This document discusses root cause analysis and how it can be used to identify underlying causes of problems rather than just surface-level symptoms. It introduces the "5 Whys" technique, where the investigator asks "why" five times to drill down through layers of causes to determine the fundamental reason something occurred. The document demonstrates how to use 5 Whys through examples, identifying that a car breaking down was ultimately due to the driver's poor poker skills, and that a dog attack was because the monkey was "a huge jerk." Root cause analysis aims to cure problems permanently by fixing their root, rather than just patching surface issues.

1. Root Cause Analysis
(Or “How I learned to stop worrying and love
problems”)

2. Root Cause Analysis – What is
it?
 In simple terms.
 Root Cause analysis identifies what, how, and why
something happened, thus preventing recurrence.
 Sounds easy doesn’t it - it isn’t.
 Identifying ’severe weather’ as a root cause of
parts not being delivered to your customer is not
appropriate.
 It’s easy to stop too early and not understand the
true root cause.

3. Root Cause Analysis – What is
it?
 Cure, not patch.
 In medicine, we are used to doctors working to
identify the medical condition, rather than just
treating the symptoms.
 Just taking pain killers won’t cure a broken
wrist, and other treatment is needed to ensure the
damage is fixed rather than just patching up the
problem.
 The same applies to Quality
 When something goes wrong, we could put a
simple fix in place and kid ourselves that it won’t
happen again, but it’s likely that the problem with
recur.

4. Root Cause Analysis
 Generally, mistakes do not just
happen, but can be traced to some
well-defined causes.
◦ Was the process confusing?
◦ Were the parts clearly labelled?
◦ Was the operator familiar with the task?
 But how do we get to that root cause?

5. Root Cause Analysis: 5-
Why’s
 What is 5-Why?
◦ 5-why’s is a structured method of determining the
root cause of a problem.
◦ You ask “why” five times. That’s it!!
◦ Each answer takes you closer to the root cause.
◦ You my not need to ask “why” that many
times, but generally you should ask at least three
times.

6. Root Cause Analysis: 5-
Why’s
 Problem Statement: My car stopped on the way
to work.
◦ Why did it stop?
 Because it ran out of petrol.
◦ Why did it run out of petrol?
 Because I didn’t buy any on the way to work.
◦ Why didn’t you buy any?
 Because I didn’t have any money.
◦ Why didn’t you have money?
 Because I lost it all in a poker game.
◦ Why did you lose?
 Because I’m rubbish at bluffing when I have a bad hand.
 So my car ran out of petrol because I’m rubbish
at poker!!

7. Root Cause Analysis: 5-Why’s
 5-Why’s is a quick and useful tool to
identify what is likely to be the root
cause.
 Task: watch the following video and
determine the root cause.

8. Task
 Watch the video and determine the
root cause of the final action.

9. Root Cause Analysis - Task
 Why did the dog attack the monkey?
◦ Because the monkey pulled the dogs’ leg.
 Why did the monkey pull the dogs leg?
◦ Because the dog was looking at its tail.
 Why was the dog looking at its tail?
◦ Because the monkey had pulled it.
 Why had the monkey pulled the dogs
tail?
◦ Because it’s a huge jerk!
 In only four why’s we have established that
the dog attacked the monkey because it is a
huge jerk!

10. Root Cause Analysis – next
steps
 We have understood why it is
important to establish the root cause.
 We have established a simple yet
effective method of establishing the
root cause.
 We now need to establish a method
transmitting and following the
corrective actions.
Welcome to the world of 8D!