Root Cause Determination and the Never-ending Search for Answers

The search for the root cause of a nonconformity defines the path of continual improvement. Organizations that take the effort in patiently determining the root cause of a problem stand a greater chance of uncovering the weaker parts of their system and uprooting the cause of their problems.  The determination of the root cause requires careful consideration and acknowledgement of the facts.  There should be no shortcuts.

Organizations that are into ISO 9001 quality management system have a great use for good root cause analysis tools. The more popular tools include the 5-Whys Technique, Why-Why Diagram, Cause Mapping and the use of the Fishbone or Ishikawa Diagram. The usefulness of any one of the previously mentioned root cause analysis tools requires ample preparation and deliberation.

The Why-Why and 5-Whys Technique


Beginners may start with the Why-Why or the 5-Whys because of the seeming portability and ease of use of the tools. This belief can be misleading especially when the activity is done in a haphazard manner and the wrong "Whys" are asked. An example scenario will be:

This practice limits the opportunity for the organization to benefit from its continual improvement process. It is also possible to arrive at a completely different corrective action when the subsequent answers take a different turn, such as shown in the example below:

To improve on the usefulness of the Why-Why or the 5-Whys as tool for root cause analysis, the organization may want to conduct the root cause analysis activity by conducting CauseMapping by ThinkReliability. The site has extensive tools and materials for this method.

Another tool is the Fishbone or the Ishikawa Diagram. The link below is a presentation from the NASA website on the use of the Fishbone Diagram for root cause analysis.
process.nasa.gov/documents/RootCauseAnalysis.pdf

Root Cause Determination

Introduction

A well-established process is expected to be implemented in a consistent manner and to deliver the expected result (ideal condition). When the ideal condition is not achieved, it is necessary to identify the point that led to the attainment of the actual undesirable condition.  This observed undesirable condition, sometimes referred to as a problem or non-conformity or a nonconforming product, happened as a result of an earlier action/ decision/activity. To prevent the problems or nonconformity from recurring, the organization conducts root cause determination.  Root cause determination involves taking steps to identify the turning point, whether an action or decision or activity, that caused the planned event to take a different (unacceptable) turn. When an organization addresses the root cause, the activity is likened to the uprooting of a plant. Root cause determination then is important in order to ensure that an undesirable condition does not recur.

Problem Statement

Problems or nonconformities negatively impact the goals of the organization. To ensure problems do not recur, it is necessary to eliminate the root cause of the problem. Non-familiarity with the root cause determination process hinders the ability of the organization to deliver consistent results.

Existing Practice

Root Cause Determination, also known as Root Cause Analysis, is conducted by using the 5-Whys Tool of Total Quality Management (TQM). It entails asking “Why” five times until the root cause is identified. The 5 Whys is the easiest and most portable tool in Root Cause Analysis.  It does not require sophisticated techniques.  The disadvantage in using this tool is that it requires having a good understanding of the process in order to ask the right “Why” questions.

Proposed Solution

Cause Mapping of ThinkReliability is another tool that can be used for root cause determination.  The Cause Mapping tool expands the utility of the 5 Whys technique and enables the organization to examine the series of activities that led to the final result.   The following steps comprise the Cause Mapping Technique:

1. Creating the problem statement.

2. Identifying the goals impacted

3. Listing the possible cause(s)

4. Testing the identified cause(s)

5. Identifying the root cause

Creating the problem statement . 
What goal was not achieved because of the presence of the undesirable condition?

What – statement of the undesirable condition

When – date and time the undesirable condition was observed

Where – location, facility or task being performed

Listing the Possible Cause(s)

This is done by creating “cause boxes”.  Cause boxes are rectangular shapes that contain a description of an observable condition. Cause boxes go from left to right. The first cause box which is located in the leftmost portion states the nonconformity. Subsequent boxes are then drawn to the right of the first cause box.  These subsequent cause boxes answers the question “...is caused by…”

Testing the Identified Cause(s)

Caution should be taken in testing the validity of the identified cause.  Those who are working on determining the root cause should refrain from jumping to conclusion or adopting a pet cause.  Always look for evidence and not on assumptions.

Identifying the Root Cause

The root cause will answer the question: “What was the earliest decision/ action/ activity that led to the development of the undesirable condition?

Conclusion

The proper implementation of root cause determination helps organizations to implement activities for continual improvement.  Cause mapping is among the effective tools that can be used for this purpose.

References

1. Cause Mapping – available online http://www.thinkreliability.com/Root-Cause-Analysis.aspx

2. The Five Whys Technique – available online www.adb.org/Documents/Information/Knowledge-Solutions/The-Five-Whys-Technique.pdf

3. Total Quality Management- available online http://en.wikipedia.org/wiki/Total_quality_management

Learning by Writing

Writing has many different uses for many people.  Some people write just for the fun of it.  Others write to express themselves, to show others how they see the world. Others write to persuade, to urge the readers to take stand or to make decisions.  Others also write to teach, to explain how things work so that the readers get to have a better understanding on a particular subject.  One other practical use of writing is by using writing as a learning tool.  Learning by writing has been discussed in  Writers Inc as one of the ways that can help improve a student's study skills.

The following steps have been discussed in Writer's Inc as useful guides when one is using writing as a tool for learning:

1. State the learning in your own words.  After reading something, or hearing a lecture or taking part in a discussion, state your conclusion.  Write the information that you found useful or interesting.  Also state if there were opinions that you agreed with, or disagreed with, and the reason for your decision.

2. Personalize new ideas or concepts.  One way to learn is by fitting in the new knowledge with what you already know. When you learn about Taichi, how is the new knowledge different or similar from another martial arts discipline that you are already familiar with.

3. Ask yourself why this particular learning is important.   When you learn about the Law of Inertia for example, you may try to observe how this applies in your everyday life such as understanding why it is necessary for you to fasten your seat belts always.

4. Identify the people who will need to know about the learning. Who will benefit from this knowledge? Is the learning accessible to the people who need them?

4. Add pictures to your writing. Adding pictures, especially colored ones help you better remember the new learning. After all, the phrase "to get a better picture" may have originated from this idea.  Doodle in the pages or cut out pictures.  You can also try making charts or maps.

5. Keep a New Words List.  Some disciplines have their own unique way of referring at things. List down the words that are peculiar to the particular subject and try to use them frequently in your conversations.  

Learning by writing allows the student to analyze the newly-acquired knowledge. It helps the student become an effective learner.