Root Cause Analysis

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 Followed
10
Look Beyond the Obvious
Invariably, the root cause of a problem is not

the initial reaction or response
Which leads to faulty mitigation 11

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.
The PII Performance Pyramid TM 14

RCA Analysis Process
It’s Not Rocket Science…
but there is a process 15

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 identified
18
Investigation
19
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
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
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
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
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
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
“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
Step two —
Fishbone Cause and Effect
Ishikawa fishbone diagram process:

 Brainstorm causes
 Put into pre-defined categories
 Vote on which most likely to cause problems
 Generate solutions 29
Step Three—
Root cause identification
After a list of Causal factors have been identified,

begin Root Cause identification
30
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 causes 31

Production Stoppage Possible Root Causes:
Dirty control panels

Emergency stop button too close to the start button
32
Unacceptable Root Causes
• Human Error
• Mistake
• Distraction
33
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
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
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
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
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
Why did this happen
Cause Map
44
Why did this happen
Completed Cause Map

45
5 Whys Analysis
46
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, D
47
What caused the burn by hot coffee?
Answer: E – A, B, C, D
48
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
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
Contact Information
Orlando Brandon obrandon@frcc.com (813) 609-4778
54

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Introduction to

Bad things will happen…

The extent of the damage, or whether bad

“A bad system will

So if a bad system will beat a good

• Improve the system so that success is built into

• Don’t rely on individual heroic measures as a

• Root cause analysis is a systematic process

Benefits of Root Cause Analysis

• Prevent problems from recurring

Prevention, not blame or punishment, is

Initial response is usually the symptom, not

Common “symptoms” mistaken for Root

Invariably, the root cause of a problem is not

Which leads to faulty mitigation 11

• To get to the root cause, we must look at the

• What looks like a people problem is often a

• Process or program failure

• System or organization failure

• Poorly written procedures

• Lack of internal controls

• To get to the root cause, we must look at the

The PII Performance Pyramid TM 14

It’s Not Rocket Science…

but there is a process 15

• Investigate the incident

• Attempt to understand the underlying

• Generate effective Corrective Actions to

Step One—Data collection

Without an understanding of the event, the root

Without an understanding of the event, the causal

Sakichi Toyoda, one of the fathers of the Japanese

Toyoda has a "go and see" philosophy. This means

The 5 Whys technique is most effective when the

Writing the issue helps you to formalize the problem

Ask "Why" the problem happens and write the answer

If the answer you just provided doesn't identify the

Keep looping back to step 3 until the team is in

This may take more or less than five “Whys”

Production Line Stoppage Issue

The operator pushed the emergency stop button

The Business Improvement Leader asked why?

Why was it an operator error?

A brief inspection of the start and stop buttons on the

Revealed both buttons were dirty to the point that the

And the buttons were also very close to each other

“Why does it happens now and again” asked the

Operator pushed the stop button by mistake.

Ishikawa fishbone diagram process:

After a list of Causal factors have been identified,

• 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 causes 31

Production Stoppage Possible Root Causes:

Dirty control panels

Unacceptable Root Causes

Corrective Action – Mitigation Plan

• Actions to eliminate the cause of a

• Designed to prevent reoccurrence

Unacceptable Corrective Actions

• Instructed to pay more attention