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Problem Solving Techniques
 Root
Cause Analysis (RCA)
 Fishbone
(Ishikawa) Diagram
 8D
 TRIZ
 GROW
Model
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for 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).
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Focus is on systems and processes
Focus is not on individuals
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for Root Cause Analysis
Significant
events
Repetitive
human errors are occurring
during a specific process
Repetitive
equipment failures associated
with a specific process
Performance
standard
is generally below desired
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for Root Cause Analysis
 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
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for Root Cause Analysis
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Assign the task to a person (team if necessary)
knowledgeable of the systems and processes involved
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Define the problem
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Collect and analyze facts and data
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Develop theories and possible causes - there may be
multiple causes that are interrelated
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Systematically reduce the possible theories and
possible causes using the facts
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Develop possible solutions
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Define and implement an action plan (e.g., improve
communication, revise processes or procedures or
work instructions, perform additional training, etc.)
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Monitor and assess results of the action plan for
appropriateness and effectiveness
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Repeat analysis if problem persists- if it persists, did
we get to the root cause?
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for Root Cause Analysis
 Aiming
corrective actions at root causes is more
effective than just treating the symptoms of a
problem.
 To
be effective, RCA must be performed
systematically and conclusions must be backed up by
evidence.
 There
is usually more than one root cause for any
given problem and therefore there may be more than
one corrective action.
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for Root Cause Analysis
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Root Cause Analysis (RCA)
Root Cause Analysis Applications
Common Errors Of Root Cause
How To Determine The Real Root Cause?
Principles Of RCA
Symptom Approach Vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples Of Five Whys For Root Cause Analysis
By eliminating the root cause…
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Problems are not repeated
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Reduce rework, retest, re-inspect, poor quality costs,
etc…
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Problems are prevented in other areas
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Communication improves between groups
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Process cycle times improve (no rework loops)
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Secure long term company performance and profits
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for Root Cause Analysis
3 types of Corrective Action:
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Immediate action
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Permanent root cause corrective action
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The action taken to quickly fix the impact of the
problem so the “customer” is not further impacted
The action taken to eliminate the error on the
affected process or product
Preventive (Systemic) root cause corrective action
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The action taken to Prevent the error from recurring
on any process or product
Problem: A product is returned because a broken part
Immediate
Part removed and replaced in product, retested
Permanent
Product redesigned to replace this part
Preventive
Design process changed to require variation analysis testing on
similar supplier parts
If preventive not addressed, problem will return!!
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for Root Cause Analysis
The
“5 Whys”
Pareto Analysis (Vital Few, Trivial Many)
Brainstorming
Flow Charts / Process Mapping
Cause and Effect Diagram, etc
Some tools are more complex than others
Man
Method
Materials
Problem
Management System
Machine
Environment
Ishikawa or Fishbone Diagram
(Cause and effect)
Pareto Chart
The tackle is the one that has the highest score. This
one will give you the biggest benefit if you solve it.
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for Root Cause Analysis
Asking the question ‘Why’ 5 times, will lead you to
the root cause of the problem.
Steps:
1. Write down the specific problem. Writing the
problem helps team focus on the same problem.
2.
Ask why the problem happens and write down the
answer. Repeat 5 times – 5 ‘Whys’, until team is
in agreement that problem is identified.
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Note: It may take less or more than five times to
reach the root cause of a problem.
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Root Cause Analysis (RCA)
Root cause analysis applications
Common Errors of Root Cause
How to Determine the Real Root Cause?
Principles of RCA
Symptom Approach vs. Root Cause
Benefits OF RCA
Corrective Actions
Useful Tools For Determining Root Cause
The Five Whys
Examples of Five Whys for Root Cause Analysis
 Problem
– Late for work
Why?
 Getting out late
Why?
Woke up late
Why?
 Alarm didn’t work
Why?
 Batteries were dead
Why?
 Forgot to replace them
Solution:
Buy an alarm clock the plugs in or buy batteries regularly on a set
interval (e.g. every 4 months)
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Part reversed
Why?
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Part reversed
Worker not sure of correct part orientation
Why?
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Part reversed
Worker not sure of correct part orientation
Part is not marked properly
Why?
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Part reversed
Worker not sure of correct part orientation
Part is not marked properly
Engineering ordered it that way from vendor
Why?
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Part reversed
Worker not sure of correct part orientation
Part is not marked properly
Engineering ordered it that way from vendor
Process didn’t account for possible
manufacturing issues
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Puddle of water on the floor
Why?
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Puddle of water on the floor
Leak in overhead pipe
Why?
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Puddle of water on the floor
Leak in overhead pipe
Water pressure is set too high
Why?
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Puddle of water on the floor
Leak in overhead pipe
Water pressure is set too high
Water pressure valve is faulty
Why?
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Puddle of water on the floor
Leak in overhead pipe
Water pressure is set too high
Water pressure valve is faulty
Valve not in preventative maintenance program
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 Permanent
– Water pressure valves placed in
preventative maintenance program.
 Preventive
- Developed checklist form to ensure
new equipment is reviewed for possible inclusion
in preventative maintenance program.
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Root Cause Analysis
Example # 4
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Identify Problem
Customers are unhappy because they are
being shipped products that don't meet
their specifications.
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Inspect all finished and in-process
product to ensure it meets customer
specifications.
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Product doesn’t meet specifications
Why?
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Product doesn’t meet specifications
Manufacturing specification is different from
what customer and sales person agreed to
Why?
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Product doesn’t meet specifications
Manufacturing specification is different from
what customer and sales person agreed to
Sales person tries to expedite work by calling
head of manufacturing directly
Why?
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Product doesn’t meet specifications
Manufacturing specification is different from
what customer and sales person agreed to
Sales person tries to expedite work by calling
head of manufacturing directly
Manufacturing schedule is not available for
sales person to provide realistic delivery date
Why?
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Product doesn’t meet specifications
Manufacturing specification is different from
what customer and sales person agreed to
Sales person tries to expedite work by calling
head of manufacturing directly
Manufacturing schedule is not available for
sales person to provide realistic delivery date
Confidence in manufacturing schedule is not
high enough to release/link with order system
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Confidence in manufacturing schedule is not
high enough to release/link with order system
Why?
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Confidence in manufacturing schedule is not
high enough to release/link with order system
Parts sometimes not available thereby
creating schedule changes
Why?
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Confidence in manufacturing schedule is not
high enough to release/link with order system
Parts sometimes not available thereby
creating schedule changes
Expediting and priority changes consume
parts not planned for
Why?
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Confidence in manufacturing schedule is not
high enough to release/link with order system
Parts sometimes not available thereby
creating schedule changes
Expediting and priority changes consume
parts not planned for
Manufacturing schedule does not reflect
realistic assembly and test time
Why?
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Confidence in manufacturing schedule is not
high enough to release/link with order system
Parts sometimes not available thereby
creating schedule changes
Expediting and priority changes consume
parts not planned for
Manufacturing schedule does not reflect
realistic assembly and test time
No ongoing review of manufacturing standards
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 Permanent
– Manufacturing standards reviewed
and updated.
 Preventive
- Regular ongoing review of actuals vs
standards is implemented.
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Root Cause Analysis
Example # 5
Identify Problem
Department didn’t complete their
project on time
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 Additional
resources applied to help get
the project team back on schedule
 No
new projects started until Root Cause
Analysis completed
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Didn’t complete project on time
Why?
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Procedures
Personnel
Lack of worker
knowledge
Poor project plan
Poor project
mgmt skills
Lack of resources
Didn’t complete
project on time
Inadequate
computer
programs
Materials
Poor
documentation
Inadequate
computer system
Equipment
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Procedures
Personnel
Lack of worker
knowledge
Poor project plan
Poor project
mgmt skills
Lack of resources
Didn’t complete
project on time
Inadequate
computer
programs
Materials
Poor
documentation
Inadequate
computer system
Equipment
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Didn’t complete project on time
Resources unavailable when needed
Why?
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Didn’t complete project on time
Resources unavailable when needed
Took too long to hire Project Manager
Why?
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Didn’t complete project on time
Resources unavailable when needed
Took too long to hire Project Manager
Lack of specifics given to
Human Resources Dept
Why?
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Didn’t complete project on time
Resources unavailable when needed
Took too long to hire Project Manager
Lack of specifics given to
Human Resources Dept
No formal process for submitting job opening
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 Permanent
– Hired another worker to meet needs
of next project team
 Preventive
- Developed checklist form with HR
for submitting job openings in the future
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Define the following:
Root Cause Analysis
Discuss the following:
1.Principles Of RCA
2.Symptom Approach vs. Root Cause
3.Corrective Actions
4.The Five Whys tool
5.How to Determine the Real Root Cause?
Determine the following:
1.Problem Solving Techniques
2.Root Cause Analysis Applications
3.Common Errors Of Root Cause
4.Benefits OF RCA
5.Useful Tools For Determining Root Cause