Monthly Archives: July 2013

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By Kevin Stewart

continuous improvement model

Continuous improvement is basically getting better than you were in the past.  So, how is something better than it was in the past?

In my mind it is associated with more, better, and faster.  In other words: I make more products with the same work, or I get a better quality product with the same work, or I can work faster with the same effort and therefore make more products and reduce my unit cost. 

In each case there may be a barrier, bottleneck, or something preventing you from making the improvement. While Root Cause Analysis is not always the right tool to resolve that barrier or bottleneck, it should be a foundation tool in the process of continuous improvement.  

I believe that a facility’s or a person’s continual success is directly dependent on their ability to solve problems.  

In Ron Moore’s book entitled “Making Common Sense Common Practice” he discusses three companies – an “A” company, a “B” company, and a “C” company. In his description, “A” company is the best of the best and “C” company is the one always lagging toward the back of the pack – making money in good times and struggling or failing in the tough times. Company “B” is in the middle of the pack.

Here’s a quote from his book:

“The difference between the best companies and the mediocre/ poor [companies] in this model is the emphasis the best companies give to the denominator (unit cost = cost/capacity).  That is, they focus on maximizing the capacity available through applying best practices and assuring reliability in design, operations and maintenance, and through debottlenecking.  They then use that capacity to go after additional market share, with little or no capital investment.  Note that in doing this, they also minimize the defects which result in failures and additional costs.”

The sentence in bold above is essentially saying that they aggressively follow a continuous improvement model of some kind to achieve that focus.

There are many tools available to a practitioner who is focused on continuous improvement. However, in my experience coming from an industrial environment, effective problem solving has one of the highest returns for the dollars and time spent of any of the tools.

This is not to say that the other tools mentioned in Ron’s book are not valuable – in fact I spent a large portion of my career attempting to establish and institutionalize those tools and processes. But every time something doesn’t meet expectations, or your downtime is greater than expected, or a piece of equipment can’t provide the uptime you need, that is the definition of a problem that needs resolution.

Also, in my career I discovered that many of the continuous improvement tools would not work well unless some of the more blatant and repetitive problems were resolved first. The most visible of these is planning and scheduling. Trying to plan and schedule in a reactive environment is next to impossible because every time you try to schedule a job, it gets usurped by a failure somewhere. This is frustrating for everyone and leads to an uphill battle.

So I believe that if you look deep inside an “A” company you will find a continuous improvement model that supports problem solving at its core.

Many people would say that Toyota is such a company; and they have many tools at its disposal – one of them being the 5 Whys. This is simply a problem solving methodology that allows operators and others to fix problems at the appropriate level, thereby supporting their continuous improvement model. The 5 Whys problem solving tool was developed to support Toyota’s original foundation premise of “Eliminate Waste” which is basically what Ron Says the “A” companies are doing. They are solving problems by identifying causes for the waste and then putting in place solutions to eliminate it.

If you think about the automotive industry as an example, are they driven by continuous improvement due to competition?

Do you remember when you had to replace or set the points in a distributor on a regular basis?  

Nowadays, through continuous improvement, there is no wear and electronic ignition has all but eliminated the need for that task…thereby eliminating waste and putting the original auto manufacturers ahead. The others had to follow suit in order to not lose market share or reputation.

The same thing happened with spark plugs. I haven’t change a set in quite a while since they started lasting 100,000 miles. You could make the case that it has cost companies money since they don’t sell parts anymore, however, I think anyone that didn’t move with these new technologies would have been left in the dust and lost market share.

As illustrated in the above examples, the best of the best are driven by continuous improvement to stay ahead of the game or to catch up quickly – no matter what the industry. This status is achieved through a combination of tools and problem solving techniques, with cause and effect being one that, in my opinion, should be at the core of your continuous improvement model.


Webinar Elements to Sustain a RCA Program


By Kevin Stewart

root cause analysis template

Wouldn’t it be great if problems presented themselves in a manner that would allow
them to perfectly fit a standard root cause analysis (RCA) template or process so that we could just plug in a few details and say “Voilà, here is the answer”?

Or even if they were close enough for us to adapt a standard template to allow us to quickly modify a standard analysis and come up with a reasonable standard answer? Life would be great!

If we look up “template” in the dictionary we get: “something that establishes or serves as a pattern”.  As luck would have it, the dictionary has used the following example: “The software includes templates for common marketing documents like pamphlets and flyers”.  If you’re reading this article, then most likely you are interested in how the RCA software can provide templates or standards for RCA analysis. In general, I am a big fan of templates; I’ve actually designed some to speed up data entry, or to allow me to quickly identify standard methodologies and information that may be missing.  Templates are great tools. But as with all tools, the old phrase applies: If all I have is a hammer – everything looks like a nail.  In our context, what I’m concerned about is that – if all I have is RCA – every problem will fit the template! Unfortunately not every problem fits neatly into a template.  Just as everything is not a nail.

For large industries this would be fantastic – if someone broke their arm we could fill in a few fields and print out a cause and effect chart of the incident!  If this were the case, then it would follow that most broken arms would fit a template – and that we could prevent several of the causes and again fix all or most broken arms.  As you already know, this won’t work very well, considering there are thousands of ways to break your arm and many different causes that would need be identified.

Perhaps we aren’t looking for such a prescriptive methodology but just something to help speed things up?  Or maybe to give a sense of confidence in what we are doing.

In the scheme of true cause and effect, it is very difficult to make templates for large chunks of an event. 

Consider the small example in Figure 1. 

Figure 1

root cause analysis template

I’ve used “action taken” as a starting point because it could be many things, such as measurement taken, preventative maintenance performed, incision made, etc.  This template works well if a procedure exists, as the only two options are: the procedure was followed or not followed.  If a procedure exists and it was followed, then the template would indicate that you could use the causes shown.  However, given the same starting point, what if the procedure is not followed? 

In figure 2, I’ve shown some possible causes of a procedure not followed.  However those are already dependent on “the true cause”.  Couldn’t the causes just as easily be “procedure known” and “employee decision”?  Or “procedure unknown” and “employee not trained”?  Or other causes that you may be able to come up with.  

Figure 2

root cause analysis template












So does this mean root cause analysis templates don’t apply?  Not necessarily. As you can see from the examples above, you could consider a template where procedures exist or don’t exist, and are followed or not followed, as a form of template for certain items that make sense to use. In cause and effect analysis, these templates are referred to as Causal Elements which will start to show up as you do more and more analysis.  

Some examples where templates might work include:

  • An action of some kind may be the result of ‘procedure exists’ (or doesn’t exist) and ‘followed’ or ‘not followed’
  • Something broken would have to have contact with sufficient force to cause the breakage
  • Something out of specification is caused by the specification value and the actual value
  • A contact is caused by something moving and something else in the path
  • A fall is caused by an action that initiates the fall, gravity, height, and the object that falls
  • Any fire is caused by an act that triggers combustion, combustible material, oxygen, and an ignition source
  • A quality excursion is caused by the ‘part in error existing’ and ‘missed inspection’ (missed inspection can be due to ‘sampling error’ or ‘not inspected as planned’)
  • Personal decision is the result of the ability to act, a reason to act, and absence of consequences of the act

In the above examples, using a template could work because the logic never changes, only the variables.

In summary

In the majority of cases, due to the sheer number of causes to any given problem, using a one-size-fits-all root cause analysis template is just unrealistic. However, in respect to cause and effect analysis, templates may play a role in some cases. This is when the logic is consistent and causal elements can emerge over time and be added to develop robust charts.

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By Jack Jager

Understanding the root cause of a problem is the purpose of many or all investigations. However, the concept of “root cause” suggests that there is only one, singular cause that is at the “root” of any problem.


Searching for Root Cause

The root cause concept and how it is applied often leads to this perception of a singular cause. For example, the statement “What is the root cause of the problem?”

So what is “root cause” and how is it defined? It can be difficult to find a clear and precise definition. The following  well-defined description reveals something very simplistic;  “Root Cause can be described as that cause, which if it were controlled or eliminated would make the problem go away. Therefore it may be considered a root cause”.

This is an interesting concept as it can be applied to a number of causes within a cause and effect chart, therefore, it can be said that there are many “root causes”.

Cause and Effect analysis and Reality charting indicates that a problem doesn’t occur from a single cause, but for any problem there can be many cause and effect relationships that can trigger a problem. Therefore how do we know which of these causes is the root cause?

If you were to ask this question to various people, there may be a number of different answers.  One person may think the root cause is one thing, while another would consider the root cause to be something else. Each party may in fact be right. So how can a “root cause” be assigned unless we are certain that a solution will prevent the problem from recurring?

Let’s look at the example below:

What are the causes of a fire? For a fire to occur there must be certain conditions present. Each of these conditions are a contributing cause of the fire.

  • There must be oxygen present (a conditional cause)
  • Fuel to burn (a conditional cause)
  • An ignition source, such as a match or lighter (also a conditional cause)

All of these causes can exist in harmony with each other and can do so for some time.

It is only when an “action” cause occurs, such as the lighting of a match that the fire will actually occur.

So what is the “root cause” here?

If we apply the definition provided above for “root cause” here, then by eliminating the oxygen, there would be no fire. Therefore “oxygen” is a root cause of the fire.

If you were to remove the combustible material, fuel, then this too will satisfy the definition requirement. The problem would not reoccur. Therefore “fuel” is also the root cause of the fire.

If you were to also remove all of the ignition sources, then there would be no possibility of a fire. This too satisfies the definition requirements. Therefore the “ignition source” is the root cause of the fire.

If no match was to be lit, then there would be no fire. Therefore “the lighting of the match” must be the root cause of the fire as well.

Based on this example, there are potentially four root causes and each of them satisfies the root cause definition. This can be quite confronting in a sense to recognise that there are many potential root causes for a problem. It is, however, liberating too because now you have many potential corrective actions rather than just one.

How often have you heard someone ask “What is the root cause of the problem?” and “you can’t control the problem until you have identified what the root cause is”.

How do we determine which causes to control? In the fire example, who will determine the control or controls to put into place? It’s unlikely that oxygen will be eliminated, as this can be a very costly and difficult process (although we do use this concept in confined spaces).

Can we control the combustible material? If we were to eliminate the fuel then would we have an effective control? This is possible in some cases but not in others.

What about the ignition sources? If there were no lighters or matches present or available, then there would be no fire. Do we have the ability to remove these?

If we could stop the persons action from occurring then we would also have controlled the possibility of a fire happening.

Based on these rationales, which of these controls should be implemented? Is this decision governed by certain criteria? And then the question about what we can control also comes into play.

So what criteria can we use to determine our choices?

  • Money – it needs to be cost effective
  • Safety – it needs to be safe
  • Easy – if possible it should be easy to do
  • Quick – being able to do it quickly has merit
  • Doesn’t cause other problems – at least not unacceptable problems
  • Is an ongoing fix – and is not a band-aid. The solution will fix the problem for today and tomorrow, as well as next week and next year.

and other criteria may also be considered.

The above criteria are taken into consideration when making the decision about which solutions to implement. At the end of the day, it is important to have an understanding of the problem and how many of the causes you need to control to prevent recurrence.

Did the notion or understanding of what the “root cause” is come into consideration when making the decision about which solutions to implement?  No, therefore what is the value of identifying “root cause”?

In my mind, it is the concept of “root cause” that is important. Applying this concept requires us to understand the problem as completely as possible, before we make decisions about corrective actions. If we do this, then we are in the best possible position to make good decisions about which corrective actions to implement. 

The decision of which solutions to implement is a choice. It is a choice we make according to a set of criteria. It is based on the answers you acquire when applying the criteria questions that allow you to be objective in your decision making process to find the best solution.

In Summary

In many ways the concept of “root cause”, whilst being important in the broader application, is often a misnomer when used to describe the critical cause for a unique incident. It is not the only cause. Other causes must also exist.  

At the end of the day it is your choice about which causes you wish to control. Therefore it is important to remain objective in this decision making process, via utilising a set of criteria, and applying them to all possible solutions. Let the answers to the criteria questions determine what the best solutions are, and that will determine what you consider to be the “root cause” of the problem.

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