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1Determining Root Cause1 Determining the Root Cause of a Problem Approved for Public Release.

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1 1Determining Root Cause1 Determining the Root Cause of a Problem Approved for Public Release

2 2Determining Root Cause2 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 Approved for Public Release

3 3Determining Root Cause3 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 Approved for Public Release

4 4Determining Root Cause4 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. Approved for Public Release

5 5Determining Root Cause5 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 Approved for Public Release

6 6Determining Root Cause6 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 (problem). Focus is on systems and processes Focus is not on individuals Approved for Public Release

7 7Determining Root Cause7 When Should Root Cause Analysis be Performed? Significant or consequential events Repetitive human errors are occurring during a specific process Repetitive equipment failures associated with a specific process Performance is generally below desired standard May be SCAR or CPAR (NGNN) driven Repetitive VIRs Approved for Public Release

8 8Determining Root Cause8 How to Determine the Real Root Cause? 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 Approved for Public Release

9 9Determining Root Cause9 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? Approved for Public Release

10 10Determining Root Cause10 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 Approved for Public Release

11 11Determining Root Cause11 Example of Five Whys for Root Cause Analysis 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 Approved for Public Release

12 12Determining Root Cause12 Pareto Analysis Vital Few Trivial Many 60 % of Material Rejections Approved for Public Release

13 13Determining Root Cause13 Cause and Effect Diagram (Fishbone/Ishikawa Diagrams) EFFECT CAUSES (METHODS) EFFECT (RESULTS) “Four M’s” Model MAN/WOMANMETHODS MATERIALS MACHINERY OTHER Approved for Public Release

14 14Determining Root Cause14 Cause and Effect Diagram Loading My Computer MAN/WOMAN METHODS MATERIALSMACHINERY OTHER Cannot Load Softwar e on PC Inserted CD Wrong Instructions are Wrong Upside Down Backward Not Enough Free Memory Inadequate System Graphics Card Incompatible Hard Disk Crashed Not Following Instructions Cannot Answer Prompt Question Brain Fade CD Missing Wrong Type CD Bad CD Power Interruption Approved for Public Release

15 15Determining Root Cause15 Tree Diagram ResultCause/Result Cause Result Primary Causes Secondary Causes Tertiary Causes Approved for Public Release

16 16Determining Root Cause16 Tree Diagram Poor Safety Performance Stale/Tired Approaches Inappropriate Behaviors Lack of Employee Attention Lack of Models/ Benchmarks No Outside Input Research Not Funded No Money for Reference Materials No Funds for Classes No Consequences Infrequent Inspections Inadequate Training No Publicity Lack of Sr. Management Attention No Performance Reviews No Special Subject Classes Lack of Regular Safety Meetings Zero Written Safety Messages No Injury Cost Tracking ResultCause/Result Cause Approved for Public Release

17 17Determining Root Cause17 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 performance." —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. Approved for Public Release

18 18Determining Root Cause18 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 Approved for Public Release

19 19Determining Root Cause19 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 Approved for Public Release

20 20Determining Root Cause20 Successful application of the analysis and determination of the Root Cause should result in elimination of the problem and create Happy Campers! Approved for Public Release

21 21Determining Root Cause21 Summary: 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? Approved for Public Release

22 22Determining Root Cause22 Where Can I Learn More? “Solving a Problem & Getting Along: Toward the Effective Root Cause Analysis”, Khaimovich,1998. “The Quality Freeway”, Goodman, 1990 “Potential Failure Modes & Effects Analysis: A Business Perspective”, Hatty & Owens, 1994 “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, 1993 Approved for Public Release

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