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IDENTIFY,ELIMINATE,PREVENT

Presenter : Gloria Kgagabi

ROOT CAUSE ANALYSIS

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OBJECTIVES

• Gain an overview of a problem solving process.• Learn how to apply common root cause

analysis tools such as 5 whys and cause effect diagrams to identify root causes.• Learn how to prioritise root causes with a

pareto chart.• Understand the pitfalls in root cause

analysis.

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PROGRAM OUTLINE

• Introduction to root cause analysis.• Overview of a problem solving process.• Root cause analysis using 5 whys.• Root cause analysis using cause effect

diagrams.• Root cause prioritisation using pareto

chart.• Pitfalls to avoid.

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15Introduction To

Root cause analysis

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“When we fail to grasp the systematic source of problems, we are left to ‘push on` symptoms rather than eliminate causes”

-Peter Senge the fifth discipline

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What is root cause analysis ? Root cause analysis (RCA) is a technique that helps guide

people to discover and understand the initiating cause(s) of a problem, with the goal of determining missing or inadequately applied that prevent reoccurrence(s).

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Root cause-the evil at the bottom• The root cause is the – “evil at the bottom” that sets in motion

the entire cause- and –effect cause chain causing the problem(s)

Symptom

Visible problem

Higher- level cause

First- level cause

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Why Root cause analysis ?

• RCA helps to identify what, how and why an event or failure occurred.• Root causes are underlying, are reasonably

identifiable, can be controlled by management and allow for the generation of solutions.• Only when you are able to determine why an

event or failure occurred will you be able to specify workable corrective and preventative measure(s)

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Principles of RCA

•System thinking approach•Prevention of reoccurrence•Pareto principle•Employee engagement•Continuous improvement

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Overview of problem solving process

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Root cause analysisAlbert Einstein

“Problems that exist in the world cannot be solved by the level of thinking that created them”

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A simple problem solving process

DEFINE THE PROBLEM

COLLECT DATA

IDENTIFY ROOT CAUSES

IMPLEMENT COUNTERMEASURES

EVALUATE AND FOLLOW UP

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Dealing with root causes• Solutions must deal with root causes not symptoms.• Ask “WHY”? five times to get to the root cause.• Use the cause and diagram.

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5 WHYS

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Every defect is a treasure !Kiichiro Toyada-founder of

toyota

“Every defect is a treasure, if the company can uncover its and work to prevent it across the corporation”

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Benefits of 5 whys

•Helps to identify the root of a problem.•Determines the relationship between

different root causes of a problem.•One of the simplest tools , easy to

complete without statistical analysis.

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Example of 5 whys

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Cause and effect diagram

PURPOSE:• To capture the casual relationship between cause and

effect.• To stratify the causes into meaningful groupings

The cause and effect diagram is also known as the ‘fishbone diagram or Ishikawa

diagram’

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Cause and effect diagram(Manufacturing)

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Manufacturing example

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Combining 5 whys and cause effect diagrams• The 5 whys can be used individually or as a part

of the C & E diagram.• The C & E diagram helps you to explore all

potential or real causes that result in a single defect or failure.• Once all inputs are established on the fish bone

you can use the 5 whys technique to drill down to the root causes.

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PARETO CHART

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Pareto chart

PURPOSE:• To show relative significance of the

identified root causes.WHEN TO USE:• To differentiate the ‘vital few’ problems or

causes from the ‘trivial many’.

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EXAMPLE-Pareto chart

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PITFALLS TO AVOID

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Pitfalls to avoid

• The use of RCA is focused on who caused the problem-placing blame instead of finding out how the problem arises.• The use of RCA focuses only on analysis rather

than eliminating the problem.• No one can solve a problem at their desk, involve

relevant stake holders.(Otherwise the problem will keep on reoccurring).

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THERE IS NO STUPID QUESTION: STUPID PEOPLE DON’T ASK QUESTIONS.

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