College of Engineering

ES11- ENGINEERING MANAGEMENT

Root Cause Analysis

RCA

ENGR . JOVIN A. MANARIN

INSTRUCTOR
Root Cause Analysis
Definition

 Root cause analysis (RCA) is a class of problem solving

methods aimed at identifying the root causes of
problems or events.

 RCA is based on the belief that problems are best solved

by attempting to correct or eliminate root causes, as
opposed to merely addressing the immediately obvious
symptoms.
Principles of RCA?

 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.
 General process for performing
root cause analysis
1. Define the problem.
2. Gather data/evidence.
3. Identify issues that contributed to the problem.

4. Identify which causes to remove

Find root causes.
or change to prevent repeated problem.
5. Develop solution recommendations that effectively prevent repeating
the problem.
6. Implement the recommendations / changes.
7. Observe the recommended solutions/changes to ensure effectiveness of
eliminating the problem.
Cause Mapping of Root Cause Analysis

 “ROOT” refers to the causes beneath the surface. It is

the system of causes that shows all the options for
solutions.
 Do not focus on a single cause as this can limit the
solutions set resulting in missing a better solution.
 A Cause Map provides a simple visual look at all the
elements that produced the problem.
Three Basic Steps of Cause
Mapping
1. Define the issue by its impact to overall goals

2. Analyze the cause in a visual map.

3. Prevent or mitigate any negative impact of the goals

by selecting the most effective solutions.
  5 whys
Tools for RCA
 4Ps
 Pareto Chart
 Fishbone or Ishikawa Diagram
 Chart and/or Graphs

Why? 50% 25

Why? 80%

Why?
Why? 0%
10%
5% 5%
0

Why?
P ric e P ro m o t io n P e o p le P ro c e s s e s
Incidences
D e t a il D e t a il D e t a il D e t a il
D e t a il D e t a il D e t a il D e t a il
D e t a il D e t a il D e t a il D e t a il

T h e P ro b le m

D e t a il D e t a il D e t a il D e t a il
D e t a il D e t a il D e t a il D e t a il
D e t a il D e t a il D e t a il D e t a il

P la c e / P la n t P o lic ie s P ro c e d u re s P ro d u c t
 Man Method Materials

Problem

Management System Machine Environment

Ishikawa or Fishbone Diagram

(Cause and effect)
 Brain storm possible causes
Man Method Materials

Cause A
Cause D Cause E

Problem

Cause F
Cause C
Cause B

Management System Machine Environment

6 M’s sample
Sample
4Ps
4P’s – People, Process, Policies and Plant

 People is nothing but Man as per 6 M

 Process is Method of 6 M
 Policies are company policies like HR
policies, work policies or can be
government policies as well. We cover
policies under Method of 6M
 Plant covers basically your machine,
materials as well as the work
environment
5 Whys

 Why
 Why
 Why
 Why
 Why
 Basis for the 20 questions toy
 The 5 Whys uses "counter-measures," rather
than "solutions." A counter-measure is an
action or set of actions that seeks to prevent the
problem from arising again, while a solution
may just seek to deal with the symptom. As
such, counter-measures are more robust, and
will more likely prevent the problem from
recurring.
When to Use a 5 Whys Analysis

 You can use 5 Whys for troubleshooting,

quality improvement, and problem solving, but
it is most effective when used to resolve simple
or moderately difficult problems.
How to Use the 5 Whys
The model follows a very simple seven-step process:

 1. Assemble a Team
Gather together people who are familiar with the
specifics of the problem, and with the process that
you're trying to fix. Include someone to act as a
facilitator , who can keep the team focused on
identifying effective counter-measures.
2. Define the Problem
 If you can, observe the problem in action. Discuss
it with your team and write a brief, clear problem
statement that you all agree on. For example,
"Team A isn't meeting its response time targets" or
"Software release B resulted in too many rollback
failures."
 Then, write your statement on a whiteboard or
sticky note, leaving enough space around it to add
your answers to the repeated question, "Why?"
3. Ask the First "Why?"
 Ask your team why the problem is occurring. (For
example, "Why isn't Team A meeting its response time
targets?")
 Asking "Why?" sounds simple, but answering it requires
serious thought. Search for answers that are grounded in
fact: they must be accounts of things that have actually
happened, not guesses at what might have happened.
 This prevents 5 Whys from becoming just a process of
deductive reasoning, which can generate a large number
of possible causes and, sometimes, create more confusion
as you chase down hypothetical problems.
4. Ask "Why?" Four More Times
 For each of the answers that you generated in Step 3,
ask four further "whys" in succession. Each time, frame
the question in response to the answer you've just
recorded.
Step 5. Know When to Stop
 You'll know that you've revealed the root cause of the
problem when asking "why" produces no more useful
responses, and you can go no further. An appropriate
counter-measure or process change should then become
evident. (As we said earlier, if you're not sure that
you've uncovered the real root cause, consider using a
more in-depth problem-solving technique like Cause and
Effect Analysis , Root Cause Analysis , or FMEA .)
6. Address the Root Cause(s)
 Now that you've identified at least one root cause, you
need to discuss and agree on the counter-measures that
will prevent the problem from recurring.
7. Monitor Your Measures
 Keep a close watch on how effectively your counter-
measures eliminate or minimize the initial problem. You
may need to amend them, or replace them entirely. If
this happens, it's a good idea to repeat the 5 Whys
process to ensure that you've identified the correct root
cause.
Pareto Chart
 The tackle is the one that has the highest score. This one will give you the
biggest benefit if you solve it.

Defining the problem

Charts and Graphs
7 Best Practices to Remember
1. Your root cause analysis is only as good as the info you collect.
2. Your knowledge (or lack of it) can get in the way of a good root cause
analysis.
3. You have to understand what happened before you can understand why
it happened.
4. Interviews are not about asking questions.
5. You can’t solve all human performance problems with discipline,
training, and procedures.
6. Often people can’t see effective corrective actions even if they can find
the root cause.
7. All investigations do not need to be equal (but some steps can’t be
skipped.
 References

SixSigmaStats.com (2018) 4 Steps to do Fishbone analysis/Cause and Effect

(retrieve from: https://sixsigmastats.com/steps-fishbone/#:~: text=4%20P's
%20%E2%80%93% 20People%2C%20Process%2C%20 Policies
%20and%20Plant&text= Plant%20covers %20basically%20your%20machine,well
%20as%20the%20work%20environment.

MindTools (2021) 5 Whys Getting to the Root of a Problem Quickly (retrieved from:
https://www.mindtools.com/pages/article/newTMC_5W.htm
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