Root Cause Analysis

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Root Cause Analysis
WHY WHY WHY WHY WHY
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Root Cause Analysis
TUFF
SHIT HAPPENS
000
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Root Cause Analysis

• The fact is bad things do happen. Someone has
  defined a lifetime as time spent repairing our
  or someone elses mistakes.

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Root Cause Analysis

• This is not the total picture, however, because
  good things happen, as well.
• It is just as important to sustain the good
  happenings as to eliminate the bad.

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Root Cause Analysis

• The bad thingsand the good thingsare simply
  effects.
• For every effect, there is at least one, and
  possibly more, causes, i.e., the law of cause and
  effect.

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Root Cause Analysis

Effect
Cause
Cause
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Root Cause Analysis
In the case of a negative effect, a solution is
to change or eliminate the cause of the effect.
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Root Cause Analysis

• Due to the urgency inherent in many negative
  situations, there is a tendency to opt for a
  quick solution that is most expedient. The result
  typically is the symptom is treated rather than
  the underlying fundamental problem.

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Root Cause Analysis

• An excellent example of such resolution is
  physicians most simply treat symptoms based on
  past experience (you hurt, they give you
  different pills until you get better).
• Many times they fail to determine the actual
  (root) cause on the first iteration.

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Root Cause Analysis

• A root cause is a primary cause of a chain of
  causes, which leads to an outcome.
• It is the most basic reason for a negative
  condition (effect), which, if not eliminated,
  would be perceived as bad.
• Orit is the most basic reason for a positive
  condition or effect, which, if perpetuated, would
  be perceived as good.

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Root Cause Analysis

• Root Cause Analysis (RCA) is directed toward
  finding, and treating, these basic, underlying
  issues not just treating symptoms.
• Physicians who run diagnostic tests before
  prescribing medicine are practicing a form of RCA.

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Root Cause Analysis

• RCA is a class of methodologies aimed at
  identifying the basic causes of eventsin our
  caseevents perceived as negative.
• Throughout the processthe focus is on a
  permanent solution to problems.
• RCA is not an end unto itself it is only a tool
  in the process of developing a solution.

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Root Cause Analysis

• For example a simple solution to a worker
  cutting a metal brace too short may be to
  discipline and retrain him. He will, however,
  keep cutting the brace too short if he follows a
  procedure that is flawed.
• Disciplining him certainly wont help and
  retraining him on the same procedure is a total
  waste of time.

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Root Cause Analysis

• Another example a guy gets up in the morning
  and his wife is a grouch (that is the problemthe
  effect). She tells him that she didnt sleep
  well (a cause). It is because he snored (another
  cause).
• Somewhere beyond that fact may be a more basic
  cause. He needs to know the cause so that he can
  fix the problem.

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Root Cause Analysis

Wife Grouchy
Didnt Sleep Well
Hubby Snored All Night
His Allergy
Cat Hair
The New Cat
Wife Bought Cat
For Whatever Reason--Just Likes Cats, Lonely, Her
Friends Have Cats--It Doesnt Matter
The presence of the cat is the root cause of the
initial problem. (The fact that the wife was
responsible for the cat is immaterial at this
point). A solution can be implemented kill the
cat give it away put it in a shelter, etc.
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Root Cause Analysis

• But, whichever solution is selected, monitoring
  of that solution reveals that disposing of the
  cat doesnt correct the problem. The wife is
  still grouchy. Another root cause analysis is in
  order.

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Root Cause Analysis

Wife Grouchy
Misses The Cat
The Cat Is Gone
The fact that the cat is gone is now a root cause
that must be addressed to fix the new problem.
A new solution is required. It may be get the
thing back and give you allergy shots or let you
sleep in a cat-free room. It may be to buy a
hairless cat or shave the one you have--whatever
worksbut you know the root cause.
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Root Cause Analysis

Getting rid of the cat demonstrates the strong
possibility of unintended consequences even when
fixing a root cause. That is why monitoring of
results of solutionsand mid-course corrections
are absolutely necessary.
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Root Cause Analysis

• The bottom line is this RCA is a toolnot an
  end unto itself. Regardless of how many root
  causes there are, the emphasis has to be on the
  end resultaddressing the problem.

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Root Cause Analysis

• APPROACH TO PROBLEM SOLVING USING ROOT CAUSE
  ANALYSIS

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Root Cause Analysis

• To effectively solve problems, RCA must be
  performed systematically, with conclusions and
  causes backed up by documented evidence. RCA
  follows the Deming P/D/C/A (Plan/Do/Check/Act)
  cycle of management.

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Root Cause Analysis
Identify The Problem
Identify Causes Associated With The Problem
Collect and Evaluate Data
PLAN
DO
ACT
Corrections Yes/No
Identify Root Cause(s)
Formulate Solutions
Implement Solutions
Monitor The Outcome
Monitor The Outcome
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CHECK
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Root Cause Analysis

• Identify/Define Problem
• Only if a problem is correctly identified and
  completely understood, can a root cause and
  subsequent root corrective action be implemented.
  (A misunderstood problem becomes a root cause of
  failure to solve the problem)

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Root Cause Analysis

• Gather And Evaluate Data/Evidence
• Identify facts surrounding the undesired outcome.
• - Timing
• - Location
• - Employees
• - Equipment/Materials
• - General Conditions

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Root Cause Analysis

• Identify The Causes Associated With The Problem
• Peel away the onion. What are all the potential
  causes? Dont eliminate anything out of hand the
  slightest detail could hold the answer to the
  riddle.
• Determine if the potential causes fall into any
  broad areas Technical, Personnel, Materials,
  Procedures, Processes.

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Root Cause Analysis

• Identify Root Cause(s) And Formulate Solutions To
  Prevent Recurrence
• Within your control
• That meet your objectives and
• Do not cause additional problems (unintended
  consequences).

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Root Cause Analysis

• Implement The Solution(s)
• Monitor Their Outcome To Ensure Success
• Be prepared to make mid-course corrections.

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Root Cause Analysis

• For purposes of this class, we will focus on two
  analytical methods Cause and Effect (CE)
  Diagrams and 5 Whysboth highly effective in
  likely situations at Smithfield facilities.

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Root Cause Analysis

• CAUSE AND EFFECT ANALYSIS

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Root Cause Analysis

• Cause and effect analysis is a technique that
  organizes knowledge of a system into a cause and
  effect chain.
• A cause and effect (CE) diagram is a first step
  in addressing and understanding the problem.

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Root Cause Analysis

Effect
Cause
Cause
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Root Cause Analysis

• The major purpose of the CE Diagram is to
  generate a comprehensive list of possible causes.
  It can lead to immediate identification of major
  causes or (most often) can point to other
  potential areas for further exploration and
  analysis.

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Root Cause Analysis

• To construct a CE diagram
• First, gather a cross-functional team of 2 or
  more individuals with diverse knowledge,
  experience, and interest
• Smithfields EMS teams should already be composed
  of such diverse members so they are ideally
  suited for RCA.

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Root Cause Analysis

• To construct a CE diagram (cont)
• Be sure everyone on the analytical team agrees on
  the effect (problem) and the results of the data
  gathering.
• Begin the diagram by listing the effect and
  drawing a line to it. This is the main line of
  the diagram

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Root Cause Analysis

• To construct a CE diagram (cont.)
• Then collect as much pertinent data on possible
  causes as possible. Make sure all team members
  provide input from their areas of interest or
  expertise.

Effect
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Root Cause Analysis

• To construct a CE diagram (cont.)
• If you have or can prepare a process-flow
  diagram, begin by listing the broad categories of
  processes. For example
• - Design
• - Purchasing
• - Installation
• - Maintenance

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Root Cause Analysis
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Root Cause Analysis

• To construct a CE diagram (cont.)
• Each stage in the process leading up to the
  effect being examined is shown along the main
  line of the diagram.

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Root Cause Analysis
(Effect) Faulty Equipment
Installation (Cause?)
Maintenance (Cause?)
Cause and Effect Diagram
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Root Cause Analysis

• Determine all the detailed associated causes in
  each of the broad areas of enquiry as shown in
  the following example

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Root Cause Analysis
Specifications
Procedure
Procedure
Personnel
(Effect) Faulty Equipment
Installation
Personnel
Personnel
Procedure
Equipment
QA
Maintenance
QA
Personnel
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Root Cause Analysis

• Continue the process of branching off into more
  and more directions until every possible cause
  has been identified.
• The final result will represent a compendium of
  the factors relating to the effect being explored
  and the relationships between them. An example of
  an actual CE diagram for a manufacturing problem

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Root Cause Analysis
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Root Cause Analysis

• When all of the potential causes have been
  discussed and all ideas exhausted, the team
  decides which cause(s) are relevant to the
  problem.

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Root Cause Analysis

• The team then begins the 5 Why analysis of each
  cause to isolate the root cause of the problem.

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Root Cause Analysis

• THE 5 WHYS ANALYSIS

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Root Cause Analysis

• The 5 Whys is a question-asking method used to
  explore and analyze the cause/effect
  relationships underlying a particular problem.
• Remember, the goal of applying the 5 Whys method
  is to solve a problem, it is not an end unto
  itself.

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Root Cause Analysis

• The methodology is called 5 Whys because five
  iterations is a typical average but it is not a
  hard rule.
• The 5 Whys concept is easy to remember, simple
  to apply, and probes considerably deeper than
  traditional trouble shooting.

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Root Cause Analysis

• The process begins by asking why did X occur
  after concluding that Y caused it, ask why did Y
  occur and so on. Keep asking until a root cause
  is determined or until a cause or condition
  beyond your control is found.

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Root Cause Analysis

• For Example
• Car will not start. (the effect/problem)
• Why 1? - The battery is dead.
• Why 2? - The alternator is not functioning.
• Why 3? - The alternator belt looks too loose to
  work properly.

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Root Cause Analysis

• Why 4? - The alternator belt is well beyond its
  useful service life and has never been replaced.
  
• Although possibly not the root cause, this could
  provide a starting point for an action
• Replace the alternator belt and charge the
  battery.
• For a long-term solution, you may want to
  continue with Why 5

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Root Cause Analysis

• Why 5? - Car has not been maintained according
  to the service schedule.
• Why 6? - Cant afford it.
• Why 7? - Have no job.
• Why 8? - Been laid off.
• Why 9? - Stole from employer.
• Why 10?- Im a drug addict need money.

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Root Cause Analysis

• The last cause is only marginally germane to the
  dead car but, may provide a starting point for
  another analysispossibly by the persons parole
  officer.

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Root Cause Analysis

• Although 5 Whys is a good approach, it contains
  a couple of potential problems
• Humans make mistakes. If a mistake is made
  answering just one why question, the entire
  analysis may be thrown off. The earlier such a
  mistake is made in the process, the more
  inaccurate the root cause is likely to be. (What
  if it isnt the alternator?)

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Root Cause Analysis

• 2. There is a potential for a cause that is
  beyond the investigator's scope and
  knowledgeleading to a potential for the
  investigator to ask the wrong why questions.
• (What is a solution?)

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Root Cause Analysis

• Most of these potential problems can be
  eliminated or significantly reduced by
• Involving a team in the analytical process (2 or
  more heads)
• Asking additional questions of yourself or the
  team
• - Are we qualified for this analysis?
• - Is anything else needed, along with this
  cause, for the stated effect to occur?

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Root Cause Analysis

• - Are there alternative explanations that
  better fit circumstances?
• - Are there potential unintended consequences
  to addressing this cause? Lots of what ifs.
• - What other risks are there?

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Root Cause Analysis

• In order to avoid these issues, a good practice
  is on-the-spot verification of the answer to the
  current why question, before proceeding to the
  next.
• (In the car example is the alternator truly
  brokenor is the battery just bad? (test it
  find out)

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Root Cause Analysis

• One good way to focus the investigation is to
  establish a series of checkpoints at which data
  are collected to help sort out the problem. Mark
  them on the CE diagram for reference.

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Root Cause Analysis

CAUSE-EFFECT DIAGRAM
Procedure
QA
Requisition
Personnel
Ck 2
Effect (Failed Parts)
Installation
Calibration
Ck 3
Ck 1
Personnel
Manufacturer
Equipment
Maintenance
Ck 4
Procedure
QA
Personnel
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Root Cause Analysis

• In the example, begin by addressing one potential
  cause for the failed parts. For
  examplemaintenance.
• Collect data on the maintenance
  (PMs/repairs/parts). Confirm if they have been
  maintained properly (Ck 1).

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Root Cause Analysis

• If there are solid data indicating that
  maintenance is not a candidate, it is eliminated
  from further analysis.

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Root Cause Analysis

Ck 2
Effect (Faulty Parts)
Installation
Ck 3
Ck 1
Maintenance
Ck 4
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Root Cause Analysis

• If maintenance is not the problem
• Review installation diagrams and procedures (Ck
  2). Are the parts installed according to the
  diagram/procedures?
• If not, this is a cause, so ask why (this may be
  Why 1). Data checking (Ck-3) may lead to an
  install procedure at odds with the diagram. This
  is also a cause, so, ask why (this could be Why
  2).

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Root Cause Analysis

• This leads to data collection concerning the
  procedureit may require collecting information
  from the document control person (Ck 4). If you
  determine the procedure is out of date, another
  cause, and you ask why (Why 3).

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Root Cause Analysis

• Continue to collect data and ask why until the
  root cause is determined, another pathway is
  indicated, or a cause is out of your control.

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Root Cause Analysis

• CAUSE AND EFFECT EXERCISE

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Root Cause Analysis

• Exercise A
• The Smithfield Operations Manager inspects a tank
  installation by XYZ Contractors. The contractors
  are installing two tanksa UST and an AST. The
  Ops Manager knows the tanks are installed
  incorrectly. The impact is potentially
  environmentally disastrous.
• What is the effect?

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Root Cause Analysis

• Exercise A Effect

Incorrect Tank Installation
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Root Cause Analysis

• Exercise A
• Divide into teams and look at the supplied
  packet. There should be
• A hard copy of the scenario
• A process-flow diagram and
• Several documents relating to the process.

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Root Cause Analysis

• Exercise A Cause and Effect Diagram
• You have determined the effect. Now prepare a
  cause and effect diagrambased on the process
  flow diagram in your packet and what you have
  just learnedto describe how you would go about
  preparing to determine the root cause of the
  problem.

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Root Cause Analysis

EXAMPLE OF A DETAILED CAUSE-EFFECT DIAGRAM
Procedure
QA
Requisition
Personnel
Ck 2
Effect (Failed Parts)
Installation
Calibration
Ck 3
Ck 1
Personnel
Manufacturer
Equipment
Maintenance
Ck 4
This detail is to demonstrate the depth necessary
on occasion. For the Exercise, do not go beyond
each major stage (boxes) in the process.
Procedure
QA
Personnel
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Root Cause Analysis

• Exercise A Cause and Effect Diagram
• In the interest of time, do not go beyond the
  major stage detail. For example, if installation
  is a cause, do not delve into personnel,
  equipment, QA, calibration, etc.

Installation
Personnel
QA
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Root Cause Analysis

• Exercise A Cause and Effect Diagram
• When you complete the CE diagram, stop and we
  will look at all teams results. Then we will go
  on to do the 5 Whys analysis.

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Root Cause Analysis

• 5 WHYS EXERCISES

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Root Cause Analysis

• BLANK

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Root Cause Analysis

• SCENARIO A
• EffectImproper tank installation (Ops Manager
  found 5,000-gallon UST for storage of 2 fuel oil
  and 500-gallon AST for storage of NaOH)
• WHY 1 were the tanks installed incorrectly?
• Questions before initiating Data Check 1
• Were the specs correct?
• Data Check 1(Engineering SpecsDoc 2)
• ResultsSFI specs different from what
  contractors installed(500- gallon Tank A to
  be installed below ground and the 5,000-gallon
  Tank B to be installed above ground).
• AnswerThe installers used the wrong specs.

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Root Cause Analysis

• WHY 2 did they use the wrong specs?
• Questions before Data Check 2
• - Were workers properly trained?
• Data Check 2(XYZ Training DocumentDoc 5)
• Resultsemployees trained by XYZ supervisors on
  specs (500-gallon Tank A to be installed above
  ground (AST) and 5,000-gallon Tank B to be
  installed below ground (UST)Contrary to
  Smithfield Engineering Specs-Document 2).
• Answerthey were not trained properly.

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Root Cause Analysis

• WHY 3 were employees improperly trained?
• Questions before Data Check 3
• - Why did XYZ supervisors train the installers
  on wrong specs?
• Data Check 3(Smithfield HR Contractor Training
  DocumentDoc 4)
• Results Smithfield Trainers training XYZ
  employees to specs different than original
  engineering specs500-gallon Tank A to be
  installed above ground (AST) 5,000-gallon Tank B
  to be installed below ground (UST).
• AnswerXYZ supervisors received wrong specs from
  SFI HR Trainers.

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Root Cause Analysis

• WHY 4 were Smithfield Trainers training XYZ
  Contractors on incorrect installation data?
• Questions before Data Check 4
• - What data were HR Training given by Document
  Production?
• - Did Document Supervisor approve?
• Data Check 4(Document Production Installation
  Procedure Approval by Document Production
  Supervisor Doc 3 and 3A)
• ResultsDocument Production delivered incorrect
  documents Document Production Supervisor
  approved incorrect data.
• Answer HR was training XYZ supervisors on
  approved documents they were given.

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Root Cause Analysis

• WHY 5 did Document Production prepare faulty
  documents and why did Supervisor approve faulty
  data?
• Questions before Data Check 5
• - Did Document Production get faulty engineering
  data?
• Data Check 5(Engineering Tank Installation
  Specs as approved by Operations Manager Doc 2 and
  2A)
• ResultsEngineering documentation totally
  correct as approved.
• Answer Document Production was given correct
  installation specifications. Document Production
  and DP Supervisor screwed up.

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Root Cause Analysis

• Why 6 did Document Production screw up?
• Data Check 6(Check training for Document
  Production personnel, including Document
  Production Supervisor Check resourcesenough
  personnel? Workload? Interview personnel for
  personal problemsfrom here it is detective work)
• Conclusion You choose root causeThen propose a
  corrective action.

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Root Cause Analysis
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Root Cause Analysis
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