MIKE MICKLEWRIGHT
QualityQuest, Inc.
Kaizen Institute
847-401-0442
2117 N. Williamsburg Street
Arlington Heights, IL 60004
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Introduction
Top Ten Reasons Why Root Cause Analysis
Fails
The Inputs (Requirements, Evidence, and
History)
Root Cause and the Five Whys
Examples
The Output -Corrective Actions
Relationship Between Lean and Preventive
Actions
Root Cause is:
An initiating cause of a causal chain which
leads to an outcome or effect of interest.
Root cause is:
Commonly used to describe the depth in
the causal chain where an intervention
could reasonably be implemented to change
performance and prevent an undesirable
outcome.
Lean is:
A systematic approach to identifying and
eliminating waste and non-value added
activities, through continuous improvement,
by flowing the product at the pull of the
customer in pursuit of perfection.
Lean is:
Respect for and involvement of the people
Why is Lean so popular?
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What are the Root Cause(s) of why we have so
much waste in our organizations?
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Think of one instance in which your
organization has too much ________. Why
does it exist?
◦ Inventory (i.e. finished goods) ___________________
____________________________________________
◦ Excess Processing (i.e.
inspection)___________________
_______________________________________________
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What are the Root Cause(s) to Toyota’s
Success?
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The Root Causes to Toyota’s success lie in its
Principles, not the tools. Principles such as:
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Constant focus on the elimination of waste
Respect and involvement of all employees
Self-Reliance
Root Cause Analysis
Process Focus
Exposing problems and not hiding them
Leadership (training, mentoring, and coaching)
Long-Term focus
What are the Root Causes as to why so many
Lean efforts fail?
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Based on an article I wrote (with pretty close
to the same title). Go to:
http://www.mikemick.com/articles.htm
1. It’s more fun to blame people!
2. Top Managers don’t want to find out they are to
blame.
3. I was told to “shut-up” after asking “why” one
time.*
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Example:
Five Year Old, “Daddy, why do we have to die? “
Daddy, “So we can go to heaven?”
Five Year Old, “Why do we have to go to heaven?”
Daddy, “So we can live with God and other good (insert faith
here – Catholic, Muslim, Orthodox, Jewish, Buddhist) people
forever.
Five Year Old, “Why do we have to live with God?”
Daddy, “Shut up kid and go watch TV”
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This Dad allowed way too many “whys”. He’s an inexperienced
young Dad and will learn to shut the kid up after one “why” thus
properly preparing the kid for world of work.
4. We don’t have time to think long-term right now.
5. Fixing root causes is too expensive*
Note: They went to the Gemba…and discovered the memorial suffered more than other
buildings in the area!
This lead to good “why” questions.
Why?
The
Jefferson
Memorial is
requiring
excessive
power
washes
X
Stop washing
?
Why?
Why?
Because
pigeons and
gulls are
swarming to
the
monument
and
depositing
large
amounts of
droppings
Because the
pigeons are
feeding on
an unusually
large
number of
spiders
living under
the roof line
Because the
spiders are
feeding on
an unusually
high
number of
lacewing
moths and
midge flies
(mosquitoes
)
X
Remove the
spiders ?
Remove the
birds ?
X
Remove the
moths &
mosquitoes ?
X
Why?
Because the
moths and
midge flies
are attracted
to lights
illuminating
the Memorial
at night
Why?
Because the
lights remain
on throughout
the night
(ideal
condition for
mating)
(for mating)
X
Remove the
lights ?
Minimize
time lights
are on
14
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Example:
The Washington Monument was degrading
Why? Use of harsh chemicals
Why? To clean up after pigeons
Why so many pigeons? They eat spiders and there are a lot of
spiders at the monument
Why so many spiders? They eat gnats and lots of gnats at the
monument
Why so many gnats? They are attracted to the light at dusk.
Why are the lights on at dusk? Because the timing of the
lights going on does not change with sunlight change
throughout the year
Solution: Turn on the lights at a later time for now, and
develop a system to change the “lights on” setting every week
depending on the date and amount of sunlight. Automate.
Further?
6. My Peeps Can’t Do This and I’m a
Micromanager
7. It Requires Thinking
8. Why Do Root Cause Analysis Training,
When We Can Buy all the Solutions Anyway?
*
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Examples:
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5S, TPM, TPM,
Kaizen Events
Value Stream Mapping
Six Sigma
Balanced Score Card
ISO 9001 Certification
MRP
Outsourcing
9. We Don’t Practice It At Home, Why Should
We Do it at Work?
10. Getting to Root Cause Would Require Us
to Work with Other Kingdoms
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What are the tools of Lean?
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“Be flexible in style,
but unwavering, like a rock, in principle.”
Thomas Jefferson
A
Principle is:
◦ A fundamentally accepted rule of
action or conduct that is generally
inarguable depending on one’s
purpose or goal (i.e. raising a family,
playing a sport, or building a
business).
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“Principles are guidelines for human conduct that
are proven to have enduring, permanent value.
They’re fundamental. They’re essentially
unarguable because they are self-evident. One
way to quickly grasp the self-evident nature of
principles is to simply consider the absurdity of
attempting to live an effective life based on their
opposites. I doubt that anyone would seriously
consider unfairness, deceit, baseness, uselessness,
mediocrity, or degeneration to be a solid
foundation for lasting happiness and success”
Dr. Stephen Covey
The Seven Habits of Highly Effective People
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The root causes to many of our problems,
lie in the lack of stated and demonstrated
Principles, at the organization level.
If the Culture and Practices (2nd) within a
company are not aligned with the Principles
of Lean, Lean improvements made from the
use of Lean tools (3rd) will not be sustained!
Real Problem
Vague
problem
Proven Root
Chosen
Cause(s)
counter
Potential
Potential -measures Implement &
causes
counter
Sustain
-measures
Vague
problem
Potential
counter –
measures
Chosen
Countermeasures
Root Cause(s)
Real Problem
Potential
causes
Implement
& Sustain
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To clarify the problem, you must start by
going to see the problem
Lean calls this the gemba walk or genchi
genbutsu (going to the place to see the actual
situation for understanding)
You must “see” and “study” the process
with the people who are involved. You
must “see” how the process could cause a
mistake.
Ideally, you see the problem recreated
DOE encourages this as well
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Record the Requirement
◦ For a Corrective Action…
 Specification
 Contractual Requirement
 Statement from a Standard, Procedure, Work Instruction,
Drawing
 Objective/Goal
◦ For a Preventive Action…
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Customer Assumption or Expectation
“There is no requirement”
Quality Policy, Values, Mission
Objective/Goal
Competitor Move
◦ QUOTE IT!! Word for word!
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Record the Evidence
◦ # of good and bad samples (e.g. “2 out 3 P.O.s”,
“55 out 100 units shipped”)*(see next page)
◦ Record PO #s, Work Order #s, specific locations,
gage #s, Router #s, Part #s, etc.
◦ Think and act like a detective, or …
 A CSI Miami member
 Mr. Spock
 Joe Friday
Your Percent
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____
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____
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____
____
____
%
%
%
%
%
%
%
%
%
%
%
Often
Rarely
Always
Sometimes
Never
Usually
Occasionally
Most of the Time
Seldom
A lot
A little
What the Group Wrote:
High
Low
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Record the History
◦ Trends
◦ Major changes that have occurred over a time
period – good and bad
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Product
Process
Systems
Personnel
Hardware, software, equipment, tooling
◦ Frequency of Problem, if any, over a time period
◦ This may give early insight into the Root Cause
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This may help in defining Evidence &
History
Is
What
Where
When
Extent
Is Not
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Allow a team to predict potential failures of a
product/process/system by identifying
potential root causes.
Rate existing or expected conditions to form a
priority list of needed preventive actions
Assign actions and rate the potential failures
after action has taken place, thus providing a
feedback loop and accountability
Primarily, move us away from Management by
Crisis to Prevention Management
Potential
Failure Mode and Effects Analysis
(Process FMEA)
Item
Model #
Proc Resp:
Core Team
FMEA #
Page
Prepared by:
Orig. FMEA Date:
Rev. FMEA Date:
Key Date:
of
Action Results
Process
Function &
Req'ments
Potential
Failure
Mode
Potential
Effects of
Failure
C
l
S a
e s
v s
Potential
Causes of
Failure
O
c
c
u
r
Current
Process
Controls Prevention
Current
Process
Controls Detection
D
e
t
e
c
R
P Recommended Responsibility
N
Actions
& Target Date
Actions
Taken
S
e
v
O
c
c
D
e
t
R
P
N
Though FMEA is a great tool, it still can be
somewhat deficient?
At what?
Root Cause Analysis must:
•
Include participation by the leadership of the
organization (team leaders, supervisors, top
management)
•
Include participation of those most closely involved in
the processes & systems
•
Be challenged by others, especially by mentors, on
whether or not the root cause was arrived at and
whether the actions will eliminate or drastically
reduce the problems for good (A3 mentality)
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Oftentimes, people ask “why” a problem
occurred just once - this results in blaming
a person, product design, or equipment –
not the system
We must ask “why” more. Asking “Why” five
times is a good guideline, but it may take
4x or 7x ….
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Or, ask “Why” 5x, going down two paths,
starting with:
◦ “Why” did the problem occur? (typical)
◦ “Why” did we not catch it?
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By the time we get to the 4th or 5th why, we
are looking squarely into management
practices or lack thereof
There may be multiple root causes
USUAL APPROACH
Problem
Identified
Firefighting!
Problem
reoccurs!
Immediate Containment
Action Implemented
Find
someone to
blame!
PREFERRED APPROACH
Problem
Identified
Immediate
Containment
Action
Implemented
Define the
Root Cause
Develop
Solutions
& verify
effectiven
ess
Solutions are
applied across
company!
Defect found at “Customer”…
PROCESS
A
PROCESS
B
PROCESS
C
PROCESS
D
CUSTOMER
“Customer” can be
Internal or External
Contain the problem…
PROCESS
A
PROCESS
B
PROCESS
C
PROCESS
D
CUSTOMER
Nothing is allowed to further
escape to the customer
Contain the root process…
PROCESS
A
PROCESS
B
PROCESS
C
PROCESS
D
CUSTOMER
Nothing is allowed to further
escape to the next process
Prevent the problem…
PROCESS
A
PROCESS
B
PROCESS
C
PROCESS
D
CUSTOMER
Corrective action implemented
so root cause of problem does
not occur again!
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To do Root Cause Analysis well, the following
“Lean” principles must be in place:
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Respect and involvement of all employees*
Self-Reliance (should be)
Process Focus
Exposing problems and not hiding them
Leadership (training, mentoring, and coaching)
Long-Term focus
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With regard to “respect of the employees”:
◦ The “no blame” environment is critical
 Most human errors are due to a process error
◦ A sufficiently robust process can eliminate human
errors
 Lean tools (i.e. 5S) are simply solutions to making it more
difficult for human error to occur.
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Stop asking “why” when the system has been
blamed
Must identify the system deficiency that caused the
problem
◦ Oftentimes Root Cause Analysis needs to be elevated to
upper management to address
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This is why Toyota developed “systems” to their
problems, that we all now copy, like:
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5S
TPM
Quick Changeover (SMED)
TWI
Kaizen
When we blame people and not the system, we
end up with the following Top 10 examples of
ineffective corrective actions….
10.The Employee was Counseled.
9.Operator Error -- I Retrained Him.
8.That Employee No Longer Works Here.
7.We Had to Use Temps This Summer and Now
they're All Gone.
6.We Put Our Disciplinary Process in Place.
5.We Sent Two Inspectors and Sorted the Product in
the Customer's Facility.
4.We Feel the Customer Applied Our Product
Incorrectly -- Not Our Fault.
3.Replacements Are on The Way.
2.We Added More Inspectors -- It Won't Happen
Again.
1. I Fired His Butt.
Identify Problem
Part polarity reversed on circuit board
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Team members:
Team Leader – Terry
Inspector – Jane
Worker – Tammy
Worker - Joe
Quality Eng – Rob
Engineer – Sally
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(Process) Additional inspection added after
this assembly process step to check for
reversed part defects
(Product) Last 10 lots of printed circuit
boards were re-inspected to check for similar
errors
Part reversed
Why?
Part reversed
Worker not sure of correct part orientation
Why?
Part reversed
Worker not sure of correct part orientation
Part is not marked properly
Why?
Part reversed
Worker not sure of correct part orientation
Part is not marked properly
Engineering ordered it that way from vendor
Why?
Part reversed
Worker not sure of correct part orientation
Part is not marked properly
Engineering ordered it that way from vendor
Design process didn’t account for possible
manufacturing issues

Permanent – Changed part to one that can only be

Preventive - Required that any new parts
placed in correct direction (Mistake proofed).
Found other products with similar problem and
made same changes.
selected must have orientation marks on them.
Changed the Design Process and Quality Planning
Checklist to reflect this.
Root Cause Analysis
Example #2
Identify Problem
A manager walks past the assembly line and
notices a puddle of water on the floor.
Knowing that the water is a safety hazard,
she asks the supervisor to have someone
get a mop and clean up the puddle. The
manager is proud of herself for “fixing” a
potential safety problem.
But What is the Root Cause?
The supervisor looks for a root cause by asking
'why?’
Knowing that the water is a safety hazard,
the manager asks the supervisor to have
someone get a mop and clean up the
puddle.
Puddle of water on the floor
Why?
Puddle of water on the floor
Leak in overhead pipe
Why?
Puddle of water on the floor
Leak in overhead pipe
Water pressure is set too high
Why?
Puddle of water on the floor
Leak in overhead pipe
Water pressure is set too high
Water pressure valve is faulty
Why?
Puddle of water on the floor
Leak in overhead pipe
Water pressure is set too high
Water pressure valve is faulty
Valve not in preventative maintenance program
Why?
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Permanent – Water pressure valves placed in
preventative maintenance program.
Preventive - Developed checklist form and
referenced mandatory use in the Equipment
Purchase Procedure to ensure newly
purchased equipment is reviewed for possible
inclusion into the Total Productive
Maintenance (TPM) program.
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Sometimes, with large scoped problems, and
when working within a team, it is wise to use
a Cause and Effect Diagram (Fishbone
Diagram) to gain focus.
Purpose: To help teams to push beyond
symptoms and explore potential root causes
before jumping to conclusions.
69
Used in a team environment in which their might exist multiple RCA paths
Methods
Materials
Incorrect Quantity
Late Dispatch
Spillage
Shipping Delay
Incorrect BOL
Wrong Destination
Traffic Delays
Environment
Weather
Wrong Equipment
Driver
Dispatcher
Breakdown
Equipment
Dirty Equipment
Wrong Directions
People
Attitude
Shipping
Problems
Identify Problem
Department didn’t complete their project on
time
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Team members:
Boss – Jim
Worker – Tom
Worker - Karen
Project Mgr – Bob
Admin – Sally
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(Product) Additional resources applied to help
get the project team back on schedule
(Process) No new projects started until Root
Cause Analysis completed
Didn’t complete project on time
Why?
Procedures
Personnel
Lack of worker
knowledge
Poor project plan
Poor project
mgmt skills
Lack of resources
Didn’t complete
project on time
Inadequate
computer
programs
Materials
Poor
documentation
Inadequate
computer system
Equipment
Procedures
Personnel
Lack of worker
knowledge
Poor project plan
Poor project
mgmt skills
Lack of resources
Didn’t complete
project on time
Inadequate
computer
programs
Materials
Poor
documentation
Inadequate
computer system
Equipment
Didn’t complete project on time
Resources unavailable when needed
Why?
Didn’t complete project on time
Resources unavailable when needed
Took too long to hire Project Manager
Why?
Didn’t complete project on time
Resources unavailable when needed
Took too long to hire Project Manager
Lack of specifics given to
Human Resources Dept
Why?
Didn’t complete project on time
Resources unavailable when needed
Took too long to hire Project Manager
Lack of specifics given to
Human Resources Dept
No formal process for submitting job opening
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Permanent – Hired another worker to meet
needs of next project team
Preventive - Developed checklist form (a
form of mistake-proofing) with HR for
submitting job openings in the future.
Modified the Hiring, Training, and Qualifying
Procedure to reflect this change.
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Immediate (Interim) Action is an Action that
results after asking “Why” once
Permanent Actions occur after asking “Why” 2
– 3 times
Preventive Actions results after asking “Why”
4- 6 times
These are only guidelines

Immediate (Interim) Action Examples:
◦ A. Product
 Containment issues, credits, replacement product, sorting
◦ B. Process
 Extra inspection and/or auditing
 Run product elsewhere
 Retraining people in the process
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
It results from asking “why” and blaming an
operator, design, equipment, tool
It is most often is a band-aid that must be
removed
◦ Increased Inspection is not effective and is costly in the
long-run!
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◦
◦
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Permanent Actions
One form is Mistake-Proofing (Poka-Yoke)
a.k.a. Error Proofing, Fool-Proofing, Idiot
Proofing
Soon to be called “my bad”-proofing
Designing into the product or process ways of
making human mistakes difficult or impossible
to do.
It deals with improving one __________
After completing this action, the question
must be asked if there are similar _______
to be corrected
Vague
problem
Potential
causes
Implement &
Sustain
Chosen Countermeasures
Root Cause(s)
Real Problem
Potential
Countermeasures
85
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BEST:
Contact
◦ Contact involves physical contact between two or
more things (i.e. electrical outlets use physical
shape to prevent wrong voltage appliances being
plugged in; guide pins on two molds).

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2ND BEST:
Performance step
◦ Involve monitoring steps in a process and triggering
an outcome if the step is not performed correctly.

Fixed Value
◦ Involve setting specific values that trigger an
outcome and having the process count up to that
trigger (i.e. a weigh counter stops a process when
the weight (count) is reached).

3rd BEST: Making It Easy To Do It Right
◦ Colors and color-coding (i.e. computer plugs and
ports, zipper type plastic bags)
◦ Symbols (i.e. icons)
◦ Shapes (i.e. painting tool shapes on a pegboard)
◦ Operator-initiated auto-detection (i.e. spell-check)
◦ Checklists, Forms, Procedures, and simplified work
flows
◦ 5S Related!!
DO NOW
LEAVE
JUST DO IT
Low
BENEFIT
PLAN REQUIRED
Low
EASE
High
89

Preventive Actions and Verification of Such
◦ Changed Process or Procedure (continual
improvement of the effectiveness of the
management system)
◦ Degree of Mistake-Proofing accomplished and
it’s now part of the Process/Product Design
Process
◦ New Systems initiated (5S, Quick Changeover,
TPM, TWI)
◦ Retraining of the affected employees
◦ Visual Verification of the change working and
prohibiting recurrence of nonconformity


One other possible root cause as to why
companies do root cause so poorly, is
because the form used does not force RCA to
be done. It is not mistake-proofed (pokayoked)
Formats
◦ Delphi Format
◦ An example with another company
◦ Form similar to this presentation


“There is no evidence of Preventive Actions being
performed” common finding written by ISO 9001
registrar auditors.
The purpose of Eliminating “Waste” is to prevent
problems. This includes the identification and
elimination of:
◦
◦
◦
◦
◦
◦
◦
◦
Defects
Overproduction
Waiting
Not Properly Using Employees’ Skills
Transportation
Inventory
Motion
Excessive Processing


Lean tools are just some possible answers
to performing good root cause analysis.
Root Cause Analysis should precede the use
of Lean tools.
◦ Why? Because haphazard use of 5S, etc. may not
solve your problems. One needs to define the
problem first and the root causes before deciding
on solutions!

Root Cause Analyses should be identified as
action(s) resulting from the Current Value
Stream Map on the path to a Future Value
Stream Map.

Example:
◦ Defective product was shipped to the customer.
The cause was listed as “operator error” after asking
“why” once. We can use the Five Whys to arrive at a
root cause in which the solution is the 5S System.


Defective product – why?
The operator used the wrong tool – why?
◦ He could not find the right tool – why?
 The work area is unorganized and is a mess – why?
 There is no system of organization – why?
 It was not important because elimination of waste was
never one of our management principles

Consider doing Root Cause Analysis on good
things that have happened ….
◦
◦
◦
◦
A successful project
High production
No safety issues
A successful company i.e. the root causes behind
Toyota’s success

Lean Should be Integrated into your ISO Based
Preventive Action System to:
◦
◦
◦
◦


Reduce Waste, Non-Value Added Activities, and Cost
Allow Business and Quality Objectives to be Met
Increase Effectiveness and Efficiency
Reduce Cost
Why? To ensure Root Cause Analysis and
Verification of Effectiveness is done
Employees and Internal Auditors Need to be Taught
to Identify Waste and use their Preventive Action
System (i.e. not a Waste Walk Form)

The initiation of Preventive Actions can result
from anyone witnessing waste (including the
8 process wastes), or non-value added:
◦
◦
◦
◦
◦
◦
Steps
Activities
Documents
Approvals
Processes
Stuff

The “Requirement” section of a Preventive
Action might come from:
◦ Objectives and Goals,
◦ Quality Policy
◦ Vision, Mission, Values, Principles
◦ Business Plan

Example

Example Quality Policy states,

Example Objectives State:
“… consistently exceeding customer
expectations by providing products,
services, and information of the highest
quality in terms of safety, reliability,
accuracy, and timeliness.”
1) Decrease time to make customer changes
to 3 days
2) Decrease Quality Defectives to 400 ppm
3) Increase On-Time Delivery to 98%
Exercise:
 You witnessed “8 occurrences of product
movement between operations.”

Write a Preventive Action on the CAPA form,
including:
◦
◦
◦
◦

Requirement
Description of the Problem
Root Cause Analysis
Actions
Use your imagination