Root Cause

Analysis
Group 1
Alfonso Billiones
Almontero Bolivar
Anievas Bonostro
Atim Camarse
Bamiano Campo
Bautista Carigma
Root cause analysis (RCA) is the process of
discovering the root causes of problems in order to
identify appropriate solutions. RCA assumes that it is
much more effective to systematically prevent and
solve for underlying issues rather than just treating
symptoms and putting out fires.
Origin

Before its current form as a widely used process

throughout all industries, RCA’s first appearance was
in the field of engineering. The method is credited to
none other than the founder of Toyota Industries Co.,
Ltd., Sakichi Toyoda.

Sakichi Toyoda has been called the

“King of Japanese Inventors” and
the “Japanese Thomas Edison.”
RCA can be decomposed into four steps:

• Identify and describe the problem clearly.

• Establish a timeline from the normal situation up

to the time the problem occurred.

• Distinguish between the root cause and other

causal factors (e.g., using event correlation).

• Establish a causal graph between the root cause

and the problem.
Examples

1. Imagine an investigation into a machine that stopped because it overloaded and

the fuse blew. Investigation shows that the machine overloaded because it had a
bearing that wasn't being sufficiently lubricated. The investigation proceeds further
and finds that the automatic lubrication mechanism had a pump which was not
pumping sufficiently, hence the lack of lubrication. Investigation of the pump shows
that it has a worn shaft. Investigation of why the shaft was worn discovers that there
isn't an adequate mechanism to prevent metal scrap getting into the pump. This
enabled scrap to get into the pump, and damage it.

The apparent root cause of the problem is therefore that metal scrap can
contaminate the lubrication system. Fixing this problem ought to prevent the whole
sequence of events recurring. The real root cause could be a design issue if there is
no filter to prevent the metal scrap getting into the system. Or if it has a filter that
was blocked due to lack of routine inspection, then the real root cause is a
maintenance issue.

Compare this with an investigation that does not find the root cause: replacing the
fuse, the bearing, or the lubrication pump will probably allow the machine to go
back into operation for a while. But there is a risk that the problem will simply
recur, until the root cause is dealt with.
2. A broken wrist hurts a lot but the painkillers will only take
away the pain not cure the wrist; you’ll need a different
treatment to help the bones to heal properly. In this example,
the problem is a broken wrist, the symptom is pain in the wrist
and the root cause is broken bones. So, unless the bones are
mended, the pain will not be cured.
 4M’s
Man Machine Method Material
Identifying resource requirements is typically seen as a
management activity in the business world. Organizational
failure is frequently caused by a failure to provide the
resources necessary by a corporation. In accordance to these,
the suggested 4M method considers all of the most critical
components of hand assembly, namely Method, Machine,
Man, and Material. The ultimate objective is to give a method
for improving product design, workstation ergonomics, and
assembly activities all at the same time.
Additional M’s have occasionally been added to the standard 4Ms over
time. Whether to direct more industry-specific thinking, illustrate tool
evolution or progress, or just make it more sophisticated as part of a
rebranding effort. The major four, on the other hand, haven't changed:

• huMan (Skill, Technology, Organization, Resources)

Do our employees have the ability (and the desire) to carry out their
responsibilities in a safe, consistent, and effective manner?

• Machine (Equipment)
Is our equipment capable of producing at the desired quality and pace
in a safe and dependable manner? Is their capacity to accomplish that target
hampered by breakdowns, faults, or unscheduled stoppages?

•Method (Process, Schedule, Procedure)

Do we have established standard work processes that assure and
promote consistent, safe production?
•Material (Information, Raw Materials, Consumables, Quality)
Are there any faults or shortages? Do they satisfy the relevant
specifications? Is there a reduction or elimination of excessive handling or
movement? Are they kept in the right place?

This method has been used for a long time, particularly in

root cause analysis (fish-bone diagrams, Ishikawa diagrams,
herringbone diagrams, cause-and-effect diagrams, and so on),
and it is believed that in the manufacturing environment,
people are very familiar with how to apply it to production
control, production improvement, overall efficiency
measurement, process design, and so on.
 4P’s
When formulating a fishbone diagram we anticipate the
potential causes of problems into their respective groups:

People
Policy
Procedure
Plant
People
- This section should be used to identify any people
causes to the problem.

Things to consider:

• Are the procedures being followed?

• Are they clearly communicated?
• Do employees know where to find the proper
procedures?
• Are we getting accurate results?
Policy
- Use this section to identify any organizational policies that
are in place that could be a cause to the problem. Policies
can usually be found by looking through Standard
Operating Procedures (SOPs), speaking with management,
or looking through employee handbooks.

Things to consider:

• Does the current policy conflict with another existing

policy?
• Does the current policy reflect what’s actually happening?
• Lack of a policy can also be a cause to a problem.
Procedure
- Similar to policies, lack of a procedure can also be a cause
to a problem. Procedures can also be found through
interviewing employees or looking through SOPs.

Things to Consider:

• Are the procedures being followed?

• Are they clearly communicated?
• Do employees know where to find the proper procedures?
• Are we getting accurate results?
Plant/Technology
- This section is used to identify any machine causes or
causes from technology.

Things to consider:

• Is there an issue with the current technology that is causing

the problem?
• Does the technology meet our demands?
• Do we have the right machines being used and are we using
them correctly?
• Is technology necessary?
 5 Whys
• Five whys (or 5 whys) is an iterative interrogative technique
used to explore the cause-and-effect relationships underlying a
particular problem. The primary goal of the technique is to
determine the root cause of a defect or problem by repeating
the question "Why?". Each answer forms the basis of the next
question. The "five" in the name derives from an anecdotal
observation on the number of iterations needed to resolve the
problem.

• Not all problems have a single root cause. If one wishes to

uncover multiple root causes, the method must be repeated
asking a different sequence of questions each time.
 HISTORY
• The technique was originally developed by Sakichi
Toyoda and was used within the Toyota Motor
Corporation during the evolution of its manufacturing
methodologies. It is a critical component of problem-
solving training, delivered as part of the induction
into the Toyota Production System.
TECHNIQUES
Two primary techniques are used to perform a five whys
analysis:

• the fishbone (or Ishikawa) diagram

• a tabular format

These tools allow for analysis to be branched in order to

provide multiple root causes
EXAMPLES

Example 1: The vehicle does not start.

1. Why? – The battery is dead.
2. Why? – The alternator is not functioning.
3. Why? – The alternator belt has broken.
4. Why? – The alternator belt was well beyond its useful service life and
not replaced.
5. Why? – The vehicle was not maintained according to the recommended
service schedule. (Root cause)

Example 2: Cause of Tom’s Accident.

1. Why? – Tom is injured.
2. Why? – Did he fall
3. Why? – Was the floor wet.
4. Why? – Was the valve leaking.
5. Why? – Did the seal fail. (Root cause)
 RULES OF PERFORMING A FIVE WHYS
ANALYSIS.

In order to carry out a five whys analysis properly, the

following advice should be followed:

1. It is necessary to engage the management in the five whys

process in the company. For the analysis itself, consider what
is the right working group. Also consider bringing in a
facilitator for more difficult topics.
2. Use paper or whiteboard instead of computers.
3. Write down the problem and make sure that all people
understand it.
4. Distinguish causes from symptoms.
5. Pay attention to the logic of cause-and-effect relationship.
6.Make sure that root causes certainly led to the mistake by
reversing the sentences created as a result of the analysis with
the use of the expression "and therefore".
7. Try to make answers more precise.
8. Look for the cause step by step. Don't jump to conclusions.
9. Base our statements on facts and knowledge.
10. Assess the process, not people.
11. Never leave "human error", "worker's inattention", "blame
John", etc. as the root cause.
12. Foster an atmosphere of trust and sincerity.
13. Ask the question "Why?" until the root cause is
determined, i.e. the cause the elimination of which will prevent
the error from occurring again.
14. When you form the answer to the question "Why?" it
should be from the customer's point of view.
CRITICISM

The five whys have been criticized as a poor tool for root cause
analysis. Teruyuki Minoura, former managing director of global
purchasing for Toyota, criticized them as being too basic a tool to
analyze root causes to the depth that is needed to ensure that they are
fixed. Reasons for this criticism include:

• Tendency for investigators to stop at symptoms rather than going on to

lower-level root causes.
• Inability to go beyond the investigator's current knowledge – the
investigator cannot find causes that they do not already know.
• Lack of support to help the investigator provide the right answer to
"why" questions.
• Results are not repeatable – different people using five whys come up
with different causes for the same problem.
• Tendency to isolate a single root cause, whereas each question could
elicit many different root causes.
Medical professor Alan J. Card also criticized the five whys as
a poor root cause analysis tool and suggested that it be
abandoned entirely. His reasoning also includes:

•The artificial depth of the fifth why is unlikely to correlate

with the root cause.
• The five whys is based on a misguided reuse of a strategy to
understand why new features should be added to products, not
a root cause analysis.
To avoid these issues, Card suggested abandoning the five
whys and instead use other root cause analysis tools such as
fishbone or lovebug diagrams.
Ishikawa
Diagram
Ishikawa Diagrams are sometimes referred to as fish
bone diagrams, herringbone diagrams, cause-and-effect
diagrams, or Fishikawa. They are causal diagrams created by
Kaoru Ishikawa to show the causes of a specific event. They
resemble a fish skeleton, with the "ribs" representing the
causes of an event and the final outcome appearing at the head
of the skeleton. The purpose of the Ishikawa diagram is to
allow management to determine which issues have to be
addressed in order to gain or avoid a particular event.
Kaoru Ishikawa

• He was born in the year 1915 and went on to complete his

engineering in applied chemistry from the University of
Tokyo.
• Also Known as the “Father of Japanese Quality”
• He invented major quality tools and concepts including the
Fishbone diagram (cause and effect diagram) frequently
used in the analysis of industrial processes and CWQC
Company-Wide Quality Control
Process to Make an Ishikawa Diagram

1. Agree on a problem statement (effect). Write it at the center

right of the flipchart or whiteboard. Draw a box around it and
draw a horizontal arrow running to it.
2. Brainstorm the major categories of causes of the problem. If
this is difficult use generic headings:
• Methods
• Machines (equipment)
• People (manpower)
• Materials
• Measurement
• Environment
3. Write the categories of causes as branches from the main
arrow.
4. Brainstorm all the possible causes of the problem. Ask
"Why does this happen?" As each idea is given, the facilitator
writes it as a branch from the appropriate category. Causes can
be written in several places if they relate to several categories.
5. Again ask "Why does this happen?" about each cause. Write
sub-causes branching off the causes. Continue to ask "Why?"
and generate deeper levels of causes. Layers of branches
indicate causal relationships.
6. When the group runs out of ideas, focus attention to places
on the chart where ideas are few.
Source of Variation

Manpower
The operational and/or functional labor of people engaged in
the design and delivery of a product. This is considered a fairly
rare “cause” of a given problem. Typically, if manpower is
identified as a cause of an unwanted effect, it’s often a factor
of another 6 M.

Method
A production process and its contributing service delivery
processes. Frequently, processes are found to have too many
steps, signoffs, and other activities that don’t contribute or
create much value. When not streamlined, simplified and
standardized, processes can be confusing and hard to follow.
Machine
Systems, tools, facilities and equipment used for production.
Often, machines, tools and facilities with their underlying
support systems are mismanaged or incapable of delivering a
desired output due to technical or maintenance issues.

Material
Raw materials, components and consumables needed to
produce a desired end product. Materials are often
mismanaged by way of being incorrectly specified, mislabeled,
stored improperly, out of date, among other factors.
Example
This fishbone diagram was drawn by a manufacturing team
to try to understand the source of periodic iron contamination.
The team used the six generic headings to prompt ideas.
Layers of branches show thorough thinking about the causes of
the problem.
For example, under the heading "Machines," the idea
"materials of construction" shows four kinds of equipment and
then several specific machine numbers.

Note that some ideas appear in two different places.

"Calibration" shows up under "Methods" as a factor in the
analytical procedure, and also under "Measurement" as a cause
of lab error. "Iron tools" can be considered a "Methods"
problem when taking samples or a "Manpower" problem with
maintenance personnel.
 Advantages and Disadvantages of Root
Cause Analysis

Advantages :

1. RCA usually helps in determining and identifying defect and

main causes of defect. By identifying root cause, once can find
out permanent solution to it so that possibility of its future re-
occurrence can be reduced or eliminated.
2. It helps in developing a logical approach to solving
problems. After identifying main cause of defect, one will try
to figure out and find out major problem-solving approaches
with help of information that is already present.
3. Once defect is determined, we can identify what all changes
are required for software quality improvement. We can identify
current needs as well as future needs for improvement of
organization and system.
4. It also helps in establishing repeatable and appropriate step-
by-step processes in which one process might confirm result of
another process.
5. It is used to analyze different activities of organizations like
• Analyze Quality Control
• Analyzing failure in maintenance
• Analyze process of system
• Analyze different system-based processes
• Analyze risk and change management
Disadvantages :

1. The main problem in RCA is that it only presupposes i.e.

assume and focus only one root cause of defect. But in reality,
situation can be more complex. There might be more than one
root cause of defect. So, one needs to focus on all aspects
related to defect and need to think about all root cause of
defect.
2. Organizations use RCA only to identify negative things that
are happening in organization. RCA can also be used to
identify good things that are happening in an organization.
RCA technique that is used to identify root causes of defects
can also be used to identify why some processes perform very
well in an excellent manner. Identifying positive points gives
another opportunity for continuous improvement.
 Other Types of Root Cause Analysis

Barrier Analysis

It is a technique that is used to investigate pathways that have a

negative impact on the target product. It simply analyzes why
and how barriers did not prevent energy flows from causing a
negative impact. It is simply a model or technique that is used
by several organizations to know that why a defect occurred
and how it can prevent reoccurrence.
Change Analysis

It is a type of analysis that is used to compare change that is

occurred to situations where change doesn’t exist or occurred.
Here, change is considered a problem or defect. Changes are
simply caused due to problems or defects. So, change analysis
simply determine what, where, how, and extent of the problem,
and then compare it with conditions or situations where a
particular defect is not present.
Events and Casual Factor Analysis

is a technique that is used commonly for both accidents as well

as other major incidents. In simple words, this analysis
technique simply analyzes events that lead to incidents and
identify causal and contributing factors that are possible for
each event.
Failure Mode and Effect Analysis

FMEA is basically a system engineering process to analyze

failure in system processes or products. It is simply done to
identify failures that might exist within the process of the
system or design of the product.

Pareto Diagram

It is a technique that is used to analyze only a limited number

of defects or problems and their causes. It simply states that
80% of problems or defects are caused only due to 20 % of the
problem. Therefore, it only focuses on top causes that are
needed to resolve or eliminated simply to solve more defects
or problems.