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