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Root Cause Analysis

Welcome to the session!. Objectives. Learn and be able to apply a fishbone diagram. Utilize “Why” analysis technique to uncover causes. 2. 2. “Why” Analysis . Question asking technique used to explore the cause and effect relationships underlying a particular problem.

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Root Cause Analysis

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Root Cause Analysis

Welcome to the session!Slide2


Learn and be able to apply a fishbone diagram

Utilize “Why” analysis technique to uncover causes



“Why” Analysis

Question asking technique used to explore the cause and effect relationships underlying a particular problem

Four to five iterations of asking


is generally sufficient to get to a root cause, but may go moreEXAMPLE: The vehicle will not start (problem statement)

Why? – The battery is deadWhy? – The alternator is not workingWhy? – The alternator belt is brokenWhy? – The belt was beyond its useful life Why? – The vehicle was not maintained per the recommended schedule3Slide4

Tips For Successfully Using “Why” Analysis

Root cause of the vehicle example appears to be the lack of scheduled maintenance… this is a process that can be improved

You know when you have gotten to the cause when the answer points to a process that is not working or does not exist

The root cause generally is not time, money, or manpower

Processes fail, not people or money, so ask the question “

Why did the process fail?”4Slide5

Why Analysis Example 1


Why Analysis Example 2


Why Analysis Example 3


Why Analysis Example 4



Why Analysis Example 5Slide10


Why Analysis Example 6Slide11

What is a Fishbone Diagram?

The Fishbone diagram (or Ishikawa Diagram) is used to identify possible causes for an effect

Causes are grouped into major categories to identify the sources of variation through the 6M’s



Mother nature [environment]11Slide12

Fishbone Diagram Example 1






Untrained Driver

Driver in Bad Mood





Mother Nature


Condition of Crane

Broke cell guides

Type of Crane

Additional long travels

Physical Terminal Layout



Service Overdue

Operating with Defect

Incorrect Stow Plans

Unrealistic Deadlines

Yard Planning

Stuck Cones

Damaged containers



Fishbone Example 2


Fishbone Example 3


Why Use a Fishbone?

Groups potential causes for defects into logical categories

Helps teams work together to get to root

cause (inquiry

)Highlights where additional data gathering needs to occur


Step 1: Determine the Problem/Issue

To construct a fishbone:

Start with stating the problem in the form of a question, such as “Why is crane production low?”

Agree on the problem (effect) and place it in a box at the “head” of the fishbone


Why is Crane production low?Slide17

Step 2: Establish the Categories

Determine which categories you will use to find causes and draw the lines (bones)

Feel free to modify the categories for your project and subject matter

Most common categories called 6 M’s:




Mother nature [environment]Slide18


The Machines category groups root causes related to tools or equipment

Examples of questions to be asked:

Was the correct tool/tooling used?

Does it meet production requirementsIs the machine properly maintained?Was the equipment used within its capabilities and limitations?

Are all controls clearly labeled and/or color-coded or differentiated?18Y



The Method category groups root causes related to how the work is done

Examples of questions to be asked:

Are the work instructions clearly written & complete?

Are mistake-proofing devices/techniques employed?How many “if necessary” and “approximately” phrases are found in this process?Are features of the process critical to

safety clearly spelled out?Is the work standard upgraded and to the current revision?19Y



The Materials category groups root causes related to parts, supplies, forms or information needed to execute the process

Examples of questions to be asked:

Is all needed information available and accurate?

Was the material substituted?Was the material defective?Was the raw material the wrong

type for the job?Was the material handled properly(stored, dispensed, used & disposed)?20




The Measurement category groups root causes related to the measurement and measuring of a process activity or output

Examples of questions to be asked:

Is there a metric issue?

Is there a valid measurement system? Is the data good enough?Is data readily available?

Does the measuring gage have proper measurement resolution?21




The Manpower category groups root causes related to people, staffing and organizational structure

Examples of questions to be asked:

Was the proper training to perform the task administered to the person?

Was too much judgment required to perform the task? Were guidelines for judgment available? Is fatigue a contributing factor?

How much experience does the individual have in performing this task?22



Mother Nature (Environment)

The Mother Nature category groups root causes related to the work environment, market conditions, and regulatory issues

Examples of questions to be asked:

Is the workplace safe and suitable/ comfortable?

Are outside regulations impacting the business?Is the process affected by temperature changes over the course of a day?Are associates distracted by noise,

uncomfortable temperatures, fluorescent lighting, etc.?23Y

Mother NatureSlide24

Step 3: Brainstorm Causes

For each category, brainstorm possible root causes of the problem that may be related to the problem/ issue

For each cause identified, continue to ask “why does that happen?” and attach that information as another line (bone) of the category branch


Step 4: Review the Diagram

The diagram should now show all of the possible causes of the problem that you can think of

Prioritize the key causes identified on the fishbone

Agree on which of these possible causes are actually contributing



Identify the problem or issue

Draw horizontal line across center of page

Write problem at fish head

Establish the categories

Use the 6M’s: Manpower, Machine, Method, Measurement, Material, Mother Nature (Environment) - or choose your ownDraw lines (bones) and the labelsBrainstorm/ record ideas onto fishboneCreate sub-branches as neededReview completed diagram and set focusScore / Vote or Rank as appropriate to group thoughts, or prioritize the issues by data analysis (most frequently occurring) or cost impact on the process or risk of failure/ work stoppage, etc.26Slide27

Exercise: Create a Fishbone Diagram

With your team, construct a detailed Cause and Effect Diagram on the process / example presented

Identify and label categories

Examine using the “why” analysis

Brainstorm as many inputs as possible with each branch and/ or sub-branch



Learn and be able to capture thoughts using a fishbone diagram

Learn to apply “Why” analysis technique to uncover root causes