A problem well defined

is a problem half
solved
-Anonymous

Root-Cause Analysis

At the end of this training, you will

be able to..
Understand the basic steps in
problem-solving
Be more familiar with the term RootCause Analysis
Learn to use 2 simple RCA
techniques

Problem Solving Process

1.Diagnos
tic Phase
2.
Solution
(Fix it)
Phase

Define problem
Perform RCA

Provide action
plan
Implement
Determine
effectiveness

If I had 60 minutes to solve a problem, Id spend

55 minutes defining it and 5 minutes solving it .
Albert Einstein

Root Cause Defined

Main / root or most
basic cause or
problem
Management has
control to fix
Will prevent or
significantly reduce
the likelihood of
recurrence

Root Cause Analysis

5 Whys

FMEA

Pareto Charts

Risk Tree Diagrams Process Maps

Tree Diagram
Diagrams

Fish-bone

Cause-Effect Diagram

Affinity

Brainstorming

Fish-Bone (Ishikawa) Analysis

Skull =
Problem /
Challenge

Man - people involved

Machine -equipment,
tools
Method- procedure,
requirements

Spines = Causes (5
Ms)

Material raw materials,

reagents
Mother Nature /
Environment temperature,
location, natural
phenomenon

5 Whys Analysis
Why?

Why?

Why?

Why?

Why?

Why?

butWhy?

5 Whys Analysis
Why?

NOT JUST

5x

Why?

Why?

Why?

Why?

Why?

butWhy?

Why did it fell?

It fell because of
gravity.
Why is there
gravity?
I dont care
(doesnt matter
here)

Keep going until the answer

is I dont care
(management can no
longer fix it)

Making the most of both..

Fish-Bone
x
- Exploring
causes from all
possible sources

5 Whys
- Drilling down
to the rootcause
-(why? or so
what?)

Example: Fish-Bone x 5 Whys

Initial Concern: Total N result (<MDL) is lower
than combined NO3- (0.120 ppm)
and NH4+ (0.170 ppm)

Example
Initial concern: Total N result (<MDL) is lower than combined NO3-N
(0.120 ppm)
and NH4+N (0.170
ppm)

Dont just stop the bleeding! Stop the bleeding

first, and then address the root-cause. Do RCA.

If I had 60 minutes to solve a problem, Id spend

55 minutes defining it and 5 minutes solving it .
Albert Einstein