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Introduction to
Root Cause Analysis
As a Tool For Compliance Mitigation
Root Cause Analysis Truism #1
Bad things will happen…
The extent of the damage, or whether bad
things happen again, is a product of how
well we respond. 2
Root Cause Analysis Truism #2
“A bad system will
beat a good person
every time”
W. Edwards Deming
3
Root Cause Analysis Proposals
So if a bad system will beat a good
person every time what can you do?
• Improve the system so that success is built into
the system
• Don’t rely on individual heroic measures as a
component of your process
4
Root Cause Analysis (RCA) Objectives
• Describe RCA
• Applying RCA
– Develop mitigation activities
– Create corrective action plan
5
RCA
Description of Root Cause Analysis
• Root cause analysis is a systematic process
…for identifying “root causes” of problems or
events
• RCA serves as an effective management tool
…more than merely “putting out fires” for problems
that develop, but finding a way to prevent them
6
RCA
Benefits of Root Cause Analysis
• Prevent problems from recurring
• Reduce possible injury to personnel
• Reduce rework and scrap
• Increase competitiveness
• Ultimately, reduce cost and save money
7
RCA
Applying Root Cause Analysis
• Major accidents
• Everyday incidents
• Near-misses
• Human errors
• Maintenance problems
• Medical mistakes
• Productivity issues
• Development of corrective actions and mitigation plans
8
RCA Process
Prevention, not blame or punishment, is
the key element to having a successful RCA
9
Common Root Cause Mistakes
Initial response is usually the symptom, not the root cause of the problem.
Common “symptoms” mistaken for Root Causes:
• Equipment Failure
• Human Error
• Procedure Not Followed10
Look Beyond the Obvious
Invariably, the root cause of a problem is not
the initial reaction or response
Which leads to faulty mitigation11
Human Error
• To get to the root cause, we must look at the
systems and how they can be changed to make
the process easier on everyone
• What looks like a people problem is often a
system problem 12
Most Root Causes are System Related
• Process or program failure
• System or organization failure
• Poorly written procedures
• Lack of internal controls
• Inadequate training
13
Human Error
• To get to the root cause, we must look at the
systems and how they can be changed to make
the process easier on everyone.
• We won’t ask the question “Who?”
• This is not the place for blame.
• What looks like a people problem is often a
system problem.
14The PII Performance Pyramid TM
RCA Analysis Process
It’s Not Rocket Science…
but there is a process15
Root Cause Analysis Must-Haves
• Collaborative Effort
• Inter-disciplinary Process
• Requires participation (buy-in) by the
leadership of the organization
16
Using the RCA Process
• Investigate the incident
via Data Collection
• Attempt to understand the underlying
causes of the incident thru Analysis
• Generate effective Corrective Actions to
prevent and mitigate future incidents
17
Basic steps of the RCA process...
Step One—Data collection
Without an understanding of the event, the root
causes and causal factors cannot be identified18
Basic steps of the RCA process...
Investigation
19
Basic steps of the RCA process...
Step two—Analysis
• 5 Whys
•Causal factor charting
Without an understanding of the event, the causal
factors and root causes cannot be identified
20
Analysis Tool: 5 Whys
Sakichi Toyoda, one of the fathers of the Japanese
industrial revolution, developed the 5 Whys technique
in the 1930s
Toyoda has a "go and see" philosophy. This means
that its decision making is based upon an in-depth
understanding of the processes and conditions on the
production floor
21
Analysis Tool: 5 Whys
Sakichi Toyoda:
The 5 Whys technique is most effective when the
answers come from people who have hands-on
experience of the process being examined.
22
Analysis Tool: 5 Whys
Where do we start?
Write down the specific problem
Writing the issue helps you to formalize the problem
and describe it completely. It also helps a team focus
on the same problem
Ask "Why" the problem happens and write the answer
down below the problem
23
Analysis Tool: 5 Whys
If the answer you just provided doesn't identify the
root cause of the problem that you wrote down in step
1, ask “Why” again and write that answer down
Keep looping back to step 3 until the team is in
agreement that the problem's root cause is identified
This may take more or less than five “Whys”
24
Analysis Tool: 5 Whys Example
Production Line Stoppage Issue
A large production company had an unusual
amount of scrap reported from the previous day’s
production on one machine.
The operator pushed the emergency stop button
by mistake during a production run.25
Analysis Tool: 5 Whys Example
The Business Improvement Leader asked why?
“Operator error,” was the reply from the senior
manager
Why was it an operator error?
“Because it happens now and again,” was the
reply
26
Analysis Tool: 5 Whys Example
A brief inspection of the start and stop buttons on the
machine:
Revealed both buttons were dirty to the point that the
red stop and green go buttons were not
distinguishable
And the buttons were also very close to each other
27
Analysis Tool: 5 Whys Example
“Why does it happens now and again” asked the
Business Improvement Leader?
Operator pushed the stop button by mistake.
Why?
The buttons were unclear and dirty, and the stop
button was right next to the start button
28
Basic steps of the RCA process...
29
Ishikawa fishbone diagram process:
Brainstorm causes
Put into pre-defined categories
Vote on which most likely to cause problems
Generate solutions
Step two —
Fishbone Cause and Effect
Basic steps of the RCA process...
Step Three—
Root cause identification
After a list of Causal factors have been identified,
begin Root Cause identification30
Basic steps of the RCA process...
Step Three—
Root cause identification
• Finding root cause encourages brainstorming
• There is no judgment and no wrong answers
• We are encouraged to find multiple root causes
• Pick the most appropriate root causes31
Basic steps of the RCA process...
Production Stoppage Possible Root Causes:
Dirty control panels
Emergency stop button too close to the start button
32
Basic steps of the RCA process...
Unacceptable Root Causes
• Human Error
• Mistake
• Distraction
33
Basic steps of the RCA process...
Step 4 –
Recommendations and implementation
34
Corrective Action
Corrective Action – Mitigation Plan
• Actions to eliminate the cause of a
detected issue/problem
• Designed to prevent reoccurrence
35
Corrective Action
Unacceptable Corrective Actions
• Reminded employees
• Retraining
• Instructed to pay more attention
36
Basic steps of the RCA process...
Possible Corrective Actions:
• Clean the area and control panels
• Move the emergency stop button to the other side
of the machine, away from the start button
37
Follow Up Monitoring
Monitor results to ensure that corrective
actions are effective
This is a check step to ask:
• How’s it going?
• What’s working?
• What’s not working?
• What could be improved?
• Are corrective actions effective?38
Keys to Success
Take an active approach. Having employees simply
read and sign a procedure is often not enough.
• Improve procedures and worksheets to make the
system more effective
• Communicate the new process through training
• Evaluate the new process through Internal Audits
39
McDonald’s Spilled Coffee Case
McDonald's sued over hot coffee spill
40
McDonald’s Spilled Coffee Case
The Investigation
• The subject, a 79 yr. old woman was a passenger in a
car at a McDonald's drive-thru
• She received a cup of hot coffee, sealed by a lid, with an
estimated temperature of 180 degrees F
• While attempting to remove the lid and add cream and
sugar, she spilled the contents of the cup into her lap
41
McDonald’s Spilled Coffee Case
The Investigation
• She was wearing sweat pants that held the hot
liquid against her skin for over 90 seconds
• Subject suffered severe, third-degree burns that
required extensive hospital treatment, including
skin grafts 42
McDonald’s Spilled Coffee Case
The Investigation
• McDonald's defended its policy of serving coffee
at a temperature of 180 degrees or greater
• However, McDonald's had received over 700
complaints of coffee burns (of varying severity)
over the past 10 years 43
McDonald’s Spilled Coffee Case
Why did this happen
Cause Map
44
McDonald’s Spilled Coffee Case
Why did this happen
Completed Cause Map45
McDonald’s Spilled Coffee Case
5 Whys Analysis
46
McDonald’s Spilled Coffee Case
What caused the burn by hot coffee?
A – the person spilled the coffee on her leg (Human Error)
B – the coffee at 180F (Process)
C – the coffee cup lid is hard to open (Equipment)
D – customer adding cream and sugar at drive thru (Process)
E – A, B, C, D47
McDonald’s Spilled Coffee Case
What caused the burn by hot coffee?
Answer: E – A, B, C, D
48
McDonald’s Spilled Coffee Case
Describing Root Cause(s)
- The 3rd degree burns required both the coffee to
be 180F, and the person to spill the coffee on her
lap
- Controlling either causes prevents the burn
- Removing the lid to add cream and
sugar while sitting at the drive thru
are also contributors to the
incident, and should be mitigated
49
McDonald’s Spilled Coffee Case
Effective Solutions: Brainstorming
Completed Cause Map
50
Summary
The ability to deal with a crisis
situation is largely dependent on the
structures that have been developed
before chaos arrives
51
Summary
An aggressive RCA Program can
improve a bad system every time
52
Questions
53
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