Tools to Achieve Performance Excellence

A Thoughtful Approach to Root Cause Analysis

Andrew KirschMaster Black Belt

Enterprise ExcellenceECOLAB

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 Why’s and the Washington MonumentProblem: 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 droppings3. Why were the pigeons on the monument? To eat the spiders4. Why were there spiders on the monument? To eat the insects5. Why were the insects there? They are attracted to the brightly lit surface at sunset.

A Template for 5 Why AnalysisEffect 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 22.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

Tips for Use:1. There is nothing magic about 5, but push yourself to go further than 1 or 22.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)

Represents the relationship between an effect (problem) and its potential causes where causes are organized by categories

Categories of Causes

Effect of Interest

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

Effect: Same1. Why? Have to pay a high price for the reagents in the quantities needed

2. Why? xxxxxxxxxxxxx3. Why? xxxxxxxxxxxxxxxxxxx

4. Why? xxxxxxxxxxxxxxxxxx5. Why? xxxxxxxxxxxxxx

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

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

The 5 Why method is often used with a Cause and Effect Diagram to drill down to a root cause

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 fix5. 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

Cause 3 Cause 3.1 Cause 3.1.1

Cause 3.1.2

Cause 3.2 Cause 3.2.1

Cause 3.2.2

Two or More Causes per Level (per Why)Effect 1st Level Why 2nd Level Why 3rd Level Why

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

Cause 1The floor was wet

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 1.2.2

Cause 2 The worker’s shoes had poor tread

Cause 2.1 The shoes were 5 years old

Cause 2.1.1

Cause 2.2.2

Cause 2.2 The shoes hadn’t been replaced

Cause 2.2.1 Thought ok

Cause 2.2.2 Busy

Cause 3The worker chose to go through this area

Cause 3.1 Alternate route takes longer

Cause 3.1.1 Plant design

Cause 3.1.2

Cause 3.2 No barrier to prevent

Cause 3.2.1 Not expected

Cause 3.2.2

Considerations beyond Root Cause

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

Two or More Causes: Reconsidering the Washington Monument

Problem: Washington Monument repairs.

1. Why? Frequent washing was damaging the monument.2. Why did it need to be washed so much? Pigeon droppings3. 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 insectsAttraction for the insects (brightly lit surface).

5 Why for an Act of Gang Violence

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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 causes2. 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 causes4. 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?