Root Cause Analysis

We have thus far reviewed the following modules in the process improvement or continuous improvement journey:

• Process improvement road map – Introduction
• Establishing objectives & strategy
• Identify process value stream
• How to select processes for PI assessment (a.k.a Assess Process Impact & Maturity)
• Collecting process health data (a.k.a QCPC assessment)

We are now ready to analyze the data we have collected and conduct a comprehensive root cause analysis. Keep in my mind that our objective is to improve the current process and as such collecting the health of the current process (QCPC data) and doing a root cause analysis forms the foundation of continuous improvement (CI).

The idea behind root cause analysis is that each problem or turnback is to be treated as a golden nugget, offering an opportunity to get better. Using QCPC data, root case analysis tells a story about how and why a problem occurs. It offers the “CI doctor” an opportunity to dig deep down in the process and prescribe the correct medicine for the cure.

In order to do a comprehensive root cause analysis, the process improvement participants must have an open mind, be alert and be persistent and tenacious in their approach. Also, the process improvement participants must dig deep down and not limit the assessment to the surface. Often, the real root cause is hidden somewhere else in the process or the process value chain and not visible on surface. Finally, before a solution is identified, the root cause must be confirmed with the customer and all stakeholders.

Management at the leadership level plays a very critical role in root cause analysis. They must not give lip service or solve the problem through a shot gun approach. Management must display the proper attitude by adhering to a defined and disciplined approach to problem solving. They must provide the appropriate level of support and resources and ensure that a solution is only implemented once the root cause has been properly identified and confirmed with the customer.

Following are the key steps in doing a root cause analysis:

• Identify and define the breakdown in process
• Utilize the underlying data collected in the QCPC phase of CI
• Brainstorm causes of breakdown
• Ask “Why? Why? Why?” multiple times
• Apply DIVE Technique: Define the problem; Investigate the problem; Verify the root cause; Ensure a mistake proof solution is achieved and implemented
• Confirm root cause with the customer

The following are a few different tools and techniques available to analyze the root cause:

Generating ideas through brainstorming and the use of 5 Whys

Brainstorming – helps to generate and collect ideas and helps facilitate the involvement of various stakeholders

5 Why’s - The following practical example demonstrates the basic process:

My car will not start. (Problem)

Why? - The battery is dead. (first why)
Why? - The alternator is not functioning. (second why)
Why? - The alternator belt has broken. (third why)
Why? - The alternator belt was well beyond its useful service life and has never been replaced (fourth why)
Why? - I have not been maintaining my car according to the recommended service schedule. (fifth why, a root cause)
Why? - Replacement parts are not available because of the extreme age of my vehicle. (sixth why, optional footnote)

I will start maintaining my car according to the recommended service schedule. (Solution)

Finding patterns and relationships through the use of a cause and effect diagram such as a fish-bone diagram.

Such a diagram helps analyze causes across different dimensions (typically equipment, process, people, materials, environment and management as shown in the picture below) and understand their effect (problem) on the process.


Several other techniques are also available such as storyboarding, grouping ideas through the use of nominal group techniques, prioritizing action through the use of histograms and pareto charts, etc. However, no matter what technique you use, the goal is to use the data collected in the QCPC phase of CI and breakdown the process problem down to its root cause and not limit the solution only to the symptom.

The next blog will be devoted to process flow assessment, also known as value stream mapping.

For questions or comments or help in implementing, please contact me via email.