My Views: Root cause Analysis - Preventing the True source of a Problem

"If you are unable to understand the cause of the problem, it is impossible to solve it." - Naoto Kan

Preface to Root cause Analysis

Root cause analysis (RCA) is a systematic process aimed at identifying the fundamental factors or reasons behind a problem, rather than just addressing its symptoms. This method is crucial in various fields, including business, healthcare, engineering, and more. The primary objective of RCA is to identify and address the underlying causes of problems or issues within a system, process, or organization. The goal is not merely to treat the symptoms but to delve deep into the root causes to prevent the recurrence of the problem. RCA involves a thorough investigation, data collection, and analysis to trace back the contributing factors that lead to a specific event or issue. By addressing these root causes, organizations can implement more effective and sustainable solutions, improving processes and preventing future occurrences of the problem at hand. Root cause analysis is an essential tool for continuous improvement and problem-solving, fostering a proactive approach to managing challenges.

RCA is Everywhere!!

RCA is applied in :

• Information Technology (IT)

In IT, RCA is employed to investigate system failures, software bugs, and cyber-security incidents. It helps enhance the reliability and security of IT systems.

• Human Resources

In human resources, RCA may be used to investigate issues related to employee performance, workplace conflicts, or organizational culture to implement improvements and foster a positive work environment.

• Healthcare

In healthcare, RCA is used to investigate adverse events, medical errors, and patient safety incidents to improve the quality of care and prevent future occurrences.

• Manufacturing

In manufacturing, RCA helps identify the causes of defects, production delays, and equipment failures to improve efficiency, reduce downtime, and enhance product quality.

• Aerospace and Aviation

In the aerospace and aviation industries, RCA is crucial for investigating accidents, incidents, and equipment failures to enhance safety and prevent future occurrences.

• Energy sector

In the energy sector, RCA is used to investigate equipment failures, outages, and safety incidents to improve operational reliability and prevent disruptions.

• Telecommunications

In telecommunications, RCA is used to identify and address network failures, service disruptions, and quality issues to enhance the reliability of communication services.

• Automotive Industry

In the automotive sector, RCA is applied to investigate product defects, safety issues, and manufacturing problems to improve the quality and safety of vehicles.

Steps to conduct Root cause Analysis

Tools and Techniques used for Root cause Analyisis

Fishbone diagram

Fishbone diagram (Ishikawa or Cause-and-Effect Diagram) helps to identify potential causes of a problem by categorizing them into branches of a fishbone-shaped diagram. The diagram takes its name from its shape, resembling the skeleton of a fish, with the "spine" representing the problem or effect, and the "bones" representing different categories of causes. Categories include people, process, equipment, materials, and environment.

Categories & Examples

• People:

1. Example: Lack of training for customer service representatives could lead to errors in handling customer inquiries.
2. Example: The staff responsible for quality control may lack the necessary skills to identify defects in the manufacturing process.

• Process:

1. Example: Inefficient order processing procedures might cause delays in delivering products to customers.

• Equipment:

1. Example: Outdated or malfunctioning manufacturing equipment may result in defects in the final product.
2. Example: Aging machinery on the production line is prone to breakdowns, causing downtime and affecting overall productivity.

• Materials:

1. Example: Poor-quality raw materials could be a factor in the production of substandard goods.
2. Example: The use of substandard packaging materials results in products being damaged during transit.

• Environment:

1. Example: A poorly ventilated office environment contributes to employee discomfort and decreased productivity.
2. High noise levels in a production area might contribute to communication breakdowns and errors.

• Methods:

1. Example: Inconsistent data collection methods can lead to inaccurate reporting and decision-making.
2. Inconsistent project management methods lead to misunderstandings and delays in project delivery.

5 Whys Technique

The 5 Whys is a straightforward but powerful root cause analysis tool used to identify the underlying causes of a problem. It involves asking the question "Why?" repeatedly, usually five times, to drill down into the root cause of an issue. The technique is based on the idea that by asking "Why?" multiple times, you can uncover deeper layers of causation and get beyond the symptoms of a problem.

Steps to apply 5 Whys Technique

Step1: Define the Problem

Step2: Ask why the problem occurred and identify the immediate or most apparent cause.(i.e, Symptom)

Step3: For each answer obtained in Step 2, ask "Why?" again. Continue this process

Step4: Repeat Until Root Cause is Identified

Note : Aim to reach a point where the answers are no longer symptoms but rather fundamental will prevent the problem from recurring.

Step5: Validate the Root Cause

Example

Problem: Products are being shipped with defects.

Why are products shipped with defects?

Because the final inspection missed the defects.

Why?

Because the inspection process relies on visual checks only.

Why?

Because there are no automated quality control tools in place.

Why?

Because the budget for upgrading equipment was not approved.

Why?

Because the cost benefits of upgrading were not adequately communicated to the decision-makers.

In the above example, the root cause of products being shipped with defects is the lack of communication about the cost benefits of upgrading equipment. Addressing this root cause by improving communication could prevent future instances of manufacturing defects.

Note: The 5 Whys technique has been previously discussed in my article on Critical Thinking skills. I recommend reviewing it for further insights.

Click here to view

Pareto chart

A Pareto chart is a graphical tool that can be very useful in the process of root cause analysis. It is based on the Pareto principle, also called as the 80/20 rule, which states that 80% of the effects come from 20% of the causes. This chart helps prioritize issues by displaying them in descending order of frequency or impact.

Steps to prepare Pareto chart:

1. Collect the data related to the problem.

2. categorize the data into different groups. For example, if you're dealing with product defects, you might categorize them into issues like manufacturing defects, design flaws, supplier problems, and so on.

3. calculate the frequency or occurrence of each category

4. Using the frequency data, create a Pareto chart. The categories are usually represented on the horizontal axis, and the frequency is represented on the vertical axis. The categories are typically arranged in descending order of frequency.

After Preparing Chart

• Analyze the chart and focus on “vital few”.
• With the vital few categories identified, you can now delve deeper into each one to identify the underlying causes.
• Resolve the problem using 5whys technique or Fishbone diagram.

Brainstorming

Brainstorming is a way to start figuring out why a problem happened. It's like a group of people getting together and sharing their ideas about what might be causing the problem. This is helpful because different people have different thoughts, and it helps gather lots of possible reasons. These ideas are like clues, and you need to follow them to find out what's really causing the problem. So, brainstorming is like the first step in solving the problem. After that, you need to use other methods to dig deeper and find the real cause.

Other Tools & Techniques

• Failure Mode and Effects Analysis (FMEA)
• Fault Tree Analysis (FTA)
• Scatter Diagrams
• Root Cause Analysis Software

References

• How to Determine the Root Cause Analysis Techniques in a Management System?, by PECB (slideshare).
• Root cause analysis by Mindtools.
• Root cause analysis by tableau
• other AI tools

Acknowledgement

This is my third article subsequent to completing a course on Root cause Analysis via LinkedIn Learning. This piece encapsulates both the insights garnered from the course as well as additional knowledge acquired through online research. Within this article, I intend to expound upon my personal perspective and opinions regarding the concept of Root cause Analysis.

Note : I've used Canva for image creation and AI tools for better English & detecting grammatical mistakes.

My Previous Articles

My Views: Introduction to Project management

My views on Critical Thinking Skills