Root Cause Analysis


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Root Cause Analysis

  1. 1. Root Cause Analysis Problem Solving Method
  2. 2. Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. Proponents belief that problems are best solved by attempting to correct or eliminate root causes, than by treating the immediately obvious symptoms. Puspal 2
  3. 3. By directing corrective measures at root causes, it is hoped that the likelihood of problem recurrence will be minimized. - Wikipedia Puspal 3
  4. 4. General Principles of Root Cause Analysis Aiming corrective measures at root causes is more effective than merely treating the symptoms of a problem. To be effective, RCA must be performed systematically, and conclusions must be backed up by evidence. There is usually more than one root cause for any given problem. - Wikipedia Puspal 4
  5. 5. Example: Treating Symptoms Organizations have a well defined process for accepting, processing, and shipping customer orders. However, when a customer complains about not getting their order the most normal response is to expedite. This means that someone personally tracks down this customer's order, assigns it a #1 priority, and ensures it gets shipped ahead of everything else. Puspal 5
  6. 6. Few people realize that in expediting this order one or more other orders were delayed because the process was disrupted to get this customer's order out the door. Expediting orders simply ensures that more orders will have to be expedited later. - Gene Bellinger Puspal 6
  7. 7. Finding Root Causes To find root causes there is one really only one question that's relevant, quot;What can we learn from this situation?quot; Research has repeatedly proven that unwanted situations within organizations are about 95% related to process problems and only 5% related to personnel problems. Puspal 7
  8. 8. So organizations should spend far more time and effort looking for causes (rather than trying to find culprits). Then they can gain from understanding the foundation of the unwanted situation. Puspal 8
  9. 9. Scenario # 1 The Plant Manager walked into the plant and found oil on the floor. He called the Foreman over and told him to have maintenance clean up the oil. The next day while the Plant Manager was in the same area of the plant. He found oil on the floor again. Puspal 9
  10. 10. Get the oil cleaned up or I’ll find someone who would! He rebuked the Foreman for not following his directions from the day before. Puspal 10
  11. 11. Scenario # 2 The Plant Manager walked into the plant and found oil on the floor. He said “Foreman, why is there oil on the floor?”. Foreman “It is due to a leaky gasket in the pipe joint above”. Plant Manager “When was the gasket last replaced?”. Foreman “Maintenance had installed 4 gaskets over the past few weeks and they all seem to leak”. Puspal 11
  12. 12. Foreman “Maintenance had been talking to Purchase Dept. about the gaskets because it seemed they were all bad”. Plant Manager then speaks to Purchase Dept. Purchase Manager “We have received a bad batch of gaskets. We have been asking the supplier for the past 2 months to replace 5,000 bad gaskets”. Plant Manager “ Why are we purchasing from this supplier?”. Purchase Manager “Because they were the lowest bidder”. Puspal 12
  13. 13. Plant Manager “ Why are we going with the lowest bidder”. Purchase Manager “ Direction has come from the VP of Finance”. The Plant Manager then talks to the VP of Finance. VP of Finance “Purchase had been directed to always select lowest bidder because you indicated that we had to be as cost conscious as possible!quot; The Plant Manager was horrified when he realized that he was the reason there was oil on the plant floor. Bingo! Puspal 13
  14. 14. You may find scenario # 2 somewhat funny. However this is often true in numerous variations on the same theme. Everyone in the organization doing their best to do the right things, and everything ends screwed up. The root cause of this whole situation is local optimization with no global thought involved. Puspal 14
  15. 15. To Resolve or Not To Resolve? Once the root cause is determined then it has to be determined whether it costs more to remove the root cause or simply continue to treat the symptoms. This is often not an easy determination. Puspal 15
  16. 16. Example Suppose it requires Rs.10,00,000 to remove the root cause of a problem and only 5 minutes for someone to resolve the situation when the customer calls with the problem. Initially one might perceive that the cost of removing the root cause is far larger than the cost of treating the symptom. Puspal 16
  17. 17. Yet suppose that this symptom is such that when it arises it so infuriates the customer that they swear they will never buy another product from you. And also advise everyone they meet what a terrible company you are to do business with. Puspal 17
  18. 18. I will never buy from you…. and advise everybody not to buy from you! How do you estimate lost business cost associated with this situation? Puspal 18
  19. 19. Finding Root Causes: Difficulties In normal chaotic organizational environments it is often quite difficult to find candidates for root cause analysis because the situations which repeat are either distributed over time. So one doesn't realize they are actually recurring. Or the situation happens to different people so there isn't an awareness of the recurring nature of the situation. Puspal 19
  20. 20. Software Some organizations use automated problem resolution support system like Solution Builder. It makes it easy to determine which situations are recurring with what frequency. Every time a solution is used its frequency counter gets updated. So all one has to do is run reports against the system to determine which solutions are being used with what frequency. Puspal 20
  21. 21. Those situations which are recurring with the greatest frequency and consume the greatest amount of resource to rectify are the candidates for root cause analysis. Puspal 21
  22. 22. Criticism Is quot;Root Cause Analysisquot; really an appropriate phrase? In this apparently endlessly interconnected world, everything seems to influence so many other things. Seeking the quot;Root Causequot; is an endless exercise because no matter how deep you go there's always at least one more cause you can look for. Puspal 22
  23. 23. Might quot;Actionable Cause Analysisquot; be more appropriate? I think I'm looking for a cause that I can act on that will provide long term relief from the symptoms, without causing more problems that I have to deal with tomorrow. - Gene Bellinger Puspal 23
  24. 24. . END of Part I Puspal 24
  25. 25. 5 Whys A Method for Root Cause Analysis
  26. 26. 5 Whys The five whys is a question asking method used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the 5 Whys method is to determine a root cause of a defect or problem. The following example demonstrates the basic process. Puspal 26
  27. 27. My car will not start. (the problem) Why? - The battery is dead. (first why) Why? - The alternator is not functioning. (second why) Why? - The alternator has broken beyond repair. (third why) Why? - The alternator is well beyond its useful service life and has never been replaced. (fourth why) Puspal 27
  28. 28. Why? Why? - I have not been maintaining my car according to the recommended service schedule. (fifth why, root cause) The five iterations are not gospel; rather, it is postulated that five iterations of asking why is generally sufficient to get to a root cause. - Wikipedia Puspal 28
  29. 29. The real key is to encourage the troubleshooter to avoid assumptions and logic traps and instead to trace the chain of causality in direct increments from the effect through any layers of abstraction to the first or root cause. The technique was originally developed by Sakichi Toyoda and was later used within Toyota Motor Corporation during the evolution of their manufacturing methodologies. Puspal 29
  30. 30. . END Puspal 30
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