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5 why tutorial (root cause analysis RCA)
The document outlines the 5 Whys method for root cause analysis, emphasizing the importance of understanding underlying issues rather than just symptoms. It includes a structured process for identifying root causes, practical examples, and common pitfalls to avoid during the analysis. The summary highlights that the method is rooted in Toyota's philosophy and advocates for clear problem definition and effective countermeasures.
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5 why tutorial (root cause analysis RCA)
- 1. Root cause analysis(RCA) 5 Why method KienDN, 2018-Oct-29 Daongockien.vn@gmail.com
- 2. CONFIDENTIAL Agenda • Overview • 5Why method • Practice • Common mistake & Tips 2
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- 4. CONFIDENTIAL Overview • Why rootcause analysis? • The problem is not problem. The problem is your attitude about the problem. 4
- 5. CONFIDENTIAL Overview • Type ofsolution – Mop-it (temporary) • Treat it • Tolerate it • Redirect it – Stop-it (permanent) • Prevent it • Eliminate it • Reduce it 5
- 6. CONFIDENTIAL Overview • Common knownmethod – Easy, simple – Cause & Effect, complex – Brainstorming, group 6
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- 8. CONFIDENTIAL 5 Why method •Fundamental • Template • Process • Sample 8
- 9. CONFIDENTIAL 5 Why method •Fundamental – Origin: Toyota – Why, not Who? 9 – Multiple Why – Multiple Root cause
- 10. CONFIDENTIAL 5 Why method •Template 10
- 11. CONFIDENTIAL 5 Why method •Process 11 1.Select problem 2.Define problem (be specific, small, realistic) 3.Ask why -> root cause -> problem doesn’t happen again. 4. Implement countermeasures (communicate the change with everyone) 5. Review, modify countermeasure 6. Update system procedure, training 7. Implement system, monitor
- 12. CONFIDENTIAL 5 Why method •Sample 12 John lost money in his bank account linked to a credit card Because someone used his credit card to buy something on Amazon Because John only checks bank’s balance when he’s going to buy something Because his user, password was stolen after he bought dress for his girl friend on Amazon Because he ever entered user name, password to login Amazon at cafe shop Because John could not check bank balance every day, only check when having transaction or buy smt. Because they could access to his Amazon account. Because cafe shop provides free Wifi and someone could capture data going in-out that wifi. John don’t know there was some irregular transactions. Because someone be able to access to his account using other device and bought something Because nothing notice him so that he could stop bank account right after the first irregular transaction Because his smartphone was out of 3G/4G network capacity that day Because John don’t limit and don’t know other devices was accessing to his account Because he didn’t register something that notify him immediately Because he didn’t register monthly 3G/4G service. Because trusted devices option is not turn ON. Turn ON trusted devices security option Register SMS notification - Don’t use public café wifi for money related stuff. - Register monthly 3G/4G service Why? Why? Why? Action Root cause Why? Because he saved credit card information permanently on Amazon Delete permanent credit card information on Amazon. Only input temporally when requested.
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- 14. CONFIDENTIAL Practice 1. Problem 1:Kent is get dumped by his girlfriend, Jenny, after 3 years dating. 2. Problem 2: There was a serious bug detected when user purchase over 100 goods on our released system. 14
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- 16. CONFIDENTIAL Common mistake &Tips • COMMON MISTAKE – Not right problem statement – Not the right person or one man show – Know the root cause at first time – Blame to who, someone else or human error – Try to fix others than problem in your circle influence – Think more procedures solve problem – Select lack of training, leadership or management support, or funding to be root causes. No, it’s solution. – Not confirming countermeasure really led to improvement • TIPS – Go to gemba, also ask members not only manager – Root cause often relates to organization issue or process issue 16
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