ABOUT THE TRAINING PROGRAM :- Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to address, correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is more probable that problem recurrence will be prevented. DESIGNED FOR :- Managers, Engineers, Supervisor and officers engaged in maintenance operation and engineering activities. OBJECTIVE :- At the end of the training program, participants will be able - To gain a basic understanding of the problem solving and decision-making process and the applicable quality tools that support this process. - To develop specific competencies to use the structured approach to problem solving and decision making and the supporting quality tools. TRAINING PROGRAM COVERAGE :- - Basic knowledge about RCA program. - What are the RCA tools ? - More about Why- Why analysis ? - Videos and case studies on RCA

1. RCA
Root Cause Analysis
Excellence in Problem Solving
Prepared and Presented by :-
Mr. Deepak Kumar Sahoo
Prepared By – Mr. Deepak Kumar Sahoo

2. What is RCA ?
Root Cause Analysis is an in-depth process or
technique for identifying the most basic
factor(s) underlying a variation in
performance (problem).
 Focus is on systems and processes
 Focus is not on individuals
Prepared By – Mr. Deepak Kumar Sahoo

3. Types of RCA
• Safety-based RCA
 Investigating accident , occupational safety and health.
 Root causes:- unidentified risks, or inadequate safety engineering, missing safety
barriers.
• Production-based RCA
 Quality control for industrial manufacturing.
 Root causes:- non-conformance like, malfunctioning steps in production line.
• Process-based RCA
 Extension of Production-based RCA.
 Includes business processes also.
 Root causes:- Individual process failures
• Systems-based RCA
 Hybrid of the previous types
 New concepts includes:- change management, systems thinking, and risk
management.
 Root causes:- organizational culture and strategic management
Prepared By – Mr. Deepak Kumar Sahoo

4. Whether we know the Cause?
Solution Not Known
Brain Storm / Seek Root Cause Analysis
Expert Help
Solution Known
Task Force Trial & Error
Root Cause Analysis
Cause Known Cause Not Known
Prepared By – Mr. Deepak Kumar Sahoo

5. RCA Benefits :-
By eliminating the root cause…
You save time and money!
• Problems are not repeated
• Reduce rework, retest, re-inspect, poor quality costs, etc…
• Problems are prevented in other areas
• Communication improves between groups and Process
cycle times improve (no rework loops)
• Secure long term company performance and profits
Prepared By – Mr. Deepak Kumar Sahoo

6. When we need RCA
IMPACT
5 WHY’s Cause Mapping
OBSERVATION MINOR MAJOR
FREQUENCY
Prepared By – Mr. Deepak Kumar Sahoo

7. RCA Process
A standard process of RCA is as follows:
 Identifying a problem
 Containing and analyzing the problem
 Defining the root cause
 Defining and implementing the actions required to eliminate
the root cause
 Validating that the corrective action prevented recurrence of
problem
Prepared By – Mr. Deepak Kumar Sahoo

8. RCA Process
1
Identify
8 Problem 2
Validate Identify
Team
Problem
Follow Immediate
Up Plan Solving Action
7
Process
3
Complete Root
Plan Cause
Action
6 Plan 4
5
Prepared By – Mr. Deepak Kumar Sahoo

9. RCA Process : Step - 1
Identify the Problem
• Clearly state the problem the team is to solve
– Teams should refer back to problem statement to avoid getting off track
• Use 5W2H approach
– Who? What? Why? When? Where? How? How Many?
5W2H
Who? Individuals/customers associated with problem
What? The problem statement or definition
When? Date and time problem was identified
Where? Location of complaints (area, facilities, customers)
Why? Any previously known explanations
How? How did the problem happen (root cause) and how will the problem be
corrected (corrective action)?
How Many? Size and frequency of problem
It’s the most
important step.
Prepared By – Mr. Deepak Kumar Sahoo

10. RCA Process : Step - 2
Identify Team
When a problem cannot be solved quickly by an individual,
use a team!
 Should consist of domain knowledge experts
 Small group of people (4-10) with process and product
knowledge, available time and authority to correct the
problem
 Must be empowered to “change the rules”
 Should have a designated Team leader.
 Membership in team is always changing!
Prepared By – Mr. Deepak Kumar Sahoo

11. RCA Process : Step – 2 (Continue..)
Key Ideas for Team Success
 Define roles and responsibilities
 Identify external customer needs
 Identify internal customer needs
 Appropriate levels of organization present
 Clearly defined objectives and outputs
 Solicit input from everyone!
 Good meeting location - Near work area for easy access to information.
Roles and Responsibilities
 Team Leader: Mentor, guide and direct teams, advocate to upper management
 Leader: day-to-day authority, calls meetings, facilitation of team, reports to TL.
 Record Keeper: Writes and publishes minutes
 Participants: Respect all ideas, keep an open mind, know their role within team
Prepared By – Mr. Deepak Kumar Sahoo

12. RCA Process : Step – 3
Immediate Action
 Must isolate effects of problem from customer
 Only temporary until corrective action is implemented
 Must also verify that immediate action is effective
Verify Immediate Action
 Immediate action = activity implemented to screen, detect and/or contain
the problem.
 Must verify that immediate action was effective
 Run Pilot Tests
 Make sure another problem does not arise from the temporary solutions
 Ensure effective screens and detections are in place to prevent further impact
to customer until permanent solution is implemented.
Prepared By – Mr. Deepak Kumar Sahoo

13. RCA Process : Step – 4
Finding Root Cause
• Brainstorm possible causes of problem with team
• Organize causes with Cause and Effect Diagram
• Use 5 Why? method to further define the root cause of
symptoms
– May involve additional research/analysis/investigation to get
to each “Why?”
• Must identify the process that caused the problem
– if root cause is company-wide, elevate these process issues
(outside of team control) to upper management to address
Prepared By – Mr. Deepak Kumar Sahoo

14. RCA Process : Step – 4 RCA Tools.
Most commonly use :-
– The “5 Whys”
– Brainstorming
– Fish bone Analysis or Ishikawa Diagram
– Cause Mapping or Cause and Effect Analysis
– FMEA or FMECA
Other RCA tools :-
 Process Maps  Run Chart  Risk Tree Diagrams
 Barrier Analysis  Change Analysis  Histograms
 Pareto Charts  Affinity Diagrams  Interrelationship
 pie chat  Control Plans Diagram
 Tree Diagrams  Scatter Diagram  Force Field Analysis
 Benchmarking  Event and Causal  Flowcharts
Factor Analysis  MORT Analysis
Prepared By – Mr. Deepak Kumar Sahoo

15. Why-Why 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
Prepared By – Mr. Deepak Kumar Sahoo

16. TIPS for Why-Why Analysis.
 It should be done within 24 hours of problem
occurrence
 Person who was present when the problem occurred
should be part of why-why analysis
 Why-Why analysis should be done at the location
where the problem has occurred
 Stop when the answers become less important.
 Stop when the root cause condition is isolated.
 Ask “Why?” 5 times can extend maximum 7 times. If
you will not find the possible solution then use Other
RCA tools.
Prepared By – Mr. Deepak Kumar Sahoo

17. Why-Why Analysis Examples
Why
• RAVANA KILLED
Why
• He Kidnapped SITA
Why
• She was in the Forest
• Her Father in law King Dhasaratha Promised to one
Why of his wife Kaikeyee
• One day King Dhasaratha Roaming with his chariot Vehicle it
wheel lock pin was damaged and Kaikeyee was put her finger in
Why
to the Pin hole and saved King Dhasaratha
Why
• The chariot vehicle wheel lock pin was damaged.
Prepared By – Mr. Deepak Kumar Sahoo

18. Why-Why Analysis Examples
Why
• The chariot vehicle wheel lock pin was damaged
Why
• Poor maintenance
Root
Why
• No PPM & no FMEA carried out. 
Cause
• Think …..
• Because EMCO was not there on that time
If EMCO was at that time and King Dhasaratha gave
maintenance contracts to EMCO History might Change.
Ravana life also might be saved. 
Prepared By – Mr. Deepak Kumar Sahoo

19. More about Cause-Effect Diagram :
Materials Methods
Environment Effect
Machine Man
NOTE: Causes are not limited to the 5 listed categories, but serve as a starting point
Steps used to create a Cause-Effect Diagram:
 Define the issue or problem clearly
 Decide on the root causes of the observed issue or problem
 Brainstorm each of the cause categories
 Write ideas on the cause-effect diagram.
Prepared By – Mr. Deepak Kumar Sahoo

20. Fish Bone Analysis
Materials Methods
Incorrect Quantity Late Dispatch
Spillage
Incorrect BOL Shipping Delay
Wrong Destination
Traffic Delays
Shipping
Environment
Wrong Equipment
Problems
Weather Driver
Dispatcher
Breakdown Dirty Equipment Wrong Directions
Attitude
Machine Man
Prepared By – Mr. Deepak Kumar Sahoo

21. RCA Process : Step – 5
Corrective Action Plan
• Must verify the solution will eliminate the problem
– Verification before implementation whenever possible
• Define exactly…
– What actions will be taken to eliminate the problem?
– Who is responsible?
– When will it be completed?
• Make certain customer is happy with actions
• Define how the effectiveness of the corrective action will be measured.
Verification vs. Validation
Verification
– Assures that at a point in time, the action taken will actually do what is intended without
causing another problem
Validation
– Provides measurable evidence over time that the action taken worked properly, and
problem has not recurred
Prepared By – Mr. Deepak Kumar Sahoo

22. Types of Corrective action.
3 types of Corrective Action:
• Immediate action
– The action taken to quickly fix the impact of the problem so the
“customer” is not further impacted
• Permanent root cause corrective action
– The action taken to eliminate the error on the affected process or product
• Preventive (Systemic) root cause corrective action
– The action taken to Prevent the error from recurring on any process or
product
Prepared By – Mr. Deepak Kumar Sahoo

23. Corrective Action Examples
Immediate (step #3)
All current batch of paperwork re-inspected by
another worker for same type of problem
Permanent (step #5)
Form changed to mandate completion of certain fields
Preventive (step #5)
Similar forms with same fields used all over in
company are changed to “mandatory”
Prepared By – Mr. Deepak Kumar Sahoo

24. RCA Process : Step – 6
Complete Action Plan
 Make certain all actions that are defined are completed as
planned
 If one task is still open, verification and validation is pushed
back
 If the plan is compromised, most likely the solution will not be
as effective
Prepared By – Mr. Deepak Kumar Sahoo

25. RCA Process : Step – 7
Follow Up Plan
 What actions will be completed in the future to ensure that the
root cause has been eliminated by this corrective action?
 Who will look at what data?
 How long after the action plan will this be done?
 What criteria in the data results will determine that the problem
has not recurred?
Prepared By – Mr. Deepak Kumar Sahoo

26. RCA Process : Step – 8
Validate and Celebrate
• What were the results of the follow up?
• If problem did reoccur, go back to Step #4 and re-evaluate root
cause, then re-evaluate corrective action in Step #5
• If problem did not reoccur, celebrate team success!
• Document savings to publicize team effort, obtain customer
satisfaction and continued management support of teams
Prepared By – Mr. Deepak Kumar Sahoo

27. RCA Example - 1
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.
Immediate Action
Knowing that the water is a safety hazard, the manager asks the
supervisor to have someone get a mop and clean up the puddle.
But What is the Root Cause?
The supervisor looks for a root cause by asking 'why?’
Prepared By – Mr. Deepak Kumar Sahoo

28. RCA Example – 1
WHY Puddle of water on the floor
WHY Leak in overhead pipe
WHY Water pressure is set too high
WHY Water pressure valve is faulty
Root Cause Valve not in PPM program
Prepared By – Mr. Deepak Kumar Sahoo

29. RCA Example – 1
Corrective Action
 Permanent – Water pressure valves placed in
preventative maintenance program.
 Preventive - Developed checklist form to ensure new
equipment is reviewed for possible inclusion in
preventative maintenance program.
Prepared By – Mr. Deepak Kumar Sahoo

30. RCA Example – 2
Identify Problem
Customers are unhappy because they are being shipped
products that don't meet their specifications.
Immediate Action
Inspect all finished and in-process product to ensure it
meets customer specifications.
Find out the root cause
Prepared By – Mr. Deepak Kumar Sahoo

31. RCA Example – 2
WHY Product doesn’t meet specifications
Manufacturing specification is different from what customer and sales
WHY person agreed.
Sales person tries to expedite work by calling head of manufacturing
WHY directly.
Manufacturing schedule is not available for sales person to provide
WHY realistic delivery date.
Confidence in manufacturing schedule is not high enough to
WHY release/link with order system
WHY Parts sometimes not available thereby creating schedule changes
WHY Expediting and priority changes consume parts not planned for
Manufacturing schedule does not reflect realistic assembly and test
WHY time.
Root Cause No ongoing review of manufacturing standards.
Prepared By – Mr. Deepak Kumar Sahoo

32. RCA Example – 2
Corrective Action
• Permanent – Manufacturing standards reviewed and
updated.
• Preventive - Regular ongoing review of actuals vs
standards is implemented.
Prepared By – Mr. Deepak Kumar Sahoo

33. RCA Example – 3
Identify Problem
Part polarity reversed on circuit board
Immediate Action
 Additional inspection added after this assembly
process step to check for reversed part defects.
 Last 10 lots of printed circuit boards were re-inspected
to check for similar errors.
Prepared By – Mr. Deepak Kumar Sahoo

34. RCA Example – 3
WHY Part reversed.
WHY Worker not sure of correct part orientation.
WHY Part is not marked properly.
WHY Engineering ordered it that way from vendor
Process didn’t account for possible
Root Cause
manufacturing issues
Prepared By – Mr. Deepak Kumar Sahoo

35. RCA Example – 3
Corrective Action:-
• Permanent – Changed part to one that can only be
placed in correct direction (Mistake proofed). Found
other products with similar problem and made same
changes.
• Preventive - Required that any new parts selected
must have orientation marks on them.
Prepared By – Mr. Deepak Kumar Sahoo

36. RCA Example – 4
Identify Problem
Department didn’t complete their project on time.
Immediate Action
 Additional resources applied to help get the project
team back on schedule
 No new projects started until Root Cause Analysis
completed
Now we will find the root cause
Prepared By – Mr. Deepak Kumar Sahoo

37. RCA Example – 4
WHY Didn’t complete project on time
Method Man
Lack of worker
knowledge
Poor project Lack of resources
management
skills
Didn’t complete
project on time
Inadequate
computer
programs Inadequate
computer system
Materials Machine
Prepared By – Mr. Deepak Kumar Sahoo

38. RCA Example – 4
WHY Didn’t complete project on time
WHY Resources unavailable when needed.
WHY Took too long to hire Project Manager
Lack of specifics given to
WHY Human Resources Department.
Root Cause No formal process for submitting job opening
Prepared By – Mr. Deepak Kumar Sahoo

39. RCA Example – 4
Corrective Action
 Permanent – Hired another worker to meet needs of
next project team
 Preventive - Developed checklist form with HR for
submitting job openings in the future.
Prepared By – Mr. Deepak Kumar Sahoo

40. More on Why-Why analysis ?
 Why People turnover is high in EMCO?
 Why work load is more in QF?
 Why PPM in QF is not so effective ?
 Why Rajnikant is to too famous?
 Why CM has reduced in QF from EMCO side ?
Prepared By – Mr. Deepak Kumar Sahoo

41. Why-Why Analysis (multiple cause Examples)
Employee turnover rate has been
increasing
Why? Why? Why? Why? Why?
Employees Employees Employees Other Demand for
are leaving are not feel that they employers such
for other jobs satisfied are are paying employees
underpaid higher has increased
salaries in the market
Prepared By – Mr. Deepak Kumar Sahoo

42. Thank you !!!
Connect With Me @
Mobile :- +974 – 3370 8982
Email :- dksahoo2@gmail.com
LinkedIn :- www.linkedin.com/in/dksahoo
Facebook :- www.facebook.com/dksahoo2
Twitter :- www.twitter.com/defydeepak
Slideshare :- www.slideshare.net/dksahoo2
Prepared By – Mr. Deepak Kumar Sahoo