Rootcause Analysis Tools for

effective implementation of corrective measures

V Hemantha Kumar
Chief Safety Officer, ECIL

Abstract: Root cause analysis is a reactive

approach, but this can also be employed 1. Pareto Chart
proactively to all the processes. Root Cause 2. The 5 Whys
Analysis is based on the principle that
problems can best be solved by correcting 3. Fishbone Diagram
their root causes as opposed to other methods 4. Failure Mode and Effects Analysis
that focus on addressing the symptoms of
problems. It is commonly experienced that a (FMEA)
single root cause may be the problem for the 1. Pareto Chart
incident or an accident, limiting to the single
root cause will not completely prevent the A Pareto chart is a histogram or bar chart
recurrence of similar incidents. Numerous combined with a line graph that groups the
tools, processes and philosophies that have frequency or cost of different problems to
been developed and available for identifying show their relative significance. The bars show
the various root causes to the problem. Few frequency in descending order, while the line
tools on identifying the root cause is presented shows cumulative percentage or total as you
in this paper. move from left to right.

Key Words: Root cause analysis, 5Whys, FAILURES BY CATEGORY

Fishbone Diagram, Pareto Chart, Failure 37 35 21 18 18 11 4
Mode and Effects Analysis.
Process Document Error

Percentage (%)
INTRODUCTION
Process Error

Root cause analysis is a structured step by step

Cleanliness
Equipment

Quality
People

Safety
technique that focuses on finding the real
26%

34%

cause(s) of a problem and dealing with that,

30%

30%

rather than continuing to deal with its

50%

51%
symptoms. Root cause analysis is a procedure
for ascertaining and analyzing the causes of
problems in an effort to determine what can be
done to solve or prevent them. It is a process Pareto charts are based on Pareto’s law, also
to help stake holders understand problem called the 80/20 rule, which says that 20% of
causes well enough to achieve permanent inputs drive 80% of results.
resolution of those problems.
We can apply the 80/20 rule to almost
The Goal of Root Cause Analysis is to find anything:
out:
 What happened,  80% of customer complaints arise from
 Why it happened 20% of your products and services.
 What can be done to prevent it from  80% of delays in the schedule result from
happening again 20% of the possible causes of the delays.
There are four common root cause analysis  20% of your products and services
tools, they are: account for 80% of your profit.

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 20% of your sales force produces 80% of but that doesn't mean that small, easily
your company revenues. solved problems should be ignored until
the larger problems are solved.
 20% of a systems defects cause 80% of its
problems.
2. 5 Whys
The value of the Pareto Principle is that it
reminds you to focus on the 20% of things that The 5 Whys is a method that uses a series of
matter. Of the things you do for your project, questions to drill down into successive layers
only 20% are crucial. That 20% produces 80% of a problem. The basic idea is that each time
of your results. Identify, and focus on those you ask why, the answer becomes the basis of
things first, but need not entirely ignore the the next why. It’s a simple tool useful for
remaining 80% of the causes. problems where you don’t need advanced
statistics, so you don’t necessarily want to use
Limitations of Pareto chart it for complex problems.
The Pareto chart is simple to understand and
One application of this technique is to more
use, however it has some limitations that need
deeply analyze the results of a Pareto analysis
to be considered:
.
 Data collected over a short time period, Here’s an example of how to use the 5 Whys:
especially from an unstable process, may
lead to incorrect conclusions. Because the Problem: Final assembly time exceeds target
data may not be reliable, you may get an
incorrect picture of the distribution of  Why is downtime in final assembly
defects and causes. When the process is higher than our goal? According to the
not in control, the cause system may be Pareto chart, the biggest factor is
unstable. The vital few problems may operators needing to constantly adjust
change from week to week. Short time Machine A
periods may not be representative of your
process as a whole.  Why do operators need to constantly
 Data gathered over long periods may adjust Machine A? Because it keeps
include changes. Examine the data for having alignment problems
stratification or changes in the problem
distribution over time.  Why does Machine A keep having
alignment problems? Because the seals
 Choose categories carefully. If your initial are worn
Pareto analysis does not yield useful
results, you may want to ensure that your  Why are Machine A’s seals worn?
categories are meaningful and that your Because they aren’t being replaced as part
"other" category is not too large. of our preventive maintenance program
 Choose weighting criteria carefully. For
example, cost may be a more useful  Why aren’t they being replaced as part of
measure for prioritization than number of our preventive maintenance
occurrences, especially when the costs of program? Because seal replacement
various defects differ. wasn’t captured in the needs
assessment
 Focusing on the areas of greatest
frequency should decrease the total  In 5 Whys analysis the point is to peel
number of items needing rework. away surface-level issues to get to the
Focusing on the areas of greatest cost root cause.
should increase the financial benefits of
the improvement.
 The goal of a Pareto analysis is to gain
maximum reward from the quality efforts,
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Limitations of 5 Whys analysis  Sometimes, the effort is wasted in
identifying causes which have little effect
 Tendency for investigators to stop at
on the problem.
symptoms rather than going on to lower-
level root causes  A fishbone diagram is based on opinion
 Inability to go beyond the investigator’s rather than evidence. This process
involves a democratic way of selecting
current knowledge – cannot find causes
the cause, i.e., voting down the causes,
that they do not already know
which may not be an effective way of
 Lack of support to help the investigator identifying causes.
ask the right “why” questions
 If the discussion is not appropriately
 Results are not repeatable – different controlled, it may deviate from its
people using 5 Whys come up with objective.
different causes for the same problem
The worthiness of a fishbone diagram is
 Tendency to isolate a single root cause, dependent on how you develop the diagram. If
whereas each question could elicit many the participant is less experienced, less
different root causes involved and not more knowledgeable, your
diagram will be neat and clean, and you might
 Considered a linear method of not be able to identify the root cause of the
communication for what is often a non- problem.
linear event
Therefore to develop a sound fishbone or
3. Fishbone Diagram Ishikawa diagram, involve experienced and
A fishbone diagram sorts possible causes into experts and ask as many “whys” as you can
various categories that branch off from the (up to five “whys” is more than enough).
original problem. Also called a cause-and- 4. Failure Mode and Effects Analysis
effect or Ishakawa diagram, a fishbone
(FMEA)
diagram may have multiple sub-causes
branching off of each identified category.
Failure mode and effects analysis (FMEA) is a
method used during product or process design
to explore potential defects or failures.

An FMEA chart outlines:

Potential failures, consequences and causes

Current controls to prevent each type of failure
Severity (S), occurrence (O) and detection (D)
ratings that allow you to calculate a risk
priority number (RPN) for determining further
action.

When applied to process analysis, this method

is called process failure mode and effects
analysis (PFMEA). Many manufacturers use
Limitations of Fishbone Diagram PFMEA findings to inform questions
The following are a few limitations or for process audits, using this problem-solving
drawbacks of a fishbone diagram: tool to reduce risk at the source.
 A fishbone diagram does not single out
the root cause of the problem. Graphically
speaking, all causes look equally
important.

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Limitations of FMEA More information
As any other tool in the FMEA has its own
pros and cons. Present below are some of the 1. Techniques – Tools Used to
weaknesses of FMEA. Determine the Root Cause: Project
Planning for PMs / By Ronda
 FMEA was first created for design related Bowen / Project Management
risks but now has different versions for
process risks and system risks to 2. International Journal of Computer
overcome its original limitations. These Applications (0975 – 8887) Volume
versions have no linkage among them 93 – No 14, May 2014 : FMEA and
which allows overlooking of some failure Alternatives v/s Enhanced Risk
modes Assessment Mechanism by Shri.
Gunjan Joshi Senior Engineer,
 FMEA is not an all-inclusive tool and Honeywell Aerospace, Hyderabad,
misses certain risks. For example, in a India and Shri. Himanshu Joshi
healthcare context, FMEA has been found JNTUH-CEH, Hyderabad, India
to have limited validity compared to
3. Andersen, B. & Fagerhaug, T.
another prospective hazard analysis
(2006). Root cause analysis:
method (Structured What If Technique,
simplified tools and techniques. ASQ
SWIFT) and retrospective approaches,
Quality Press.
with particular challenges around scoping
and organizational boundaries 4. Barsalou, M. A. (2014). Root Cause
Analysis: A Step-By-Step Guide to
 FMEA often has repeated information
Using the Right Tool at the Right
 The multiplication of Severity, Time. Productivity Press.
Occurrence & Detection numbers causes 5. Dankovic, D. D. (2001). Root Cause
generation of false Risk Priority Numbers Analysis. Technometrics, 43(3), 370-
 FMEA is only as good as the team since it 371.
requires brain storming and regular 6. George, M. L., Maxey, J., Rowlands,
updating. Human errors should be D. & Price, M. (2004). The Lean Six
examined Sigma Pocket Toolbook: A Quick
 Members of a team spend significant time Reference Guide to 100 Tools for
debating about the rankings and Improving Quality and
collecting/entering details Speed. McGraw-Hill Education.
 FMEA works best as a bottom-up tool
and fails to identify all the failure modes
if used for a top-down analysis
 FMEA does not provide any assessment
or discover complex failures involving
combination of failures
Summary
There are numerous root cause analyses tools
are available to analyse the events which lead
to incidents/accidents. These tools can also be
used in planning stage, design stage also. Any
of these tools can be adopted based on the
expertise available and suitable to the event /
process / product for effective implementation
of corrective measures to avoid recurrence of
the incidents / accidents.

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