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Root Cause Analysis

Root Cause Analysis is a problem solving method aimed at identifying the root causes of problems or events. Root Cause Analysis is based on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms – much like your doctor, who is more interested in treating the disease rather than the system.

Root Cause Analysis is a reactive method of problem detection and solving. This means that the analysis is done after an event has occurred.

By gaining expertise in Root Cause Analysis it becomes a pro-active method. This means that RCA is able to forecast the possibility of an event even before it could occur.

Root cause analysis is not a single, sharply defined methodology; there are many different tools, processes, and philosophies. Some common uses are:

  1. Aiming performance improvement measures at root causes is more effective than merely treating the symptoms of a problem.
  2. To be effective, it must be performed systematically, with conclusions and causes backed up by documented evidence.
  3. There is usually more than one potential root cause for any given problem.

Root cause analysis transforms an old culture that reacts to problems to a new culture that solves problems before they escalate, creating a variability reduction and risk avoidance mindset.

Consider the example of expediting customer orders in an order fulfillment process. Let’s say that the organization has a well defined process for accepting, processing, and shipping customer orders. When a customer calls and complains about not getting their order the most normal response is to expedite. This means that someone personally tracks down this customer’s order, assigns it a #1 priority, and ensures it gets shipped ahead of everything else. What isn’t realized is that, in expediting this order, one or more other orders were delayed because the process was disrupted to get this customer’s order out the door. What is all comes down to is that expediting orders simply ensures that more orders will have to be expedited later.

The appropriate response to this situation is to figure out why the order was in need of expediting in the first place – using Root Cause Analysis to find the cause.

A simple method of Root Cause Analysis is: ask the question “why” – 5 times.

1.      Why did you loose the battle? Because the king died.

2.      Why did the king die? He fell off his horse.

3.      Why did he fall off his horse? The horse stumbled.

4.      Why did the horse stumble?  The horse lost a shoe

5.      Why did the horse loose a shoe? He was missing a nail in his shoe.

“For want of a nail, the battle was lost!”

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