Tools to Achieve Performance Excellence

A Thoughtful Approach to
Root Cause Analysis
Andrew Kirsch
Master Black Belt
Enterprise Excellence
ECOLAB

Two Philosophical
Assumptions

Three Imperfect Definitions

Effect - A change in a state of being that
results when something is done, or happens, or
does not happen.
Cause Something that contributes to
producing an effect
Root Cause One or a few of the most
fundamental of a chain of causes that product
an effect

5 Whys and the Washington

Monument
Problem: Washington Monument required frequent,
very expensive repairs.
1. Why?
Frequent washing was damaging the monument.
2. Why did it need to be washed so much?
Pigeon droppings
3. Why were the pigeons on the monument?
To eat the spiders
4. Why were there spiders on the monument?
To eat the insects
5. Why were the insects there?
They are attracted to the brightly lit surface at
sunset.

A Template for 5 Why

Analysis
Effect of
Interest:
1. Why?
2. Why?
3. Why?
4. Why?
5. Why?
Tips for Use:
1. There is nothing magic about 5, but push yourself to go
further than 1 or 2
2.At some point you may find yourself going from the
specific to the general (poor communication, political
gridlock, lack of motivation) - back up and try to be more
specific

Cause and Effect Diagram

(Also called Fishbone or Ishikawa Diagram)

Categories of
Causes

Effect of
Interest

Represents the relationship between an effect

(problem) and its potential causes where
causes are organized by categories

Cause and Effect Diagram

Why - Use of categories ensure a full range of potential
causes have been considered
Overcome the theme effect by allowing the group to see the
categories into which their ideas fall and dig deeper on those
with fewer items

How Decide on a set of major categories before

starting to brainstorm causes
The traditional categories for manufacturing are personnel,
environment, machines, materials, methods, measurements
For non-manufacturing use, might use the 4 Ps: Place,
Procedures, People, Policies

Blending Fishbone and 5 Why Methods

The 5 Why method is often used with a Cause and Effect Diagram to drill down to a
root cause
Effect: Cost of maintaining test kits for field employees
too high
1. Why? Must frequently replace reagents in the kits
2. Why? The reagents are past expiration date
3. Why? The shelf life of many of the
reagents are a year or less

Effect: Same
1. Why? Have to pay a high price for the
reagents in the quantities needed
2. Why? xxxxxxxxxxxxx
3. Why? xxxxxxxxxxxxxxxxxxx
4. Why? xxxxxxxxxxxxxxxxxx
5. Why? xxxxxxxxxxxxxx

4. Why? At the time that the shelf lives

were determined, the software for
recording the official shelf life only
had two choices in the pulldown
menu 6 months and 12 months!
Corrective Action = Qualify and
document a longer shelf life where
possible

Limitations of a Simplistic
Analysis
1. An effect may require two or more causes to
occur in the same place and time
2. The analysis may be limited by the current
level of knowledge
3. The analysis may be based on conventional
wisdom or restricted by prejudice
4. The root cause may not be the easiest to fix
5. An effect may be part of a system loop

A Template for Two or More Causes

per Level (per Why)
Effect

1st Level Why

2nd Level Why

3rd Level Why

Cause 1

Cause 1.1

Cause
1.1.1
Cause
1.1.2

Cause 1.2

Cause
1.2.1
Cause
1.2.2

Cause 2

Cause 2.1

Cause
2.1.1
Cause
2.2.2

Cause 2.2

Cause
2.2.1
Cause
2.2.2

Two or More Causes per Level (per

Why)
Effect
1 Level Why
2 Level Why
3 Level Why
st

Worker
hurt his
hand and
shoulder
by
slipping
on a wet
floor,
while
walking
through
an area
not
intended
for foot
traffic

Cause 1
The floor was
wet

Cause 2
The workers
shoes had poor
tread

Cause 3

nd

rd

Cause 1.1 The

drain was not
working

Cause
1.1.1

Plugged

Cause
1.1.2

Not
checked

Cause 1.2 The

vessel had to be
rinsed

Cause
1.2.1

SOP
requires

Cause 2.1 The

shoes were 5
years old

Cause
2.1.1

Cause 2.2 The

shoes hadnt
been replaced

Cause
2.2.1

Thought
ok

Cause
2.2.2

Busy

Cause 3.1

Cause

Plant

Cause
1.2.2

Cause
2.2.2

Considerations beyond Root

Cause
Tradeoffs
Span of Influence or Control
Legality, Propriety, Respectfulness

Two or More Causes:

Reconsidering the Washington
Problem: Washington Monument repairs.
Monument
1. Why?
Frequent washing was damaging the monument.
2. Why did it need to be washed so much?
Pigeon droppings
3. Why?
Pigeons AND a food source (spiders)
4. Why?
A nearby population of pigeons
Spiders AND a food source (insects)
5. Why?
A nearby population of spiders
A nearby population of insects
Attraction for the insects (brightly lit surface).

5 Why for an Act of Gang

Violence
+

+
+

Role of Evidence/Data
Makes all the difference between
conventional wisdom and sound analysis
A single instance is not strong proof of root cause

Each link in the chain of causes should be

verified with evidence/data
Physical scientific studies (e.g. chemical analysis)
Statistical studies (e.g. clinical trials)
Behavioral studies (e.g. Hawthorne effect)
Historical data review (e.g. drunk driving)
Is/Is Not analysis

Is/Is Not Analysis

Consider the what, where, when, extent of
the problem/deviation:
What specific object has the problem/deviation?
What is the nature of the problem/deviation?
What similar object could have the
problem/deviation but does not?
What other problems/deviations might
reasonably be observed but are not?

Test if possible causes against the is and is

not facts to rule out some, judge likelihood

IS

IS NOT

Boiling it down
1. Start with a fishbone diagram to enlarge your
view of possible causes
2. Use the 5 Why approach to go deep

Be open to multiple causes at each level

Use simple (linear) 5 Why when possible
Be open to a system loop

3. Look for data to support the chain of causes

4. Decide on the root cause(s)

Give preference to prevention at that cause

Factor in tradeoffs, span of influence, etc. as
appropriate

Summary of Tools Discussed

Fishbone Diagram
5 Why (Simple and Multiple Cause)
Systems Thinking (the Loop)
See Peter Senge, The Fifth Discipline

Is/Is Not Analysis

See Charles Kepner and Benjamin
Tregoe, The New Rational Manager

QUESTIONS?