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ROOT CAUSE ANALYSIS
Identify, Eliminate, Prevent
© Operational Excellence Consulting. All rights reserved.
© Operational Excellence Consulting
LEARNING OBJECTIVES
2
Understand the critical
role of identifying root
causes in effective
problem-solving.
Learn to prioritize root
causes using Pareto
Charts for impactful
solutions.
Apply 5 Whys and
Cause & Effect
Diagram for practical
root cause analysis.
Recognize common
pitfalls and strategies
for overcoming them.
NOTE: This is a PARTIAL PREVIEW.
To download the complete presentation, please
visit: https://www.oeconsulting.com.sg
© Operational Excellence Consulting
CONTENTS
3
01 INTRODUCTION TO ROOT
CAUSE ANALYSIS
02 OVERVIEW OF PROBLEM
SOLVING
03 5 WHYS
04
CAUSE & EFFECT
DIAGRAM
05
ROOT CAUSE
PRIORITIZATION
06
EFFECTIVE RCA
PRACTICES
© Operational Excellence Consulting
INTRODUCTION TO ROOT CAUSE
ANALYSIS
● Root Cause Analysis (RCA) is a
technique that helps guide people to
discover and understand the initiating
cause(s) of a problem, with the goal of
determining missing or inadequately
applied controls that will prevent
recurrence.
4
© Operational Excellence Consulting
ROOT CAUSE ANALYSIS (RCA): BRIEF DEFINITION
5
Root Cause Analysis (RCA) is a systematic approach
used to identify the underlying, fundamental reasons
for problems or issues within a process or system. It
goes beyond addressing surface-level symptoms,
aiming to discover the primary causes to implement
effective and sustainable solutions.
© Operational Excellence Consulting
WHAT RCA IS NOT
6
Depth of Analysis
Not superficial; delves
into deeper issues.
Blame Avoidance
Not a blame game;
focuses on systemic
understanding.
Quick Fix Myth
Not a quick fix; requires
systematic analysis.
Pattern Recognition
Not isolated incident
investigation; looks for
patterns.
Specialized Approach
Not a routine problem-
solving substitute;
specialized approach.
Core Issue Focus
Not about addressing
only visible symptoms;
targets core issues.
© Operational Excellence Consulting
ROOT CAUSE – THE “EVIL AT
THE BOTTOM”
7
The root cause is the “evil at the
bottom” that sets in motion the
entire cause-and-effect chain
causing the problem(s).
Deeper-level cause
First-level cause
Symptom
The deepest-level
cause of a
problem is called
the root cause.
Root
Cause
Visible Problem
© Operational Excellence Consulting
RELATIONSHIP OF PROBLEMS, SYMPTOMS AND CAUSES
SYMPTOMS
§ Result or outcome of the problem
§ What you see as a problem
(Obvious)
ROOT CAUSES
§ System below the surface, bringing
about the problem (Not obvious)
SYMPTOMS
CAUSES
PROBLEM
§ Gap from goal or standard
PROBLEM
Infection
Don’t feel well
Aches and fever
8
ILLUSTRATIVE
© Operational Excellence Consulting
PROBLEM SYMPTOMS vs. ROOT CAUSES
9
PROBLEM
(Reduced Productivity)
ROOT CAUSES
(Scrap & Rework)
QUALITY
ISSUE
CAUSES
AS A RESULT OF THE
PROBLEM
SYMPTOMS
(Increased Cost, Poor
Customer Service)
© Operational Excellence Consulting
● Understanding Events: RCA
identifies what, how, and why
events or failures occur.
● Underlying Causes: Recognizes
underlying, reasonably identifiable
causes controllable by
management.
WHY ROOT CAUSE ANALYSIS?
● Importance of Causes: Highlights
that not all causes are equally
important.
● Effective Solutions: Pinpointing
root causes enables the
specification of corrective and
preventive measures for desired
outcomes.
10
© Operational Excellence Consulting
“
When we fail to grasp the
systemic source of problems,
we are left to ‘push on’
symptoms rather than
eliminate underlying causes.”
PETER SENGE
11
The Fifth Discipline
© Operational Excellence Consulting
PRINCIPLES OF ROOT CAUSE ANALYSIS
12
Systems Thinking
Approach
Employ a holistic
perspective,
considering
interactions and
relationships within
the system.
Prevention of
Recurrence
Focus on identifying
and addressing root
causes to prevent the
recurrence of issues.
Pareto Principle
Prioritize efforts by
addressing the vital
few factors that
contribute the most
to a problem.
Employee
Engagement
Involve and empower
employees in the
analysis process for
valuable insights.
Continuous
Improvement
Embrace an ongoing
commitment to
enhance processes
and outcomes
systematically.
© Operational Excellence Consulting
APPLICATIONS OF ROOT CAUSE ANALYSIS
13
Examine issues
related to customer
complaints and
dissatisfaction.
Analyze the root
causes of waste
within any
organization.
Uncover the
underlying causes of
financial
discrepancies or
losses.
Investigate delays in
project timelines and
deadlines.
Uncover the reasons
behind defects in
manufacturing lines.
Identify the causes of
accidents and health
incidents.
Determine the
causes of product
returns in retail
shops.
Investigate failures in
engineering or
maintenance works.
© Operational Excellence Consulting
“
You can’t solve a
problem on the same
level that it was created.
You have to rise above it
to the next level.”
ALBERT EINSTEIN
14
© Operational Excellence Consulting
PROBLEM SOLVING FUNNEL
15
Source: Adapted from Dennis
Breakdown
Go See
Grasp the situation
§ Actual vs. standard
§ Actual vs. ideal
Point of cause
§ Time and place where
events cause abnormality
5 Why
Analysis Why?
Root cause
Countermeasures
Big vague concern
© Operational Excellence Consulting
5 WHYS: PURPOSES
16
Problem Solving
Systematically identify
and address the root
cause of issues.
Continuous
Improvement
Support ongoing
improvement efforts by
addressing core
problems.
Root Cause
Analysis
Uncover the
fundamental reasons
behind a problem.
© Operational Excellence Consulting
EXAMPLE 1: 5 WHYS ANALYSIS
17
Symptom: The machine stopped!
Causes:
2. The shaft wore down and seized up
3. Metal cutting chips penetrated the area
4. Chips passed through the lubrication system
5. There was no strainer on the inlet pipe from the tank
1. The circuit overload tripped
1st Why
2nd Why
3rd Why
4th Why
5th Why
ILLUSTRATIVE
© Operational Excellence Consulting
EXAMPLE 3: 5 WHYS ANALYSIS
18
Late Pack Change
Technical Problem
MRP Parameter
Wrong
Short Lead
Time Order
Printing Problem
Wrong Specification
Production Problem
Storage / Handling
Problem
Late Order
from Supplier
Schedule Error
Documentation Error
Damaged Packs
QC Hold
Late Delivery
from Supplier
LATE DELIVERY
TO CUSTOMER
Production
Problem
WHY?
WHY?
WHY?
WHY?
WHY?
WHY?
WHY?
WHY?
KEEP ON ASKING WHY?
ILLUSTRATIVE
Horizontal Tree Diagram
© Operational Excellence Consulting
● Clearly articulate the problem to
address with the “5 Whys”
● Repeatedly ask “Why” to uncover
deeper causes of the issue
● Aim to identify the fundamental,
root causes, not just symptoms
5 WHYS: PRACTICAL TIPS
● Foster open dialogue to explore
various perspectives
● Record answers systematically to
trace the cause-and-effect chain
● Stop the questioning process once
the root cause is identified
19
© Operational Excellence Consulting 20
CAUSE & EFFECT DIAGRAM: WHEN TO USE
Quality
Improvement
Projects
In quality control
initiatives to enhance
processes.
Team
Brainstorming
Sessions
During team sessions to
explore and analyze
issues collaboratively.
Root Cause
Analysis
When investigating and
addressing the root
causes of a problem.
© Operational Excellence Consulting
CAUSE & EFFECT DIAGRAM (MANUFACTURING)
21
EFFECT
CAUSES
S
u
b
-
c
a
u
s
e
Cause
Machines
Measurements Materials
Methods
Environment
Manpower
Problem
Statement
© Operational Excellence Consulting
HIGH
SCRAP OF
BARCODE
LABELS
MAN MACHINE
MATERIAL METHOD
Handling
Wrinkled
Torn
Improper
training
Machine
Breakdown
Ineffective
adhesive
Illegible
Smear
Printwheel Dirty
Worn Ribbon
Design of label
Damage
Poor printing
Improper storage
Wrong orientation
Process changes
Improper storage
Size of label
Process changes
EXAMPLE 2: CAUSE AND EFFECT DIAGRAM FOR “HIGH SCRAP OF
BARCODE LABELS” ILLUSTRATIVE
ACTION!
© Operational Excellence Consulting
1. In your groups, leverage the Cause & Effect Diagram
to dissect the causes of a recent workplace challenge.
2. Pinpoint the three most likely root causes.
3. Afterwards, present and discuss your analysis with the
class.
ACTIVITY: ROOT CAUSE ANALYSIS
23
Time: 20 mins
© Operational Excellence Consulting
PARETO CHART: PURPOSES
24
Visualize
Contributions
Visually represent the
contributions of various
factors to a problem.
Identify Critical
Areas
Identify critical areas for
improvement in a
process.
Issue Prioritization
Prioritize and focus
efforts on the most
significant issues.
© Operational Excellence Consulting
EXAMPLE 2: COMPARING ‘BEFORE’ AND ‘AFTER’ RESULTS
25
ILLUSTRATIVE
Before:
Jan-Jun 2021
Errors Made on Faxed Orders
After:
Jul-Dec 2021
20
40
60
80
100
120
0
Missing
Information
Wrong Product
Information
Unreadable Wrong Billing
Information
PO and Order
Form don’t Match
Other
Count
Error Type
© Operational Excellence Consulting
1. Begin RCA by assessing the
impact on organizational goals for
a focused problem definition.
2. Shift the focus of RCA from
analysis to proactive problem
elimination.
3. Avoid blame; investigate how
problems arise instead of
identifying individuals responsible.
EFFECTIVE RCA PRACTICES
4. Consider broader categories like
resource shortages and adopt a
systems thinking approach.
5. Ensure RCA involves diverse
perspectives; avoid bias and
include people from different
functions.
6. Use 5 Whys judiciously; if the
cause is unknown, it may not lead
to meaningful answers.
26
© Operational Excellence Consulting
“
If you do not change
direction, you may end up
where you are heading.”
LAO TZU
27
© Operational Excellence Consulting
Operational Excellence Consulting is a
management training and consulting firm
that assists organizations in improving
business performance and effectiveness.
Based in Singapore, the firm’s mission is to
create business value for organizations
through innovative design and operational
excellence management training and
consulting solutions. For more information,
please visit www.oeconsulting.com.sg
ABOUT OPERATIONAL EXCELLENCE CONSULTING

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Root Cause Analysis (RCA)

  • 1. ROOT CAUSE ANALYSIS Identify, Eliminate, Prevent © Operational Excellence Consulting. All rights reserved.
  • 2. © Operational Excellence Consulting LEARNING OBJECTIVES 2 Understand the critical role of identifying root causes in effective problem-solving. Learn to prioritize root causes using Pareto Charts for impactful solutions. Apply 5 Whys and Cause & Effect Diagram for practical root cause analysis. Recognize common pitfalls and strategies for overcoming them. NOTE: This is a PARTIAL PREVIEW. To download the complete presentation, please visit: https://www.oeconsulting.com.sg
  • 3. © Operational Excellence Consulting CONTENTS 3 01 INTRODUCTION TO ROOT CAUSE ANALYSIS 02 OVERVIEW OF PROBLEM SOLVING 03 5 WHYS 04 CAUSE & EFFECT DIAGRAM 05 ROOT CAUSE PRIORITIZATION 06 EFFECTIVE RCA PRACTICES
  • 4. © Operational Excellence Consulting INTRODUCTION TO ROOT CAUSE ANALYSIS ● Root Cause Analysis (RCA) is a technique that helps guide people to discover and understand the initiating cause(s) of a problem, with the goal of determining missing or inadequately applied controls that will prevent recurrence. 4
  • 5. © Operational Excellence Consulting ROOT CAUSE ANALYSIS (RCA): BRIEF DEFINITION 5 Root Cause Analysis (RCA) is a systematic approach used to identify the underlying, fundamental reasons for problems or issues within a process or system. It goes beyond addressing surface-level symptoms, aiming to discover the primary causes to implement effective and sustainable solutions.
  • 6. © Operational Excellence Consulting WHAT RCA IS NOT 6 Depth of Analysis Not superficial; delves into deeper issues. Blame Avoidance Not a blame game; focuses on systemic understanding. Quick Fix Myth Not a quick fix; requires systematic analysis. Pattern Recognition Not isolated incident investigation; looks for patterns. Specialized Approach Not a routine problem- solving substitute; specialized approach. Core Issue Focus Not about addressing only visible symptoms; targets core issues.
  • 7. © Operational Excellence Consulting ROOT CAUSE – THE “EVIL AT THE BOTTOM” 7 The root cause is the “evil at the bottom” that sets in motion the entire cause-and-effect chain causing the problem(s). Deeper-level cause First-level cause Symptom The deepest-level cause of a problem is called the root cause. Root Cause Visible Problem
  • 8. © Operational Excellence Consulting RELATIONSHIP OF PROBLEMS, SYMPTOMS AND CAUSES SYMPTOMS § Result or outcome of the problem § What you see as a problem (Obvious) ROOT CAUSES § System below the surface, bringing about the problem (Not obvious) SYMPTOMS CAUSES PROBLEM § Gap from goal or standard PROBLEM Infection Don’t feel well Aches and fever 8 ILLUSTRATIVE
  • 9. © Operational Excellence Consulting PROBLEM SYMPTOMS vs. ROOT CAUSES 9 PROBLEM (Reduced Productivity) ROOT CAUSES (Scrap & Rework) QUALITY ISSUE CAUSES AS A RESULT OF THE PROBLEM SYMPTOMS (Increased Cost, Poor Customer Service)
  • 10. © Operational Excellence Consulting ● Understanding Events: RCA identifies what, how, and why events or failures occur. ● Underlying Causes: Recognizes underlying, reasonably identifiable causes controllable by management. WHY ROOT CAUSE ANALYSIS? ● Importance of Causes: Highlights that not all causes are equally important. ● Effective Solutions: Pinpointing root causes enables the specification of corrective and preventive measures for desired outcomes. 10
  • 11. © Operational Excellence Consulting “ When we fail to grasp the systemic source of problems, we are left to ‘push on’ symptoms rather than eliminate underlying causes.” PETER SENGE 11 The Fifth Discipline
  • 12. © Operational Excellence Consulting PRINCIPLES OF ROOT CAUSE ANALYSIS 12 Systems Thinking Approach Employ a holistic perspective, considering interactions and relationships within the system. Prevention of Recurrence Focus on identifying and addressing root causes to prevent the recurrence of issues. Pareto Principle Prioritize efforts by addressing the vital few factors that contribute the most to a problem. Employee Engagement Involve and empower employees in the analysis process for valuable insights. Continuous Improvement Embrace an ongoing commitment to enhance processes and outcomes systematically.
  • 13. © Operational Excellence Consulting APPLICATIONS OF ROOT CAUSE ANALYSIS 13 Examine issues related to customer complaints and dissatisfaction. Analyze the root causes of waste within any organization. Uncover the underlying causes of financial discrepancies or losses. Investigate delays in project timelines and deadlines. Uncover the reasons behind defects in manufacturing lines. Identify the causes of accidents and health incidents. Determine the causes of product returns in retail shops. Investigate failures in engineering or maintenance works.
  • 14. © Operational Excellence Consulting “ You can’t solve a problem on the same level that it was created. You have to rise above it to the next level.” ALBERT EINSTEIN 14
  • 15. © Operational Excellence Consulting PROBLEM SOLVING FUNNEL 15 Source: Adapted from Dennis Breakdown Go See Grasp the situation § Actual vs. standard § Actual vs. ideal Point of cause § Time and place where events cause abnormality 5 Why Analysis Why? Root cause Countermeasures Big vague concern
  • 16. © Operational Excellence Consulting 5 WHYS: PURPOSES 16 Problem Solving Systematically identify and address the root cause of issues. Continuous Improvement Support ongoing improvement efforts by addressing core problems. Root Cause Analysis Uncover the fundamental reasons behind a problem.
  • 17. © Operational Excellence Consulting EXAMPLE 1: 5 WHYS ANALYSIS 17 Symptom: The machine stopped! Causes: 2. The shaft wore down and seized up 3. Metal cutting chips penetrated the area 4. Chips passed through the lubrication system 5. There was no strainer on the inlet pipe from the tank 1. The circuit overload tripped 1st Why 2nd Why 3rd Why 4th Why 5th Why ILLUSTRATIVE
  • 18. © Operational Excellence Consulting EXAMPLE 3: 5 WHYS ANALYSIS 18 Late Pack Change Technical Problem MRP Parameter Wrong Short Lead Time Order Printing Problem Wrong Specification Production Problem Storage / Handling Problem Late Order from Supplier Schedule Error Documentation Error Damaged Packs QC Hold Late Delivery from Supplier LATE DELIVERY TO CUSTOMER Production Problem WHY? WHY? WHY? WHY? WHY? WHY? WHY? WHY? KEEP ON ASKING WHY? ILLUSTRATIVE Horizontal Tree Diagram
  • 19. © Operational Excellence Consulting ● Clearly articulate the problem to address with the “5 Whys” ● Repeatedly ask “Why” to uncover deeper causes of the issue ● Aim to identify the fundamental, root causes, not just symptoms 5 WHYS: PRACTICAL TIPS ● Foster open dialogue to explore various perspectives ● Record answers systematically to trace the cause-and-effect chain ● Stop the questioning process once the root cause is identified 19
  • 20. © Operational Excellence Consulting 20 CAUSE & EFFECT DIAGRAM: WHEN TO USE Quality Improvement Projects In quality control initiatives to enhance processes. Team Brainstorming Sessions During team sessions to explore and analyze issues collaboratively. Root Cause Analysis When investigating and addressing the root causes of a problem.
  • 21. © Operational Excellence Consulting CAUSE & EFFECT DIAGRAM (MANUFACTURING) 21 EFFECT CAUSES S u b - c a u s e Cause Machines Measurements Materials Methods Environment Manpower Problem Statement
  • 22. © Operational Excellence Consulting HIGH SCRAP OF BARCODE LABELS MAN MACHINE MATERIAL METHOD Handling Wrinkled Torn Improper training Machine Breakdown Ineffective adhesive Illegible Smear Printwheel Dirty Worn Ribbon Design of label Damage Poor printing Improper storage Wrong orientation Process changes Improper storage Size of label Process changes EXAMPLE 2: CAUSE AND EFFECT DIAGRAM FOR “HIGH SCRAP OF BARCODE LABELS” ILLUSTRATIVE
  • 23. ACTION! © Operational Excellence Consulting 1. In your groups, leverage the Cause & Effect Diagram to dissect the causes of a recent workplace challenge. 2. Pinpoint the three most likely root causes. 3. Afterwards, present and discuss your analysis with the class. ACTIVITY: ROOT CAUSE ANALYSIS 23 Time: 20 mins
  • 24. © Operational Excellence Consulting PARETO CHART: PURPOSES 24 Visualize Contributions Visually represent the contributions of various factors to a problem. Identify Critical Areas Identify critical areas for improvement in a process. Issue Prioritization Prioritize and focus efforts on the most significant issues.
  • 25. © Operational Excellence Consulting EXAMPLE 2: COMPARING ‘BEFORE’ AND ‘AFTER’ RESULTS 25 ILLUSTRATIVE Before: Jan-Jun 2021 Errors Made on Faxed Orders After: Jul-Dec 2021 20 40 60 80 100 120 0 Missing Information Wrong Product Information Unreadable Wrong Billing Information PO and Order Form don’t Match Other Count Error Type
  • 26. © Operational Excellence Consulting 1. Begin RCA by assessing the impact on organizational goals for a focused problem definition. 2. Shift the focus of RCA from analysis to proactive problem elimination. 3. Avoid blame; investigate how problems arise instead of identifying individuals responsible. EFFECTIVE RCA PRACTICES 4. Consider broader categories like resource shortages and adopt a systems thinking approach. 5. Ensure RCA involves diverse perspectives; avoid bias and include people from different functions. 6. Use 5 Whys judiciously; if the cause is unknown, it may not lead to meaningful answers. 26
  • 27. © Operational Excellence Consulting “ If you do not change direction, you may end up where you are heading.” LAO TZU 27
  • 28. © Operational Excellence Consulting Operational Excellence Consulting is a management training and consulting firm that assists organizations in improving business performance and effectiveness. Based in Singapore, the firm’s mission is to create business value for organizations through innovative design and operational excellence management training and consulting solutions. For more information, please visit www.oeconsulting.com.sg ABOUT OPERATIONAL EXCELLENCE CONSULTING