Root cause analysis guidelines

Contents

1. Purpose
2. Resources needed
2.1 Computer software
2.2 Basic understanding of the following topics:
3. Definitions
3.1 Root cause analysis
3.2 Problem-solving
3.3 Root cause
3.4 Causal factor
4. Procedure
4.1 Five whys
4.1.1 Principle and general characteristics
4.1.2 Steps to perform five whys:
4.1.2.1 Agree on the problem statement and write it down.
4.1.2.2 Ask, "Why Did This Happen"
4.1.2.3 Check – Is This a Root Cause?
4.1.2.4 Fix the underlying cause, and correct the symptom – develop a countermeasure.
4.1.2.5 Document the whole procedure
4.2 Cause and effect analysis
4.2.1 Principle and general characteristics
4.2.2 Constructing steps
4.3 A3 method
4.3.1 Principle and general characteristics
4.3.2 Procedure
4.4 8D method
4.4.1 Principle and general characteristics
4.4.2 Procedure
4.4.2.0 Initiation
4.4.2.1 Select an appropriate team
4.4.2.2 Formulate the problem definition
4.4.2.3 Activate interim containment
4.4.2.4 Find root cause(s)
4.4.2.5 Develop permenant corrective action(s)
4.4.2.6 Implement and validate corrective action(s)
4.4.2.7 Take preventive steps
4.4.2.8 Congratulate the team
5. Attachements
6. References

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Root cause analysis guidelines

1. Purpose
This guideline aims to provide a user with a structured methodology for investigating the root
cause behind a particular issue or undesired outcomes. This guideline shall include process
analysis, research, causality effect, statistical parameters, analysis, etc.

2. Resources needed
2.1 Computer software
 Minitab (essential)
 Minitab workspace (recommended)

2.2 Basic understanding of the following tools:

 5whys
 5W2H
 Seven basic basic quality control tools
 Cause and effect diagram
 Flow charts
 Check chart
 Pareto chart
 Scatter diagram
 Control charts
 Histogram
 Value stream mapping (VSM)
 SIPCO (supplier, input, process, output, and customer)
 Gamba walk
 Stakeholder analysis
 Nominal group technique
 Affinity diagram
 Graph and charts
 Bar chart
 Pie chart
 Box and whisker analysis
 Bubble chart
 Time series
 Is/ is not analysis
 Force field analysis
 Benefit-cause-analysis
 Gantt chart
 RACI matrix
 FMEA (failure mode and effect analysis)
 Descriptive and inferential statistic
 Design of experiments (DOE)

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3. Definitions
3.1 Root cause analysis
 A technique used to analyze the root cause of a positive or negative event. The purpose is
to take corrective actions to prevent the recurrence of a negative outcome or facilitate the
recurrence of a positive outcome.
 Root Cause Analysis is a part of the bigger theme: "Problem Solving."
3.2 Problem-solving
 A methodology that relies on two approaches to deal with problems
1. Reactive approach
 Act once the problem happens and focus on removing the symptoms (corrections).
2. Proactive approach
 Focus on removing the cause of the problem so that problem does not happen
again (corrective action).
 To take action even before the problem happens(preventive action).
3.3 Root cause
 A cause, if corrected, will prevent the recurrence of a problem. it is the most basic reason
for the problem that can be logically identified and corrected. There could be multiple root
causes of a problem.
3.4 Causal factor
 It might remove or reduce the problem but will not help prevent it from happening again.
Causal factors are also called contributors or influencers.

4. Procedure
There are various approaches to perform root cause analysis that depends on the size and
complexity of the problem faced. The following are approaches used to detect the root cause
arranged according to problem complexity, from simple to more complex ones:
- Five Whys
- Cause and effect analysis
- A3 Problem Solving
- 8D (Eight Disciplines)

4.1 Five whys

4.1.1 Principle and general characteristics
 Simplest Root Cause Analysis that can be performed without statistical analysis.
 Based on the assumption that for every action or outcome, there is a single cause. If
there are multiple causes of a problem, this becomes difficult to manage with this tool.
 Its principle is based on repeatedly asking the question "Why" (five is a good rule of
thumb); you can peel away the layers of symptoms that can lead to the root cause of a
problem. The ostensible reason for a problem will often lead you to another question.
Although this technique is called "5 Whys," you may find that you will need to ask the
question fewer or more times than five before you find the issue related to a problem.
4.1.2 Steps to perform five whys:
4.1.2.6 Agree on the problem statement and write it down.

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 Writing the issue helps you formalize the problem and describe it completely, and it
also helps a team focus on the same problem.
 Do not skimp on this step because you will have a muddy solution if you have a
muddy problem definition.
4.1.2.7 Ask, "Why Did This Happen"
 Determine what happened to cause the problem. Just go one layer at a time here.
Don't try to get too fancy. Write the answer down below the problem as a potential
cause.
4.1.2.8 Check – Is This a Root Cause?
 Stop and ask yourself if the Why you just wrote down is the problem's real and
underlying root cause. If it's not then, you have another symptom, and you need to
go back to Step 2 and ask again.
 Repeat Steps 2 and 3 until you have the final and underlying cause of the issue.
Typically you will need to ask the Why question about five times to get to the root
cause, and it might take fewer or more than five, so be prepared to keep going until
you get it solved.
4.1.2.9 Fix the underlying cause, and correct the symptom – develop a countermeasure.
 Now you need to fix both the underlying cause that you have uncovered and the
symptom.
 You do this not to fix the problem you started with (the symptom) but to prevent the
problem from occurring again.
4.1.2.10Document the whole procedure
 Use Form-1 to document the whole steps performed

4.2 Cause and effect analysis

4.2.1 Principle and general characteristics

 Also known as the Ishikawa diagram or fishbone diagram
 A cause-effect diagram cannot identify a root cause; it presents graphically the many
causes that might contribute to the observed effect.
 It is a visual representation of the factors that might contribute to an observed effect that
is being examined.
 The interrelationships among the possible causal factors are clearly shown. One causal
factor may appear in several places in the diagram.
 The interrelationships are generally qualitative and hypothetical.
 It focuses the attention of all team members on the specific problem at hand in a
structured, systematic way.
4.2.2 Constructing steps

 You can use Microsoft word to construct the chart, but it is highly advisable to use
Minitab workspace due to its flexibility and ease of constructing it in a professional way.

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Steps Illustration
1. Identify and clarify the problem (effect).

Place the effect or symptom at the right, enclosed

in a box. Draw the central spine as a thicker line
pointing to it.

2. Identify the main cause categories.

It may be helpful to start with some simple lists of

possible major areas such as:

1. Manpower
2. Materials
3. Methods
4. Machines
5. Measurements

3. Brainstorm causes for each category. Add causes

to the appropriate category lines.

4. Identify the most significant causes

Use the Pareto chart to determine the most

significant problem (cause)

4.3 A3 method

4.3.1 Principle and general characteristics

 A3 is the size of A3 paper (29.7 x 42.0 cm)
 There are four parts with a variety of formats/templates available; see Form-2.
 Includes text, pictures, diagrams, charts and tables etc.
4.3.2 Procedure
 Select the team and provide basic training

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 Understand the problem (current state). This requires using one or more of the following
tools depending on the type of the problem and nature of the available data:
 Is/is not matrix
 Value stream mapping
 The seven basic quality tools
1. Cause and effect diagrams
2. Flowcharts (process maps)
3. Check sheets
4. Pareto charts
5. Scatter diagrams
6. Control charts
7. Histograms
 Descriptive and inferential statistics
 Root cause and data analysis
 Provide solutions (future state)
 Implement solution (assign responsibilities, target date)
 Document the steps using Form-2.

4.4 8D method
4.4.1 Principle and general characteristics
 Also called global 8D
 It is a team-oriented method to solve problems. 8D stands for eight discipline problem-
solving methodology. The 8Ds are:
1. Select an appropriate team
2. Formulate the problem definition
3. Activate interim containment
4. Find root cause(s)
5. Develop permenant corrective action(s)
6. Implement and validate corrective action(s)
7. Take preventive steps
8. Congratulate the team
4..4.2 Procedure
4.4.2.0 Initiation
 a customer or internal management indicates they have a specific problem that needs to be
addressed.
 At this time, a quality alert is generated, and a vigorous containment effort is started to
isolate the problem from the customer(s).
 Understand, define and quantify symptoms
 Identify the customer and other affected parties
 Protect the customer
 Management will decide whether this problem is simple and can be handled by an
individual or significant enough to launch an 8D problem-solving team.

4.4.2.1 Select an appropriate team

 Typically the team consists of 3 to 7 members
 Management is responsible for assembling a team that has relevant knowledge and
experience to address the issue.
 Management assigns a team leader for the project.

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 Should be experienced (subject matter expert) and familiar with 8D approach

 have the authority as needed to allocate time and acquire other resources needed for the
team.
 Responsible for documenting the steps performed; see Form-3.

4.4.2.2 Formulate the problem definition

 Define the problem in qualifiable terms
 Use 5W2H (What, When, Where, Why, Who, How and How Many)
 Who? Who is complaining?
 What? What are they complaining about?
 When? When did it start?
 Where? Where is the problem occurring?
 Why? Why is this problem occurring (an educated guess)?
 How? How did this problem occur (an educated guess)?
 How? How many problems (measurable and magnitude)?
 Establish the problem boundaries using Is/Is Not Matrix
 Review the problem description with the affected party
 Additional tools could be used in this section to understand the problem better or facilitate
the application of the third step: activate interim containment. These tools are:
 SIPOC stands for supplier, inputs, process, outputs, and customers, which aid in a better
understanding of the process and, consequently, a better defining the problem.
 Gemba walk, which is a Japanese word meaning the "actual place."
 Gemba Walk = Go and see the actual process, understand it, talk to people
performing it, learn from them, and show respect for their work.
 Stakeholder analysis
 you need to understand who the stakeholders are and who are the parties affected by
this problem? Because you might need to communicate with them or you might need
to talk to them, inform them.

4.4.2.3 Activate interim containment


 Review the Interim Containment Plan created in D0 and determine its suitability.
 These are temporary actions to isolate the customer from the outcome of this problem.
 Temporary actions to mitigate the effect of the problem
 Involve appropriate departments/functions in the decision-making.
 Consider the balance between risk and rewards (benefits)
 Consider these when containing the issue:
 Finished product already sent to the customer
 Products in transit
 Finished products
 Work in progress
 Raw material in storage
 Raw material in transit from supplier
 Finished products at supplier facility
 Work-in-progress at supplier facility
 Raw material at supplier facility
 Future orders
 Common approaches include:
 Increase inspection (100%)
 Inform customers
 Product recall if there are serious safety implications
 Consider the side-effect of these plans. That should not lead to another problem.

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 Verify the effectiveness of containment activities

4.4.2.4 Find root cause(s)

 The most challenging part of the 8D method.
 Problem-solving tools are categorized as soft or hard. The term “hard” here refers to those
using statistical analysis.
 Common tools that could be used at this stage
 Idea generation tools
 Gemba walk
 Brainstorming
 Nominal group technique
 Affinity diagram
 5W2H
 Five whys
 Basic quality tools
 Cause and effect diagram
 Flowcharts (process maps)
 Check sheets
 Pareto charts
 Scatter diagram
 Control charts
 Histogram
 Graph and charts
 Bar chart
 Pie chart
 Box and whisker plot
 Bubble chart
 Time series
 Fortunately, these simple tools are easy to learn and very effective in solving the
majority of problems. If the team is working on a complex and more sophisticated
problem, statistical tools such as hypothesis testing, analysis of variance (ANOVA),
and design of experiments (DOE) are needed. In this case, a statistical expert should
be engaged with the team. In many situations, sophisticated statistical tools will not
be needed to solve the problem.
 Three types of causes should be considered during root cause analysis:
 Occurrence root cause: the specific local cause that resulted in the problem. This is
typically the factor that “changed” in the process.
 Escape root cause: the cause that resulted in the problem not being “caught” or
detected.
 Systemic room cause: the broader cause responsible for the local cause to be present
in the first place.
4.4.2.6 Develop permenant corrective action(s)
 There can be multiple root causes for a problem. For every root cause, there could be
multiple corrective actions
 Consider the negative outcomes of the corrective action as well.
 Balance preventive measures (e.g., Poka-yoke) and reactive measures (e.g. testing and
inspection).
 Objectively evaluate each possible action and prioritize (Cost-benefit analysis)
 At this stage, the correction should be implemented on a small scale to verify its
effectiveness.
 Tools that can be used at this stage:
 Procedural changes
 Design change

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 Redundant system
 checkpoints and controls
 Poka-yoke
 Force Field Analysis
 Control Plan
 Benefit-cost analysis
4.4.2.6 Implement and validate corrective action(s)
 At this stage, a permanent correction has been verified. The next step is to validate the
correction on a large production scale. The team needs to ensure the correction does not
create other issues.
 All changes need to be documented and all procedures updated. As the team implements
the permanent solution, other people will be affected and need to be made aware and
trained.
 An environment needs to be created so that the user(s) of the new method will have an
opportunity to participate and be encouraged to do so.
 All suggestions from other groups need to be reviewed and, if valid, be incorporated into
the total change process.
 Tools that can be used at this stage:
 Gantt chart
 RACI matrix
 Control plan
 Reports and dashboard
4.4.2.7 Take preventive steps
 If you change something, there is a good possibility that people will go back to the old
system because there is a tendency for people to fall back on the old arrangement.
Therefore, you need to make sure that the new system remains in place and people don't
start using the old system.
 The lessons learned from this effort should now be leveraged on similar processes. All
quality control systems should now be in place and validated.
 Permanent future reoccurrence efforts should be documented on the 8D form.
 Tools that can be used at this stage:
 Documentation
 Flow Charts
 Training
 Lessons Learned
 Control Plans
 FMEA (failure mode and effect analysis)
 Poka-Yoke

4.4.2.8 Congratulate the team

 Once the team task is completed and results meet all customer requirements, the team
needs to be formally recognized and thanked by the management.
 The team members should thank all others who helped them to succeed, and they should
complete all relevant paperwork and publish their work for future use.
7. Attachments
 Form#1: 5whys form
 Form#2 template-1: A3 problem solving
 Form#2 template-2: A3 problem solving
 Form#3: 8D form
8. References
 Andersen, B., & Fagerhaug, T. N. (2013). The ASQ Pocket Guide to Root Cause
Analysis (Poc Spi ed.). Quality Press.

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 Barsalou, M. A. (2015). Root cause analysis: a step-by-step guide to using the right tool at
the right time. CRC press
 Gupta, B. C. (2021). Statistical Quality Control: Using MINITAB, R, JMP and Python (1st
ed.). Wiley.
 Hartshorne, D. J. (2020). The New Science of Fixing Things: Powerful Insights About Root
Cause Analysis That Will Transform Product and Process Performance. Independently
published.
 Okes, D. (2019). Root Cause Analysis, Second Edition: The Core of Problem Solving and
Corrective Action (2nd ed.). ASQ Quality Press.
 Zarghami, A., & Benbow, D. (2017). Introduction to 8D Problem Solving: Including
Practical Applications and Examples. ASQ Quality Press.

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Form#1: 5whys form

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Form#2 template-1: A3 problem solving

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Form#2 template-2: A3 problem solving

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Form#3: 8D form

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