Determining the root cause of problems is important to prevent recurrence and reduce costs. Root cause analysis is a technique that focuses on systems and processes rather than individuals to identify underlying factors. Useful tools for root cause analysis include the five whys technique, cause-and-effect diagrams, Pareto analysis, and benchmarking against other high-performing organizations. Common errors include stopping the analysis at a symptomatic cause rather than finding the deeper root causes.
CAPA management, corrective and preventive action, Rootcause analysis, RCA, Problem mapping, FMEA, Failure Mode effect and Analysis, Fault Tree analysis, Fishbone : ISHIKAWA, CTQ Tree (Critical to Quality Tree), AFFINITY DIAGRAM, 5 Why’s, Human errors,
CAPA management, corrective and preventive action, Rootcause analysis, RCA, Problem mapping, FMEA, Failure Mode effect and Analysis, Fault Tree analysis, Fishbone : ISHIKAWA, CTQ Tree (Critical to Quality Tree), AFFINITY DIAGRAM, 5 Why’s, Human errors,
Root Cause Analysis - Tools, Tips and Tricks to Get to the Bottom of Root CauseCraig Thornton
This webinar discusses and investigates how to conduct root cause analysis. Root cause analysis is something that companies really struggle with. There will be plenty of practical advice in the webinar to help with you understand the concepts and the tools.
If you would like to watch the recording of this webinar then copy and paste the below link into your web browser:
http://www.mangolive.com/blog-mango/root-cause-analysis-tools-webinar
Introduction
Definition of Root Cause Analysis(RCA).
Benefits of RCA
Techniques and tools of RCA
Examples
Corrective Action (CA)
Preventive Action (PA)
Root Cause Analysis and Corrective ActionsHannah Stewart
A snapshot of 5 of the most popular root cause analysis methods for EHS incident investigation, plus how to manage follow up corrective and preventive actions effectively. Read the full report here: https://www.pro-sapien.com/resources/downloads/root-cause-analysis/
Root Cause Analysis Training for Healthcare Professionals : Tonex TrainingBryan Len
Root cause analysis training for healthcare professionals covers the concepts and rationale behind root cause analysis (RCA) methodology, as well as tools, techniques, and the strategies should be applied in order to execute an effective root cause analysis process.
Audience:
Root cause analysis training for healthcare professionals is a 3-day course designed for:
Healthcare managers
Nurses
Physicians
Hospital, clinics, and healthcare facility managers
All healthcare professionals who are involved in root cause analysis investigation at any level
Training Objectives:
Upon the completion of root cause analysis training for healthcare professionals, the attendees are able to:
Understand the history of RCA
Understand the definitions associated with RCA
Comprehend the theory of RCA
Demonstrate an in-depth knowledge of RCA process
Work through a patient safety even using RCA
Efficiently facilitate RCA investigations
Apply other useful patient safety resources
Establish effective action and preventive plan
Evaluate the effectiveness of their action plans in patient safety
Course Outline:
Overview of RCA in Healthcare
How a Root Cause Analysis Works
Features Impact Clinical Exercise and Medical Error
How a RCA Can Enhance Healthcare?
Action Categories Defined by the National Center for Patient Safety
RCA Characteristics
Guidelines to Expose the Potential Causes Led to The Incident
Healthcare RCA Methods
Establishing Sequence of Events (Initial Flow Diagram)
Action Plan Development
Iterating the Actions
TONEX Hands-On Workshop Sample
Request more information. Visit Tonex website link below.
https://www.tonex.com/training-courses/root-cause-analysis-training-healthcare-professionals/
تتحدث هذه المحاضرة عن تحليل أسباب جذور المشكلة أو
Root Cause Analysis (RCA)
وهي أداة يتم استخدامها بغرض معرفة جذر أو جذور أسباب مشكلة ما ومن ثم وضع الحل المناسب لعدم تكرار حدوث المشكلة
قمت في هذه المحاضرة بتعريف تحليل أسباب جذور المشكلة او ال
Root Cause Analysis (RCA)
والمبادئ التي يقوم عليها وأنه يركز على تقديم حلول جذرية تمنع عودة المشكلة مرة أخرى بدلا عن التركيز على وضع حلول وقتية لأعراض المشاكل
قمت بعد ذلك بتوضيح خطوات تحليل أسباب جذور المشكلة او ال
Root Cause Analysis (RCA)
متطرقا لعدة أدوات تستخدم في تحليل أسباب جذور المشكلة او ال
Root Cause Analysis (RCA).
Cause and Effect Analysis is a technique for identifying all the possible causes (inputs) associated with a particular problem / effect (output) before narrowing down to the small number of main, root causes which need to be addressed.
How to Determine the Root Cause Analysis Techniques in a Management System?PECB
The understanding of these techniques and their effective implementation by the auditee (Process owner) in any Management system audit shall go along way to ensure that the problem does not recur and this improves the customer or stakeholder confidence, ensure safety of personnel and saves the organization money.
Main points covered:
• What is the Root Cause Analysis Technique?
• How to Ensure customers and stakeholder confidence
• Why is important to determine the Root Cause Analysis?
Presenter:
This webinar was presented by Eng. Isaac Mbuvi is an Electrical and communications Engineer. A holder of Master’s Degree in Occupational Safety and Health. He is an Environmental consultant, a certified trainer with PECB for ISO 9001, ISO 14001 and OHSAS 18001 Management systems. He is also a certified Lead Auditor in ISO 9001, ISO 14001 and OHSAS 18001.
He has worked in the Oil and Gas industry for the last 14 years and has built his career in the Management systems as an Lead Auditor, Auditor and auditee for more than seven years in various sectors such as Pipeline transport, Health, Construction, Marine, Energy, etc.
Link of the recorded webinar published on YouTube: https://youtu.be/DBljEiv9tAw
Root Cause Analysis - Tools, Tips and Tricks to Get to the Bottom of Root CauseCraig Thornton
This webinar discusses and investigates how to conduct root cause analysis. Root cause analysis is something that companies really struggle with. There will be plenty of practical advice in the webinar to help with you understand the concepts and the tools.
If you would like to watch the recording of this webinar then copy and paste the below link into your web browser:
http://www.mangolive.com/blog-mango/root-cause-analysis-tools-webinar
Introduction
Definition of Root Cause Analysis(RCA).
Benefits of RCA
Techniques and tools of RCA
Examples
Corrective Action (CA)
Preventive Action (PA)
Root Cause Analysis and Corrective ActionsHannah Stewart
A snapshot of 5 of the most popular root cause analysis methods for EHS incident investigation, plus how to manage follow up corrective and preventive actions effectively. Read the full report here: https://www.pro-sapien.com/resources/downloads/root-cause-analysis/
Root Cause Analysis Training for Healthcare Professionals : Tonex TrainingBryan Len
Root cause analysis training for healthcare professionals covers the concepts and rationale behind root cause analysis (RCA) methodology, as well as tools, techniques, and the strategies should be applied in order to execute an effective root cause analysis process.
Audience:
Root cause analysis training for healthcare professionals is a 3-day course designed for:
Healthcare managers
Nurses
Physicians
Hospital, clinics, and healthcare facility managers
All healthcare professionals who are involved in root cause analysis investigation at any level
Training Objectives:
Upon the completion of root cause analysis training for healthcare professionals, the attendees are able to:
Understand the history of RCA
Understand the definitions associated with RCA
Comprehend the theory of RCA
Demonstrate an in-depth knowledge of RCA process
Work through a patient safety even using RCA
Efficiently facilitate RCA investigations
Apply other useful patient safety resources
Establish effective action and preventive plan
Evaluate the effectiveness of their action plans in patient safety
Course Outline:
Overview of RCA in Healthcare
How a Root Cause Analysis Works
Features Impact Clinical Exercise and Medical Error
How a RCA Can Enhance Healthcare?
Action Categories Defined by the National Center for Patient Safety
RCA Characteristics
Guidelines to Expose the Potential Causes Led to The Incident
Healthcare RCA Methods
Establishing Sequence of Events (Initial Flow Diagram)
Action Plan Development
Iterating the Actions
TONEX Hands-On Workshop Sample
Request more information. Visit Tonex website link below.
https://www.tonex.com/training-courses/root-cause-analysis-training-healthcare-professionals/
تتحدث هذه المحاضرة عن تحليل أسباب جذور المشكلة أو
Root Cause Analysis (RCA)
وهي أداة يتم استخدامها بغرض معرفة جذر أو جذور أسباب مشكلة ما ومن ثم وضع الحل المناسب لعدم تكرار حدوث المشكلة
قمت في هذه المحاضرة بتعريف تحليل أسباب جذور المشكلة او ال
Root Cause Analysis (RCA)
والمبادئ التي يقوم عليها وأنه يركز على تقديم حلول جذرية تمنع عودة المشكلة مرة أخرى بدلا عن التركيز على وضع حلول وقتية لأعراض المشاكل
قمت بعد ذلك بتوضيح خطوات تحليل أسباب جذور المشكلة او ال
Root Cause Analysis (RCA)
متطرقا لعدة أدوات تستخدم في تحليل أسباب جذور المشكلة او ال
Root Cause Analysis (RCA).
Cause and Effect Analysis is a technique for identifying all the possible causes (inputs) associated with a particular problem / effect (output) before narrowing down to the small number of main, root causes which need to be addressed.
How to Determine the Root Cause Analysis Techniques in a Management System?PECB
The understanding of these techniques and their effective implementation by the auditee (Process owner) in any Management system audit shall go along way to ensure that the problem does not recur and this improves the customer or stakeholder confidence, ensure safety of personnel and saves the organization money.
Main points covered:
• What is the Root Cause Analysis Technique?
• How to Ensure customers and stakeholder confidence
• Why is important to determine the Root Cause Analysis?
Presenter:
This webinar was presented by Eng. Isaac Mbuvi is an Electrical and communications Engineer. A holder of Master’s Degree in Occupational Safety and Health. He is an Environmental consultant, a certified trainer with PECB for ISO 9001, ISO 14001 and OHSAS 18001 Management systems. He is also a certified Lead Auditor in ISO 9001, ISO 14001 and OHSAS 18001.
He has worked in the Oil and Gas industry for the last 14 years and has built his career in the Management systems as an Lead Auditor, Auditor and auditee for more than seven years in various sectors such as Pipeline transport, Health, Construction, Marine, Energy, etc.
Link of the recorded webinar published on YouTube: https://youtu.be/DBljEiv9tAw
Invented in the 1930’s by Toyota Founder Kiichiro Toyoda’s father Sakichi and made popular in the 1970s by the Toyota Production System, the 5 Whys strategy involves looking at any problem and asking: “Why?” and “What caused this problem?”
Problem Solving Tools and Techniques by TQMIAndrew Leong
This handy guide is for anyone involved in problem solving and improvement activities. It contains guidelines on the use of many of the tools and techniques which can be used as part of a Continuous Improvement process.
This handy guide is for anyone involved in problem solving and improvement activities. It contains guidelines on the use of many of the tools and techniques which can be used as part of a Continuous Improvement process.
Operating Excellence is built on Corrective & Preventive ActionsAtanu Dhar
You see an issue and you simply set it right, but do you make the effort to find out what is the "corrective" action behind it, so that it never re-occurs?
And, do you take another extra step to come up with a "preventive" action - so that there is no other manner that issue comes up?
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
1. 1Determining Root Cause 1
Determining the Root
Cause of a Problem
Approved for Public Release
2. 2Determining Root Cause 2
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 Cause 3
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 Cause 4
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 Cause 5
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 Cause 6
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 Cause 7
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 Cause 8
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 Cause 9
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 Cause 10
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 Cause 11
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 Cause 12
Pareto Analysis
Count 14 14 11 9 7 7 3 3 3 3162 2 2 1 513934 20 19 19 15 15
Percent 3 3 2 2 1 1 1 1 1 132 0 0 0 127 7 4 4 4 3 3
Cum % 86 89 91 93 94 96 96 97 97 9832 98 99 991005966 70 74 78 80 83
Count
Defect
O
ther
EB
Dam
aged
Supplier
Cleanliness
EB
Marking
Supplier Rusted, Corroded
EB
Incorrect
Material
EB
Docum
entation
EB
Dim
ension
Supplier Missing
Parts
ESD
Packaging
Supplier Lab
Test Failure
Supplier
Shelf Life
Exceeded
Supplier W
rong
Configuration
Supplier O
ther
W
orkm
anship
Supplier
Incorrect
Material
Supplier
Dam
aged
Packaging
Supplier Dim
ensions
EB
O
ther
Supplier Docum
entation
Supplier
Marking
180
160
140
120
100
80
60
40
20
0
Supplier Material Rejections May 06 to May 07
Vital Few
Trivial Many
60 % of
Material
Rejections
Approved for Public Release
13. 13Determining Root Cause 13
Cause and Effect Diagram
(Fishbone/Ishikawa Diagrams)
EFFECT
CAUSES (METHODS) EFFECT (RESULTS)
“Four M’s” Model
MAN/WOMAN METHODS
MATERIALS MACHINERY
OTHER
Approved for Public Release
14. 14Determining Root Cause 14
Cause and Effect Diagram
Loading My Computer
MAN/WOMAN METHODS
MATERIALS MACHINERY
OTHER
Cannot
Load
Softwar
e on PC
Inserted CD Wrong
Instructions are Wrong
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 CDBad CD
Power Interruption
Approved for Public Release
15. 15Determining Root Cause 15
Tree Diagram
Result Cause/Result Cause/Result Cause
Result Primary
Causes
Secondary
Causes
Tertiary
Causes
Approved for Public Release
16. 16Determining Root Cause 16
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
Result Cause/Result Cause/Result Cause
Approved for Public Release
17. 17Determining Root Cause 17
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 Cause 18
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 Cause 19
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 Cause 20
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 Cause 21
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 Cause 22
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