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
By directing corrective measures
at root causes, it is hoped that the
likelihood of problem recurrence
will be minimized.
General Principles of Root
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
There is usually more than one root
cause for any given problem.
Organizations have a well defined process for
accepting, processing, and shipping customer
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
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
- Gene Bellinger
Finding Root Causes
To find root causes there is one
really only one question that's
relevant, quot;What can we learn from
Research has repeatedly proven
that unwanted situations within
organizations are about 95%
related to process problems and
only 5% related to personnel
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
Scenario # 1
The Plant Manager walked into
the plant and found oil on the
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
He found oil on the floor again.
Get the oil cleaned up
or I’ll find someone
He rebuked the Foreman for not
following his directions from the day
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
Foreman “Maintenance had installed 4
gaskets over the past few weeks and
they all seem to leak”.
Foreman “Maintenance had been
talking to Purchase Dept. about the
gaskets because it seemed they were
all bad”. Plant Manager then speaks to
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”.
Plant Manager “ Why are we going with
the lowest bidder”. Purchase Manager
“ Direction has come from the VP of
The Plant Manager then talks to the VP
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!
You may find scenario # 2 somewhat
funny. However this is often true in
numerous variations on the same
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
To Resolve or Not To
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
This is often not an easy
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
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.
I will never buy
from you…. and
not to buy from
How do you estimate lost business
cost associated with this situation?
Finding Root Causes:
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
Or the situation happens to different
people so there isn't an awareness of
the recurring nature of the situation.
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.
Those situations which are
recurring with the greatest
frequency and consume the
greatest amount of resource to
rectify are the candidates for root
Is quot;Root Cause Analysisquot; really an
In this apparently endlessly
interconnected world, everything
seems to influence so many other
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.
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
The five whys is a question asking
method used to explore the
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.
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)
Why? - I have not been maintaining my
car according to the recommended
service schedule. (fifth why, root
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.
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.