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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.
2023
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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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