World class solution for root cause and corrective actions
1. 02/27/2025
Determining the Root Cause and
Corrective Action of a Problem
World Class Solutions for Global Applications
Riverhawk
2. 02/27/2025
Why Determine Root Cause?
• Prevent problems from recurring
• Reduce possible injury to personnel
• Reduce rework and scrap
• Increase competitiveness
• Promote happy customers
• Ultimately, reduce cost and save money
3. 02/27/2025
Look Beyond the Obvious
• Invariably, the root cause of a
problem is not the initial reaction
• It is not just restating the Finding or
Symptom
4. 02/27/2025
Often the Stated Root Cause
is the Quick, but Incorrect Answer
For example, a normal response is:
•Equipment Failure
•Human Error
Initial response is usually the symptom, not the
root cause of the problem. This is why Root
Cause Analysis is a very useful and productive
tool.
5. 02/27/2025
Most Times Root Cause Turns Out to be
Much More
Such as:
• Process or program failure
• System or organization failure
• Poorly written work instructions
• Lack of training
6. 02/27/2025
What is Root Cause Analysis?
Root Cause Analysis is an in-depth process or
technique for identifying the most basic factor(s)
underlying a (problem).
• Focus is on systems and processes
• Focus is not on individuals
7. 02/27/2025
When Should Root Cause Analysis be Performed?
• Significant or consequential events
• Repetitive human errors are occurring during
a specific process
• Repetitive equipment failures associated
with a specific process
• Performance is generally below desired
standard
• May be MRR/SCAR driven
8. 02/27/2025
How to Determine the Real Root Cause?
• Assign the task to a person/team knowledgeable of the
systems and processes involved
• Define the problem
• Collect and analyze facts and data
• Develop theories and possible causes - there may be multiple
causes that are interrelated
• Systematically reduce the possible theories and possible
causes using the facts
9. 02/27/2025
How to Determine the Real Root
Cause? (continued)
• Develop possible solutions
• Define and implement an action plan (e.g., improve
communication, revise processes or procedures or work
instructions, perform additional training, etc.)
• Monitor and assess results of the action plan for
appropriateness and effectiveness
• Repeat analysis if problem persists- if it persists, did we get to
the root cause?
10. 02/27/2025
Useful Tools For Determining Root
Cause are:
• The “5 Whys”
• Pareto Analysis (Vital Few, Trivial Many)
• Brainstorming
• Cause and Effect Diagram (4 M’S)
• Tree Diagram
• Benchmarking (after Root Cause is found)
11. 02/27/2025
Example of Five Whys for Root
Cause Analysis
Problem - Flat Tire
• Why? Nails on garage floor
• Why? Box of nails on shelf split open
• Why? Box got wet
• Why? Rain thru hole in garage roof
• Why? Roof shingles are missing
• C/A Fix Roof
12. 02/27/2025
Pareto Analysis
Count 14 14 11 9 7 7 3 3 3 3
162 2 2 1 5
13934 20 19 19 15 15
Percent 3 3 2 2 1 1 1 1 1 1
32 0 0 0 1
27 7 4 4 4 3 3
Cum % 86 89 91 93 94 96 96 97 97 98
32 98 99 99100
5966 70 74 78 80 83
Count
Defect
O
ther
EB
Dam
aged
Supplier
Cleanliness
EB
M
arking
Supplier Rusted,
Corroded
EB
Incorrect M
aterial
EB
Docum
entation
EB
D
im
ension
Supplier
Missing
Parts
ESD
Packaging
SupplierLab
Test
Failure
Supplier Shelf Life
Exceeded
Supplier W
rong
Configuration
SupplierO
ther
W
orkm
anship
Supplier
Incorrect M
aterial
Supplier
Dam
aged
Packaging
Supplier Dim
ensions
EB
O
ther
Supplier Docum
entation
Supplier M
arking
180
160
140
120
100
80
60
40
20
0
Supplier Material Rejections May 06 to May 07
Vital Few
Trivial Many
60 % of
Material
Rejections
13. 02/27/2025
Brainstorming
• Sit down as a group and review all ideas
• Assign someone to capture the thoughts
(Whiteboard)
• Everyone participates until no one can
think of another “Why” to ask
• Don’t jump to conclusions too quickly
14. 02/27/2025
Cause and Effect Diagram
(Fishbone/Ishikawa Diagrams)
EFFECT
S (METHODS) CAUSE EFFECT (RESULTS)
“Four M’s” Model
MANPOWER -
MAN/WOMAN
METHODS
MATERIALS MACHINERY
OTHER
15. 02/27/2025
Cause and Effect Diagram
Loading My Computer
MAN/WOMAN METHODS
MATERIALS MACHINERY
OTHER
Cannot
Load
Software
on PC
Inserted CD Wrong
Instructions are Wrong
Upside Down
Backward
Not Enough Free
Memory
Inadequate System
Graphics Card Incompatible
Hard Disk Crashed
Not Following Instructions
Cannot Answer Prompt
Question
Brain Fade
CD Missing
Wrong Type CD
Bad CD
Power Interruption
17. 02/27/2025
Tree Diagram
Poor Safety
Performance
Stale/Tired
Approaches
Inappropriate
Behaviors
Lack of
Employee
Attention
Lack of Models/
Benchmarks
No Outside Input
Research Not
Funded
No Money for Reference
Materials
No Funds for Classes
No Consequences
Infrequent
Inspections
Inadequate Training
No Publicity
Lack of Sr. Management
Attention
No Performance
Reviews
No Special Subject
Classes
Lack of Regular
Safety Meetings
Zero Written Safety
Messages
No Injury Cost
Tracking
Result Cause/Result Cause/Result Cause
18. 02/27/2025
Bench Marking
Benchmarking: What is it?
• "... benchmarking ...[is] ...'the process of identifying,
understanding, and adapting outstanding practices and
processes from organizations anywhere in the world to help
your organization improve its performance.'"
—American Productivity & Quality Center
• "... benchmarking ...[is]... an on-going outreach activity; the
goal of the outreach is identification of best operating practices
that, when implemented, produce superior performance."
—Bogan and English, Benchmarking for Best Practices
• Benchmark refers to a measure of best practice performance.
Benchmarking refers to the search for the best practices that
yields the benchmark performance, with emphasis on how you
can apply the process to achieve superior results.
19. 02/27/2025
Bench Marking
All process improvement efforts require a sound methodology
and implementation, and benchmarking is no different. You
need to:
• Identify benchmarking partners
• Select a benchmarking approach
• Gather information (research, surveys, benchmarking visits)
• Distill the learning
• Select ideas to implement
• Pilot
• Implement
21. 02/27/2025
Common Errors of Root Cause
• Ending analysis at a symptomatic cause
• Assigning as the cause of the problem the
“why” event that preceded the real cause
• Looking for a single cause- often 2 or 3
which contribute and may be interacting
22. 02/27/2025
SUMMARY
• Why determine Root Cause?
• What Is Root Cause Analysis?
• When Should Root Cause Analysis be performed?
• How to determine Root Cause
• Useful Tools to Determine Root Cause
1. Five Whys
2. Pareto Analysis
3. Brainstorming
4. Cause & Effect Diagram
5. Tree Diagram
6. Benchmarking
• Common Errors of Root Cause
![02/27/2025
Bench Marking
Benchmarking: What is it?
• "... benchmarking ...[is] ...'the process of identifying,
understanding, and adapting outstanding practices and
processes from organizations anywhere in the world to help
your organization improve its performance.'"
—American Productivity & Quality Center
• "... benchmarking ...[is]... an on-going outreach activity; the
goal of the outreach is identification of best operating practices
that, when implemented, produce superior performance."
—Bogan and English, Benchmarking for Best Practices
• Benchmark refers to a measure of best practice performance.
Benchmarking refers to the search for the best practices that
yields the benchmark performance, with emphasis on how you
can apply the process to achieve superior results.](https://image.slidesharecdn.com/determining-the-root-cause-2-250227015424-243281b8/85/World-class-solution-for-root-cause-and-corrective-actions-18-320.jpg)
