainstorming
Cause and effect
Five why’s
Agree on a theory
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13. Collect data on the theory
Know the cause and effect relationship to be tested, key variables, form the data will be in,
Quantitative data
Process data
Product data
Qualitative Data
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.
12/26/2018
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14. Analyze the data Pick the right tools Low frequency data
Flowcharts
Compliance vs. results tables
High frequency tools
Pareto Diagrams
Run charts
Affinity diagrams
Analyze the variation
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15. Fishbone Diagram Three step process
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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16. Example
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17. Five Why Method Four step process
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?
12/26/2018
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18. Exercise
Why do we get such low turnout to our monthly ASQ section meetings?
Defining the problem
Understanding the process
Identification of possible causes
Collecting the right data
Analyzing the data
12/26/2018
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19. 5 Whys Steps Develop Theories Rank the potential why’s
Take time afterwards to combine as appropriate.
Ask why for each theory at least five times
Rank the potential why’s
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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20. Evaluation Matrix Potential Root Cause Root Cause or Symptom?
Causes 00% of problem
Actionable (dug deeply enough to lead to corrective action yes/no
How verify
System related yes/no
Other
12/26/2018
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21. Summary 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
12/26/2018
Focus Consulting

22. Where to Get More Information
Juran’s Quality Control Handbook
The Core of Problem Solving and Corrective Action by Duke Oakes
Focus Consulting
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San Francisco, CA
12/26/2018
Focus Consulting