root cause analysis and the boeing problem solving model

By Industry

• Oil & Gas
• Power & Water Utilities
• Manufacturing
• Aviation & Defense
• Food and Beverage
• Reliability & Maintenance
• Asset Management
• Corporate Leadership
• Project Management
• Health, Safety & Environment
• Quality Assurance
• Manage asset strategies
• Develop asset strategies
• Optimize asset strategies
• Reduce cost
• Reduce downtime
• Improve reliability
• Design for reliability
• Solve recurring problems
• Build team capability
• Remote service options

How can we help

• Asset Performance Management
• Asset Strategy Management
• RAM Analysis
• Maintenance Strategy Development
• Maintenance Strategy Optimization
• Master Data Development
• Availability and Capacity Analysis
• Spare Parts Analysis
• Life Cycle Costing (LCC) Analysis
• Defect Elimination
• Reliability Centered Maintenance (RCM)
• Failure Mode and Effect Analysis (FMEA) Failure Mode, Effect and Criticality (FMECA)
• Task Based Maintenance (TBM) Analysis
• Vulnerability Analysis Assessment (VAA)
• Root Cause Analysis
• Cordant™ Asset Strategy
• Component Strategy Library

Asset Maintenance Simulation

• Reliability Integration Tool
• Cordant™ Defect Elimination

General Support

Cordant™ asset strategy support, copperleaf c55 support, isograph support.

• Privacy Policy
• Terms & Conditions

Advisory Services

• Mentoring & Support

Methodologies

• English Español English Español

Root Cause Analysis and the Boeing Problem Solving Model

Utilizing the Apollo Root Cause Analysis methodology and RealityCharting software in Boeing's 5-step Root Cause Corrective Action Model for Effective Problem...

Jennifer MacKay, Root Cause Analysis Technical Principal, The Boeing Company

Jemma gaber, manufacturing engineer, the boeing company.

The Boeing Problem Solving Model provides a structured approach to continuous improvement. It can be used to solve problems or capture opportunities of any size or scope. 

Download this whitepaper to learn how The Boeing Company tackles their most complex and longest running aerospace production and engineering problems. 

• Define the Problem
• Perform a Root Cause Analysis 
• Identify Potential Solutions
• Sustain the Gains

Download Whitepaper

• Training Home
• Training Courses
• Public Training Calendar
• Our Customers
• A Baker Hughes Business

Why Boeing’s Problems with the 737 MAX Began More Than 25 Years Ago

Once again, Boeing’s 737 MAX is back in the headlines.

After two crashes that killed 346 people in 2018 and 2019 and five years of ensuing design changes and regulatory scrutiny, the 737 MAX is grounded again after a mid-air blowout of a fuselage panel on January 5. After loose bolts were discovered on other MAX 9s, the Federal Aviation Administration (FAA) grounded the planes and opened an investigation into whether MAX is safe to fly, accompanied by a stern warning, saying , “This incident should have never happened, and it cannot happen again.”

Boeing has also experienced repeated problems in design and production with its newest jumbo jet, the 787 Dreamliner. Such frequent, repeated crises point to a deeper issue than isolated engineering mishaps. The underlying cause of these issues is a leadership failure that has allowed cultural drift away from Boeing’s once-vaunted engineering quality.

William Boeing created the commercial aviation industry. For the next century, Boeing was the leading producer, based on its excellence in aircraft design and safety. Boeing’s problems today date back to former CEO Philip Condit, who made two ill-fated decisions that dramatically changed Boeing’s culture. The first was acquiring archrival McDonnell Douglas in 1997, a leader in military aviation with its fighter jets and Boeing’s major competitor in commercial aviation. In contrast to Boeing’s culture of engineering excellence, McDonnell Douglas focused on cost-cutting and upgrading older airplane models at the expense of all-new aircraft.

Secondly, in 2001 Condit moved Boeing’s headquarters from its original home in Seattle to Chicago—all to gain $60 million in state and local tax credits over 20 years. With none of its businesses based in Chicago, the move separated Boeing’s corporate executives from its engineering and product decisions and alienated its Seattle-based engineers.

Leader turnover, ethical lapses, and buybacks

After Condit resigned in 2003 following an ethics scandal, Boeing’s board convinced former McDonnell Douglas executive Harry Stonecipher to come out of retirement to replace Condit. Stonecipher, a General Electric (GE) alum, immediately set out to change Boeing’s culture, proclaiming , “When people say I changed the culture of Boeing, that was the intent, so that it is run like a business rather than a great engineering firm.”

One of Stonecipher’s fated decisions was to turn down the proposal from Boeing’s head of commercial aviation to design an all-new single-aisle aircraft to replace the Boeing 727 (FAA-certified in 1964), 737 (1968 certification) and 757 (1972). Instead of designing a new airplane incorporating all the advances in aviation technology from the past 30-40 years, Stonecipher elected to maximize profits from older models and use the cash to buy back Boeing stock.

Just two years after taking over, Stonecipher resigned after violating the company’s code of conduct. Rather than promoting the internal candidate, Alan Mulally, who headed up commercial aviation and led the development of the highly successful Boeing 777, the board recruited ex-GE executive Jim McNerney to succeed Stonecipher. At the time, McNerney was CEO of 3M, a tenure that lasted just four years. Meanwhile, Mulally became CEO of Ford, where he led one of the most important business turnarounds in history.

Maximizing earnings, but at what cost?

By 2011, Boeing found its 737 losing out to rival Airbus’s A320neo with major customers like American Airlines. Rather than designing a new aircraft to replace the 737, McNerney opted for a five-year program to upgrade to the 737 MAX. This decision required the redesign to stay within FAA’s original type-certification with the same flying characteristics. Boeing also agreed with customers like Southwest Airlines to avoid retraining pilots and upgrading its training manuals. These decisions minimized short-term cost to maximize short-term earnings.

In my experience with advanced technology products, quick fixes often lead to design compromises that create more problems. This happened with the 737 MAX in 2015 when it encountered stall problems. Rather than further design changes that would have risked the 737’s original type-certification, Boeing opted for a major software change that was not disclosed to the FAA or described in its pilot’s manual.

The flaws in the software design that took flight control away from the pilots without their knowledge based on data from a single sensor, ultimately led to the two 737 MAX crashes in 2018 and 2019, causing the deaths of 346 people. After the first crash, Boeing issued a statement that offered pilots and passengers “our assurance that the 737 MAX is as safe as any airplane that has ever flown the skies.” That assurance came back to haunt Boeing four months later when the second MAX crashed.

When Boeing leadership failed to ground its fleet of 737 MAX planes, the FAA forced them to do so, pushing Boeing into a lengthy set of regulatory inspections, tests, and design changes lasting 20 months. During that time, its customers waited for aircraft they desperately needed in service. Then Congress held a damaging hearing that eventually forced Boeing’s board to relieve then-CEO Dennis Muilenburg. Today, ex-GE executive David Calhoun, a Boeing board member since 2009, has the onerous task of restoring Boeing’s business and its quality standards.

The cost of reputational damage

When we discuss the Boeing cases in my classes at Harvard Business School, I ask participants, “Are Boeing’s problems caused by individual leadership failures or a flawed culture?” The answer “both” eventually emerges. It was the actions of Condit and Stonecipher that turned Boeing’s culture from excellence in aviation design, quality, and safety into emphasizing short-term profit and distributing cash to shareholders via stock buybacks.

McNerney compounded the problem through his decision to launch a quick fix to the 737 rather than design a new airplane. Muilenburg was left with the flawed aircraft, but failed to ground the planes after the first crash and pinpoint the root cause of the failure. The Boeing board, which is composed of exceptional individuals, failed to preserve Boeing’s culture and reputation.

Ironically, decisions made in the name of shareholder value over the past two decades have cost its investors $87 billion since 2018. The long-term damage to Boeing’s reputation and market position is even greater as Airbus has outsold Boeing in new aircraft orders each of the last five years.

Now CEO Calhoun faces immediate pressure to fix the MAX fuselage panel and win back market share. However, his real task must be to restore Boeing’s culture of aviation excellence—a long-term project that is the only real solution to restore this once iconic company to aviation leadership.

Bill George is an Executive Fellow at Harvard Business School, and former Chair and Chief Executive Officer of Medtronic. He doesn't hold a financial stake in Boeing, its competitors, or any airlines.

You Might Also Like:

• What Went Wrong with the Boeing 737 Max?
• Courage: The Defining Characteristic of Great Leaders
• Why Leaders Lose Their Way

Feedback or ideas to share? Email the Working Knowledge team at [email protected] .

Image note: Illustration was created with artwork from AdobeStock/John Vlahidis.

• 09 May 2024
• Research & Ideas

Called Back to the Office? How You Benefit from Ideas You Didn't Know You Were Missing

• 14 Dec 2021

To Change Your Company's Culture, Don't Start by Trying to Change the Culture

• 28 May 2024
• In Practice

Job Search Advice for a Tough Market: Think Broadly and Stay Flexible

• 06 May 2024

The Critical Minutes After a Virtual Meeting That Can Build Up or Tear Down Teams

• 22 Nov 2023

Humans vs. Machines: Untangling the Tasks AI Can (and Can't) Handle

• Leadership Development
• Research and Development
• Crisis Management
• Air Transportation
• Transportation

Sign up for our weekly newsletter

Root-cause problem solving in the Ops 4.0 era

Passionate about the “human factor”: helping people develop broad skills and deep functional expertise. Experienced operations practitioner, faculty member, and author.

Wouter Michiels, a consultant based in the Brussels Office, has more than 10 years’ experience in petrochemical manufacturing, engineering, and supply chains.

April 15, 2019 To improve, organizations must consistently seek out and solve their problems—an insight that underpins lean management ’s emphasis on root-cause problem solving (RCPS). Indeed, companies that have used RCPS to build a problem-solving culture that lasts are able to avoid continuous firefighting by effectively preventing fires from starting.

But RCPS takes discipline and patience, which some leaders resist: a manager may be reluctant to use this model if she’s convinced that she has already identified an “operational solution.” Nevertheless, persuading her to join her team on a problem-solving journey can help uncover a more effective and sustainable set of solutions—most importantly by including the people who know the problem best: shop-floor employees. Their perspective often shows that the initial idea would not have addressed the problem’s real causes, and would have met with a lot of resistance from the people charged with implementation.

Ops 4.0 technologies are making it easier to overcome that resistance and invigorate root-cause problem solving performance. What follows is a non-exhaustive overview of how different technologies ( italicized ) could be applied in each of the five RCPS elements (exhibit).

1. Identifying and defining the problem

The rise of advanced analytics and business-intelligence applications allows companies can detect many more problems than in the past, and in a more effective way—so long as they have sufficient internal support to interpret the output . Examples include fraud detection in banking and insurance, as well as deviations from normal operating conditions of equipment in manufacturing plants. For the latter, the increased availability of high-frequency, high-precision sensors , together with the rise of the Internet of Things provides companies with larger data sets from which to identify problems.

2. Assessing root cause(s)

Once the problem is defined, root causes are often identified via the five-why methodology. Instead of using the traditional colored sticky notes to facilitate this exercise, companies can now use interactive whiteboards incorporating speech-to-text or handwriting-to-text algorithms, together with high-quality touch commands . Moreover, the whiteboards can link to data warehouses , thereby enabling self-service analytics or even machine-learning algorithms for performing the analyses required in confirming or rejecting potential root causes.

3. Designing solutions

Augmented- and virtual-reality applications can help designers’ creation process become even more productive. Faster iterations between the drawing board and a more real-life representation shorten lead times toward final design. Rapid prototyping and 3D printing can accelerate this process even further by bringing intermediate versions of the solution to life.

4. Testing solutions

Once a solution has been designed, it is crucial to test its efficiency and effectiveness. The increase in computing power enables companies to perform extensive computational simulations . Using digital twins helps organizations create virtual mirrors of their operations, allowing them to test ideas more realistically before implementation.

5. Sustaining, sharing, and continuously improving

The digital communication and collaboration platforms that are now in widespread use can often be linked with interactive tools such as digital whiteboards, minimizing the time teams spend on documentation so they can instead focus on the creative parts of problem solving. Having past records of problem-solving sheets available at only one touch avoids solving the same problem all over again.

The above list shows how the ancient art of root-cause problem solving can take shape in today’s environment. The question for most organizations is how to start, especially with technologies that can sound like science fiction. A learning center designed to replicate an actual, digitally enabled working environment can provide the first step, helping people experience the impact these technologies can achieve in a practical and realistic setting.

Connect with our Operations Practice

Problem Solving

• First Online: 16 February 2022

Cite this chapter

• David Lapesa Barrera 3  

Part of the book series: Springer Series in Reliability Engineering ((RELIABILITY))

1027 Accesses

This chapter introduces some useful tools for Root Cause Analysis (RCA) and selection of optimum solutions, and aims to anticipate risks and potential issues by using Proactive Problem Solving methodologies.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

BowTie Methodology Manual. BowTieXP. Revision 15, 2015.

Maintenance Error Decision Aid (MEDA) User’s Guide. Boeing. September 2013.

Author information

Authors and affiliations.

Zaragoza, Spain

David Lapesa Barrera

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to David Lapesa Barrera .

Rights and permissions

Reprints and permissions

Copyright information

© 2022 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Lapesa Barrera, D. (2022). Problem Solving. In: Aircraft Maintenance Programs. Springer Series in Reliability Engineering. Springer, Cham. https://doi.org/10.1007/978-3-030-90263-6_28

Download citation

DOI : https://doi.org/10.1007/978-3-030-90263-6_28

Published : 16 February 2022

Publisher Name : Springer, Cham

Print ISBN : 978-3-030-90262-9

Online ISBN : 978-3-030-90263-6

eBook Packages : Engineering Engineering (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

• Business Essentials
• Leadership & Management
• Credential of Leadership, Impact, and Management in Business (CLIMB)
• Entrepreneurship & Innovation
• Digital Transformation
• Finance & Accounting
• Business in Society
• For Organizations
• Support Portal
• Media Coverage
• Founding Donors
• Leadership Team

• Harvard Business School →
• HBS Online →
• Business Insights →

Business Insights

Harvard Business School Online's Business Insights Blog provides the career insights you need to achieve your goals and gain confidence in your business skills.

• Career Development
• Communication
• Decision-Making
• Earning Your MBA
• Negotiation
• News & Events
• Productivity
• Staff Spotlight
• Student Profiles
• Work-Life Balance
• AI Essentials for Business
• Alternative Investments
• Business Analytics
• Business Strategy
• Business and Climate Change
• Design Thinking and Innovation
• Digital Marketing Strategy
• Disruptive Strategy
• Economics for Managers
• Entrepreneurship Essentials
• Financial Accounting
• Global Business
• Launching Tech Ventures
• Leadership Principles
• Leadership, Ethics, and Corporate Accountability
• Leading Change and Organizational Renewal
• Leading with Finance
• Management Essentials
• Negotiation Mastery
• Organizational Leadership
• Power and Influence for Positive Impact
• Strategy Execution
• Sustainable Business Strategy
• Sustainable Investing
• Winning with Digital Platforms

Root Cause Analysis: What It Is & How to Perform One

• 07 Mar 2023

The problems that affect a company’s success don’t always result from not understanding how to solve them. In many cases, their root causes aren’t easily identified. That’s why root cause analysis is vital to organizational leadership .

According to research described in the Harvard Business Review , 85 percent of executives believe their organizations are bad at diagnosing problems, and 87 percent think that flaw carries significant costs. As a result, more businesses seek organizational leaders who avoid costly mistakes.

If you’re a leader who wants to problem-solve effectively, here’s an overview of root cause analysis and why it’s important in organizational leadership.

Access your free e-book today.

What Is Root Cause Analysis?

According to the online course Organizational Leadership —taught by Harvard Business School professors Joshua Margolis and Anthony Mayo— root cause analysis is the process of articulating problems’ causes to suggest specific solutions.

“Leaders must perform as beacons,” Margolis says in the course. “Namely, scanning and analyzing the landscape around the organization and identifying current and emerging trends, pressures, threats, and opportunities.”

By working with others to understand a problem’s root cause, you can generate a solution. If you’re interested in performing a root cause analysis for your organization, here are eight steps you must take.

8 Essential Steps of an Organizational Root Cause Analysis

1. identify performance or opportunity gaps.

The first step in a root cause analysis is identifying the most important performance or opportunity gaps facing your team, department, or organization. Performance gaps are the ways in which your organization falls short or fails to deliver on its capabilities; opportunity gaps reflect something new or innovative it can do to create value.

Finding those gaps requires leveraging the “leader as beacon” form of leadership.

“Leaders are called upon to illuminate what's going on outside and around the organization,” Margolis says in Organizational Leadership , “identifying both challenges and opportunities and how they inform the organization's future direction.”

Without those insights, you can’t reap the benefits an effective root cause analysis can produce because external forces—including industry trends, competitors, and the economy—can affect your company’s long-term success.

2. Create an Organizational Challenge Statement

The next step is writing an organizational challenge statement explaining what the gap is and why it’s important. The statement should be three to four sentences and encapsulate the challenge’s essence.

It’s crucial to explain where your organization falls short, what problems that poses, and why it matters. Describe the gap and why you must urgently address it.

A critical responsibility is deciding which gap requires the most attention, then focusing your analysis on it. Concentrating on too many problems at once can dilute positive results.

To prioritize issues, consider which are the most time-sensitive and mission-critical, followed by which can make stakeholders happy.

3. Analyze Findings with Colleagues

It's essential to work with colleagues to gain different perspectives on a problem and its root causes. This involves understanding the problem, gathering information, and developing a comprehensive analysis.

While this can be challenging when you’re a new organizational leader, using the double helix of leadership —the coevolutionary process of executing organizational leadership's responsibilities while developing the capabilities to perform them—can help foster collaboration.

Research shows diverse ideas improve high-level decision-making, which is why you should connect with colleagues with different opinions and expertise to enhance your root cause analysis’s outcome.

4. Formulate Value-Creating Activities

Next, determine what your company must do to address your organizational challenge statement. Establish three to five value-creating activities for your team, department, or organization to close the performance or opportunity gap you’ve identified.

This requires communicating organizational direction —a clear and compelling path forward that ensures stakeholders know and work toward the same goal.

“Setting direction is typically a reciprocal process,” Margolis says in Organizational Leadership . “You don't sit down and decide your direction, nor do you input your analysis of the external context into a formula and solve for a direction. Rather, setting direction is a back-and-forth process; you move between the value you'd like to create for customers, employees, investors, and your grasp of the context.”

5. Identify Necessary Behavior Changes

Once you’ve outlined activities that can provide value to your company, identify the behavior changes needed to address your organizational challenge statement.

“Your detective work throughout your root cause analysis exposes uncomfortable realities about employee competencies, organizational inefficiencies, departmental infighting, and unclear direction from leadership at multiple levels of the company,” Mayo says in Organizational Leadership .

Factors that can affect your company’s long-term success include:

• Ineffective communication skills
• Resistance to change
• Problematic workplace stereotypes

Not all root cause analyses reveal behaviors that must be eliminated. Sometimes you can identify behaviors to enhance or foster internally, such as:

• Collaboration
• Innovative thinking
• Creative problem-solving

6. Implement Behavior Changes

Although behaviors might be easy to pinpoint, putting them into practice can be challenging.

To ensure you implement the right changes, gauge whether they’ll have a positive or negative impact. According to Organizational Leadership , you should consider the following factors:

• Motivation: Do the people at your organization have a personal desire for and commitment to change?
• Competence: Do they have the skills and know-how to implement change effectively?
• Coordination: Are they willing to work collaboratively to enact change?

Based on your answers, decide what behavior changes are plausible for your root cause analysis.

7. Map Root Causes

The next step in your analysis is mapping the root causes you’ve identified to the components of organizational alignment. Doing so helps you determine which components to adjust or change to implement employee behavior changes successfully.

Three root cause categories unrelated to behavior changes are:

• Systems and structures: The formal organization component, including talent management, product development, and budget and accountability systems
• People: Individuals’ profiles and the workforce’s overall composition, including employees’ skills, experience, values, and attitudes
• Culture: The informal, intangible part of your organization, including the norms, values, attitudes, beliefs, preferences, common practices, and habits of its employees

8. Create an Action Plan

Using your findings from the previous steps, create an action plan for addressing your organizational problem’s root cause and consider your role in it.

To make the action plan achievable, ensure you:

• Identify the problem’s root cause
• Create measurable results
• Ensure clear communication among your team

“One useful way to assess your potential impact on the challenge is to understand your locus of control,” Mayo says in Organizational Leadership , “or the extent to which you can personally drive the needed change or improvement.”

The best way to illustrate your control is by using three concentric circles: the innermost circle being full control of resources, the middle circle representing your ability to influence but not control, and the outermost circle alluding to shifts outside both your influence and control.

Consider these circles when implementing your action plan to ensure your goals don’t overreach.

The Importance of Root Cause Analysis in Organizational Leadership

Root cause analysis is a critical organizational leadership skill for effectively addressing problems and driving change. It helps you understand shifting conditions around your company and confirm that your efforts are relevant and sustainable.

As a leader, you must not only effect change but understand why it’s needed. Taking an online course, such as Organizational Leadership , can enable you to gain that knowledge.

Using root cause analysis, you can identify the issues behind your organization’s problems, develop a plan to address them, and make impactful changes.

Are you preparing to transition to a new leadership role? Enroll in our online certificate course Organizational Leadership —one of our leadership and management courses —and learn how to perform an effective root cause analysis to ensure your company’s long-term success. To learn more about what it takes to be an effective leader, download our free leadership e-book .

About the Author

(Stanford users can avoid this Captcha by logging in.)

• Send to text email RefWorks EndNote printer

Root Cause Analysis : the Core of Problem Solving and Corrective Action

Available online.

• EBSCO Academic Comprehensive Collection

More options

• Find it at other libraries via WorldCat
• Contributors

Description

Creators/contributors, contents/summary.

• Title page; CIP data; Contents; List of Figures and Tables; Preface to the Second Edition; Preface to the First Edition; Chapter 1_Getting Better Root Cause Analysis; The Problem; The Impact; Approaches to Root Cause Analysis; Existing Problem-Solving Models; A Proposed Model; Chapter 2_Multiple Causes and Types of Action; Initial Problem Response; The Diagnosis; Actions to Prevent Future Problems; The Need for Filters; Chapter 3_Step
• 1: Define the Problem; Selecting the Right Problem; Scoping the Problem Appropriately; The Problem Statement; Chapter 4_Step
• 2: Understand the Process
• Setting Process BoundariesFlowcharting the Process; Why Process is So Important; Additional Values of the Flowchart; Chapter 5_Step
• 3: Identify Possible Causes; Using the Flowchart for Causes; Using a Logic Tree for Causes; Using Brainstorming and the Cause-and-Effect Diagram for Causes; Using Barrier Analysis for Causes; Using Change Analysis for Causes; Eliminating Possible Causes; Sources for Possible Causes; Chapter 6_Step
• 4: Collect the Data; A Basic Concept; Types of Data; Using Existing Versus New Data; Where to Collect Data; Special Tests; Sample Size and Time Frame
• Data Collection Tools for Both Low- and High-Frequency ProblemsAdditional Tools for High-Frequency Problems; Enhancing Data Collection Value; Organizing the Data Collection Process; Chapter 7_Step
• 5: Analyze the Data; Tools for Low-Frequency Data; Additional Tools for High-Frequency Data; Questioning the Data; Data Analyses Summaries; Analyzing Variation; Cautions on Data Analysis; Where to Go Next?; Can't Find the Cause?; Chapter 8_Identify and Select Solutions; Step
• 6: Identify Possible Solutions; Step
• 7: Select Solution(s) to Be Implemented
• Chapter 9_Implement, Evaluate, and InstitutionalizeStep
• 8: Implement the Solution(s); Step
• 9: Evaluate the Effect(s); Step
• 10: Institutionalize the Change; Chapter 10_Organizational Issues; Cognitive Biases; Emotional Barriers; Resistance to Change; Organizational Culture; Project Ownership; Coaching/Facilitation Skills; Other Issues; Chapter 11_Human Error and Incident Analysis; Human Error; Incident Analysis; Chapter 12_Improving Corrective Action; Critical Thinking; Buddhism; Stoic Philosophy; Summary of Root Cause Analysis; Appendix A_Example Projects; A Need for Focus
• How Would They Know?How Proficient is That?; Getting the Shaft Back; Got it in the Bag!; Appendix B_Root Cause Analysis Process Guides; Generic Process Thinking; SIPOC Analysis Form; Data Collection and Analysis Tools; Do It2 Root Cause Analysis Guide; Do It2 Problem-Solving Worksheet; Checklist for Reviewing the Corrective Action Process; Expanded List of Seven Ms; Forms for Tracking Causes and Solutions; Appendix C_Enhancing the Interview; Basic Interview Problems and Process; Types of Interviews and Questions; Leveraging How Memory Works; The Importance of Time and Reflection

Bibliographic information

Browse related items.

• Stanford Home
• Maps & Directions
• Search Stanford
• Emergency Info
• Terms of Use
• Non-Discrimination
• Accessibility

© Stanford University , Stanford , California 94305 .

How it works

For Business

Join Mind Tools

Article • 8 min read

Root Cause Analysis

Tracing a problem to its origins.

By the Mind Tools Content Team

In medicine, it's easy to understand the difference between treating the symptoms and curing the condition. A broken wrist, for example, really hurts! But painkillers will only take away the symptoms; you'll need a different treatment to help your bones heal properly.

But what do you do when you have a problem at work? Do you jump straight in and treat the symptoms, or do you stop to consider whether there's actually a deeper problem that needs your attention? If you only fix the symptoms – what you see on the surface – the problem will almost certainly return, and need fixing over and over again.

However, if you look deeper to figure out what's causing the problem, you can fix the underlying systems and processes so that it goes away for good.

What Is Root Cause Analysis?

Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why the problem occurred in the first place. It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

• Determine what happened.
• Determine why it happened.
• Figure out what to do to reduce the likelihood that it will happen again.

RCA assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, you can discover where the problem started and how it grew into the symptom you're now facing.

You'll usually find three basic types of causes:

• Physical causes – Tangible, material items failed in some way (for example, a car's brakes stopped working).
• Human causes – People did something wrong, or did not do something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing).
• Organizational causes – A system, process or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid).

RCA looks at all three types of causes. It involves investigating the patterns of negative effects, finding hidden flaws in the system, and discovering specific actions that contributed to the problem. This often means that RCA reveals more than one root cause.

You can apply RCA to almost any situation. Determining how far to go in your investigation requires good judgment and common sense. Theoretically, you could continue to trace the root causes back to the Stone Age, but the effort would serve no useful purpose. Be careful to understand when you've found a significant cause that can, in fact, be changed.

Frequently Asked Questions

Why is root cause analysis important.

RCA allows you to get to the true source of a problem, and stop it in its tracks. This is more effective than simply remedying the symptoms. By identifying and alleviating the root cause of a problem, you can prevent an issue from occurring again in the future.

What is the 5 Whys technique?

The 5 Whys is a common problem-solving technique. You simply ask "why" something is happening until you get to the source of the issue.

Though a useful tool in its own right, the 5 Whys method can be used during a Root Cause Analysis to help you quickly identify different causal factors of a problem.

What are the five steps of a root cause analysis?

RCA has five identifiable steps:

• Define the problem.
• Collect data.
• Identify causal factors.
• Identify root cause(s).
• Implement solutions.

Read on to learn how to carry out each step in your own root cause analysis.

How to Perform a Root Cause Analysis

Step one: define the problem.

Ask yourself the following:

• What do you see happening?
• What are the specific symptoms?

Step Two: Collect Data

• What proof do you have that the problem exists?
• How long has the problem existed?
• What is the impact of the problem?

You need to analyze a situation fully before you can move on to look at factors that contributed to the problem. To maximize the effectiveness of your RCA, get together everyone – experts and frontline staff – who understands the situation. People who are most familiar with the problem can help lead you to a better understanding of the issues.

A helpful tool at this stage is CATWOE . With this process, you look at the same situation from different perspectives: the Customers, the people (Actors) who implement the solutions, the Transformation process that's affected, the World view, the process Owner, and Environmental constraints.

Step Three: Identify Possible Causal Factors

• What sequence of events leads to the problem?
• What conditions allow the problem to occur?
• What other problems surround the occurrence of the central problem?

During this stage, identify as many causal factors as possible. Too often, people identify one or two factors and then stop, but that's not sufficient. With RCA, you don't want to simply treat the most obvious causes – you want to dig deeper.

5 Whys Root Cause Analysis

Use the 5 Whys tool to identify the root causes of a problem quickly. Just ask "Why?" until you reveal each causal factor.

If you need a more in-depth technique to identify possible factors, try these other tools that can help you dig further into each cause:

• Appreciation – Use the facts and ask "So what?" to determine all the possible consequences of a fact.
• Drill Down – Break down a problem into small, detailed parts to better understand the big picture.
• Cause and Effect Diagrams – Create a chart of all of the possible causal factors, to see where the trouble may have begun.

Step Four: Identify the Root Cause(s)

• Why does the causal factor exist?
• What is the real reason the problem occurred?

Use the same tools you used to identify the causal factors (in Step Three) to look at the roots of each factor. These tools are designed to encourage you to dig deeper at each level of cause and effect.

Step Five: Recommend and Implement Solutions

• What can you do to prevent the problem from happening again?
• How will the solution be implemented?
• Who will be responsible for it?
• What are the risks of implementing the solution?

Analyze your cause-and-effect process, and identify the changes needed for various systems. It's also important that you plan ahead to predict the effects of your solution. This way, you can spot potential failures before they happen.

One way of doing this is to use Failure Mode and Effects Analysis (FMEA). This tool builds on the idea of risk analysis to identify points where a solution could fail. FMEA is also a great system to implement across your organization; the more systems and processes that use FMEA at the start, the less likely you are to have problems that need RCA in the future.

Impact Analysis is another useful tool here. This helps you explore possible positive and negative consequences of a change on different parts of a system or organization.

Another great strategy to adopt is Kaizen , or continuous improvement. This is the idea that continual small changes create better systems overall. Kaizen also emphasizes that the people closest to a process should identify places for improvement. Again, with Kaizen alive and well in your company, the root causes of problems can be identified and resolved quickly and effectively.

Tips for Performing Effective Root Cause Analysis

Collaborate with other teams . Gain a diverse range of experiences and expertise by working with relevant people from other teams. They can likely offer different perspectives that will help to find the various causes of the problem.

Don’t play the blame game! Root cause analysis is a tool that helps you and your team overcome problems, but it shouldn’t be used to criticize or blame someone. Instead, try to create a blame-free culture, so that your co-workers feel confident in sharing ideas and insights. This will help you to diagnose the issue quickly and effectively.

Keep your questions open-ended. Leave any assumptions you have about the potential causes of the problem at the door. RCA is a chance to look at a problem with fresh eyes, so use open-ended questions as you work through the five steps. This will allow you to reveal things you didn’t already know, and find the most effective solution.

• Root Cause Analysis is a useful process for understanding and solving a problem.
• Figure out what negative events are occurring. Then, look at the complex systems around those problems, and identify key points of failure. Finally, determine solutions to address those key points, or root causes.
• You can use many tools to support your RCA process. Cause and Effect Diagrams and 5 Whys are integral to the process itself, while FMEA and Kaizen help minimize the need for RCA in the future.
• As an analytical tool, RCA is an essential way to perform a comprehensive, system-wide review of significant problems as well as the events and factors leading to them.

Download Worksheet

You've accessed 1 of your 2 free resources.

Get unlimited access

Discover more content

Using root cause analysis.

Find the Root of Your Problems

Getting to the Root of a Problem Quickly

Add comment

Comments (0)

Be the first to comment!

Sign-up to our newsletter

Subscribing to the Mind Tools newsletter will keep you up-to-date with our latest updates and newest resources.

Subscribe now

Business Skills

Personal Development

Leadership and Management

Member Extras

Most Popular

Latest Updates

Pain Points Podcast - Presentations Pt 2

NEW! Pain Points - How Do I Decide?

Mind Tools Store

About Mind Tools Content

Discover something new today

Finding the Best Mix in Training Methods

Using Mediation To Resolve Conflict

Resolving conflicts peacefully with mediation

How Emotionally Intelligent Are You?

Boosting Your People Skills

Self-Assessment

What's Your Leadership Style?

Learn About the Strengths and Weaknesses of the Way You Like to Lead

Recommended for you

How to make change work for you.

A Guide to Why We Fear Change and How to Cope With It

How to Guides

Business Operations and Process Management

Strategy Tools

Customer Service

Business Ethics and Values

Handling Information and Data

Project Management

Knowledge Management

Self-Development and Goal Setting

Time Management

Presentation Skills

Learning Skills

Career Skills

Communication Skills

Negotiation, Persuasion and Influence

Working With Others

Difficult Conversations

Creativity Tools

Self-Management

Work-Life Balance

Stress Management and Wellbeing

Coaching and Mentoring

Change Management

Team Management

Managing Conflict

Delegation and Empowerment

Performance Management

Leadership Skills

Developing Your Team

Talent Management

Problem Solving

Decision Making

Member Podcast

• Guide: Root Cause Analysis

Daniel Croft

Daniel Croft is an experienced continuous improvement manager with a Lean Six Sigma Black Belt and a Bachelor's degree in Business Management. With more than ten years of experience applying his skills across various industries, Daniel specializes in optimizing processes and improving efficiency. His approach combines practical experience with a deep understanding of business fundamentals to drive meaningful change.

• Last Updated: September 5, 2023
• Learn Lean Sigma

Root Cause Analysis (RCA) is a key tool in continuous improvement, acting as a systematic approach to identify and tackle the underlying issues behind problems. RCA aims not only to provide a temporary fix but to offer long-lasting solutions by addressing the root causes.

RCA, such as the Fishbone Diagram , the 5 Whys , and FMEA . Whether you’re looking to solve complex challenges or improve cost-efficiency, this guide will offer understanding of how to identify the root cause of problems with useful Lean Six Sigma tools.

Table of Contents

What is root cause analysis.

Root Cause Analysis, often referred to as RCA, is like being a detective for problems in your business or project. Imagine you have a leaking pipe in your house. You could keep mopping up the water every time it leaks, but that’s not really solving the issue. The right thing to do is find out why it’s leaking in the first place and fix that. RCA works the same way; it helps you find out the “why” behind a problem so you can fix it for good.

Structured Approach

When we say RCA is a “structured approach,” we mean it’s not just random guesswork. It’s a planned way to dig deep into a problem. You will follow certain steps and use specific tools to figure out what’s really going on. This makes sure you’re not just treating the “symptoms” of the problem, like mopping up water from a leak, but you’re finding out why the problem is happening in the first place.

Identify Underlying Reasons

The “underlying reasons” are the real culprits behind a problem. For example, if a machine in a factory keeps breaking down, simply repairing it each time isn’t enough. You need to find out why it’s breaking down. Is it old? Are people using it wrong? RCA helps you answer these kinds of questions.

Long-term Solutions

The coolest part about RCA is that it’s focused on long-term solutions. Once you know the root cause of a problem, you can create a fix that will (hopefully) make sure it never happens again. This is way better than just putting out fires all the time.

By understanding and using RCA, you’re not just stopping at “What is the problem?” You’re going the extra mile to ask, “Why did this problem happen?” and “How can we make sure it doesn’t happen again?” That’s a game-changer in making things better for the long run.

Importance of Root Cause Analysis

Understanding the “why” behind a problem isn’t just something that’s nice to do; it’s crucial for several reasons.

Problem Solving

Imagine you have a puzzle, but all the pieces are jumbled up. Trying to see the whole picture from this mess would be overwhelming, right? RCA is like sorting these puzzle pieces into groups; maybe by color or edge pieces versus middle pieces. When you break down a big, complex problem into smaller parts, it becomes much easier to solve. RCA helps you dissect a problem into its basic elements so you can tackle each one individually. This makes it easier to find out what’s really going wrong and fix it.

Cost-Efficiency

You know the saying, “Time is money”? Well, constantly fixing the same problem over and over again is like throwing both time and money down the drain. If you use RCA to get to the bottom of an issue and solve it at its root, that issue is less likely to come back. This means you spend less time, effort, and money on it in the future. For a business, this is a big deal because it means you can focus on growing and improving, rather than fixing the same old problems. This is where most businesses fail to progress as they spend the day to day activities fire fighting repreated problems.

Quality Improvement

Let’s say you run a bakery, and you notice that your chocolate chip cookies are coming out burnt too often. You could just toss the burnt cookies and make a new batch, but that doesn’t stop the next batch from burning too. If you use RCA to find out why they’re burning—maybe the oven temperature is wrong or the baking time is too long—you can fix that issue and make perfect cookies every time. This makes your customers happy and keeps them coming back. In the same way, RCA helps you improve the quality of your products or services by fixing the real issues, not just the symptoms. This leads to happier customers and better reviews, which are good for any business.

Types of Root Cause Analysis Methods

When it comes to finding the real reason behind a problem, one size doesn’t fit all. Different situations may require different approaches. That’s why there are several methods for conducting RCA. Let’s explore three of the most commonly used methods.

Fishbone Diagram (Ishikawa)

Imagine a fish. The head represents the problem you’re facing, and the bones branching off from the fish’s spine are the possible causes of the problem. This is what a Fishbone Diagram looks like. Also known as an Ishikawa Diagram or Cause and Effect Diagram, this method helps you visually break down a problem into different categories or “themes.”

For example, if you’re running a restaurant and customers are complaining about long wait times, you could use a Fishbone Diagram to categorize potential causes into themes like ‘Staffing,’ ‘Kitchen Efficiency,’ ‘Order Process,’ etc. Within each theme, you list out possible root causes. This helps you see the whole picture and makes it easier to identify where the real issue might be coming from.

You can learn more about the fishbone diagram process with our guide

Remember being a curious kid and asking “Why?” about everything? The 5 Whys method is pretty much the same. Start with the problem at hand and ask “Why did this happen?” Once you have an answer, ask “Why?” again, digging deeper. Keep asking “Why?” until you’ve asked it five times or until you reach a point where the root cause becomes clear.

For example, if a machine in a factory stops working, you could ask:

• Why did the machine stop? (Answer: The motor burned out.)
• Why did the motor burn out? (Answer: The motor was overloaded.)
• Why was the motor overloaded? (Answer: The machine was running at high capacity for too long.)
• Why was the machine running at high capacity for so long? (Answer: There was a backlog of orders.)
• Why was there a backlog of orders? (Root Cause: Poor planning and scheduling.)
• This helps you trace back the chain of events to find the root cause of the problem.

You can learn more about the 5 Whys process with our guide.

FMEA (Failure Modes and Effects Analysis)

FMEA is like looking into a crystal ball to see what could go wrong in the future. It’s a way to evaluate different ways a process or product could fail and to understand the impact of those failures. You list out all possible failure modes, how likely they are to happen, how bad the impact would be, and how well you could detect them before they cause problems. This helps you prioritize which potential issues need immediate attention.

Below is an example from a manufacturing business. The higher the RPN (risk priority number) the more important it is to address the issue.

You can learn more about the FMEA with our guide

Selecting an RCA method

If you are new to root cause analysis it can be difficult knowing which approach to use to solve your problem. This can be made simpler by considering the below

Is the problem simple and straightforward?

Use The 5 Whys Method

Is the problem complex with multiple factors?

Use Fishbone Diagram (Ishikawa)

Is a quantitative risk assessment needed?

Use FMEA (Failure Modes and Effects Analysis)

Use other specialized RCA techniques or hybrid methods

The Five-Step RCA Process

RCA isn’t something you can do haphazardly; it requires a structured approach to be effective. That’s where the Five-Step RCA Process comes in handy. It provides a roadmap to tackle your problem methodically. Let’s start by discussing the first step in detail.

Step 1: Define the Problem

Before you can find a solution to any problem, you need to know exactly what that problem is. You’d be surprised how often people jump to fixing things without clearly understanding what’s wrong in the first place. Defining the problem is like setting the GPS before going on a trip; it sets the direction for everything that follows. Here’s how to go about it:

Be Specific

Let’s say you’re running a coffee shop, and you notice that customers aren’t coming back. Simply saying, “Business is slow,” is too vague. A more specific problem statement would be, “Customer return rate has dropped by 20% in the last two months.”

Numbers don’t lie. Whenever possible, use data to define your problem. In the coffee shop example, you could look at sales records, customer surveys, or loyalty program participation to pinpoint the decline.

Consider the 5 Ws

• Who:  Who is affected by this problem? Is it just one department, the whole company, or maybe your customers?
• What:  What exactly is the issue? Try to describe it in one sentence.
• Where:  Where is this problem occurring? Is it in a specific location or across various places?
• When:  When did you first notice this problem? Is it a constant issue or does it happen only at certain times?
• Why:  At this stage, you may not know the root cause, but you might have some initial thoughts on why the problem might be occurring.

Write it Down

Once you’ve gathered all this information, write down your problem statement. This serves as a reference point for everyone involved in the RCA process, making sure everyone is on the same page.

After gathering all the relevant information, the problem statement for RCA could be:

“The rejection rate for Widget A produced on Line 3 has increased by 15% in Q2 2023 compared to Q1 2023, predominantly due to ‘Cracked Surface’ defects. This issue first became apparent at the beginning of Q2 and has been consistent since. Initial observations suggest it may be due to material quality or machine calibration issues.”

Step 2: Gather Data

Once you’ve clearly defined the problem, the next step is like being a detective gathering clues. You’ll need to collect all the relevant information that will help you get to the bottom of the issue. This stage is crucial because the quality of your Root Cause Analysis depends on the quality of your data. Here’s how to go about it:

Identify Data Sources

First, figure out where you can get the information you need. This could be anything from company records and employee interviews to customer surveys and machine logs. For example, if your problem is a decrease in product quality, you might look at manufacturing data, quality control reports, and customer feedback.

Types of Data to Collect

• Quantitative Data : These are numerical data that can be measured. Examples include sales figures, production rates, and customer satisfaction scores.
• Qualitative Data : These are descriptive data that can be observed but not measured. Examples include employee morale, customer comments, and the observable state of machinery or processes.

Timing Matters

When did the problem start? Was it gradual or sudden? Understanding the timeline can offer important insights into potential causes. Collect historical data if possible, as this will help you see trends and patterns.

Use Tools to Collect Data

Depending on your needs, various tools can help in data collection. Spreadsheets can be useful for tracking numbers and metrics. Surveys and questionnaires can capture customer or employee feedback. Advanced organizations may use specialized software for data collection and analysis.

Document Everything

Make sure to keep a record of all the data you collect. Organize the data in a way that’s easy to understand and analyze. Charts, graphs, or tables can be helpful here.

Verify Your Data

Before you move on to analyzing the data, make sure it’s accurate and reliable. Double-check your numbers, verify survey results, and confirm any observations. The last thing you want is to make important decisions based on faulty information.

Gathering data might seem like a time-consuming step, but it’s essential for a successful Root Cause Analysis. The more thorough you are at this stage, the easier it will be to identify the actual root cause of the problem later on.

Example Collected Data

Here’s a snapshot of what some of the collected data could look like:

Machine Logs (June 2023)

Quality control reports (june 2023), employee interviews.

• Operators have noticed the machine making unusual noises.
• Quality control staff report an increase in defects that look like cracks on the surface.

Step 3: Identify Possible Causes

After you’ve defined your problem and collected all the relevant data, it’s time to roll up your sleeves and dig into the “why” behind the issue. This step is like brainstorming, but more structured. You’re trying to come up with a list of all the things that could possibly be causing the problem you’ve identified. Here’s how to do it:

Choose a Method

As mentioned earlier, there are various methods you can use to identify possible causes. Two of the most common are the Fishbone Diagram and the 5 Whys. The choice depends on the nature of your problem.

• Fishbone Diagram: This is good for complex problems where multiple factors could be at play. The diagram allows you to visually organize potential causes into different categories, making it easier to focus your investigation.
• The 5 Whys: This method is more straightforward and works well for simpler problems. By repeatedly asking “Why?” you dig deeper into the issue until you identify possible root causes.

Involve the Right People

Don’t try to do this all on your own. Involve team members who are familiar with the problem area. They can offer valuable insights you might not have considered. If you’re dealing with a technical issue, for instance, having an engineer in the room can be incredibly helpful.

Generate a List of Possible Causes

Using your chosen method, start listing down all the potential causes. Be as comprehensive as possible. If you’re using a Fishbone Diagram, for instance, you’d list potential causes under each category or “bone” of the fish. For the 5 Whys, you’d document the chain of reasoning that leads you to potential root causes.

Use Your Data

Remember the data you collected in Step 2? Now’s the time to use it. Align your list of possible causes with the data to see which ones are most likely. For example, if one of your potential causes is “Poor Training,” but your data shows that all employees have completed mandatory training, then you might want to reconsider that cause.

Prioritize Causes

Not all causes are created equal. Some are more likely than others to be the root cause of your problem. Use your team’s expertise and the data you’ve collected to prioritize which causes to investigate further.

By the end of this step, you should have a well-organized list of possible causes for your problem, backed by data and expert input. This sets the stage for the next steps, where you’ll zero in on the actual root cause and figure out how to fix it.

Example of Identifying Possible causes

Following on with the same example, as this is a more complex issue with multiple factors, it makes sense to conduct the root cause analysis using the Fishbone method. Therefore, we need to ensure to include the right people—a cross-functional team. In this case, that would comprise production engineers who understand the machinery, quality control experts who have the data on defects, and machine operators who can provide firsthand experience and observations.

The next step is to collectively brainstorm and categorize potential causes for the increased rejection rate in Widget A. Utilizing the Fishbone Diagram, the team breaks down the problem into six major categories: Machine, Method, Material, Manpower, Environment, and Measurement.

Identifying the possible causes in our example

Following on with the same example, as this is a more complex issue with multiple factors, it makes sense to conduct the root cause analysis using the Fishbone method. Therefore, we need to ensure to include the right people—a cross-functional team. In this case, that would comprise production engineers who understand the machinery, quality control experts who have the data on defects, and machine operators who can provide firsthand experience and observations. The next step is to collectively brainstorm and categorize potential causes for the increased rejection rate in Widget A.  Utilizing the Fishbone Diagram, the team breaks down the problem into six major categories: Machine, Method, Material, Manpower, Environment, and Measurement.

Step 4: Determine the Root Cause

After identifying a list of possible causes, it’s time to put on your detective hat again and figure out which one is the real culprit—the root cause of your problem. 

This is a critical step, as identifying the wrong cause can lead you down a path of ineffective solutions. Here’s how to go about it:

Review Your List of Possible Causes

Start by revisiting the list you made in the previous step. This will serve as your “suspect list” in identifying the root cause. At this point, you’ve already done some initial prioritization, so you have an idea of which causes are most likely.

Analyze the Data

Remember the data you collected in Step 2? Now is the time to dive deep into it. Compare each possible cause against the data to see if it holds up. Look for patterns, correlations, or anomalies that might point to one cause over the others.

For example, if you’re dealing with a decrease in product quality and one of your possible causes is “Faulty Raw Materials,” you could look at inspection reports, batch numbers, and supplier records to see if there’s a correlation.

Conduct Tests or Experiments

Sometimes, analyzing existing data isn’t enough. You might need to conduct additional tests or experiments to validate or rule out possible causes. For instance, if you suspect a machine is malfunctioning and causing a problem, you might run it under controlled conditions to see if the issue repeats.

Use Logical Reasoning

Sometimes the root cause isn’t obvious, even with data and testing. In such cases, logical reasoning can help. You might use deductive reasoning to rule out unlikely causes or inductive reasoning to generalize from specific observations.

Involve Experts

If you’re stuck or the root cause isn’t clear, don’t hesitate to consult experts. These could be internal team members with specific expertise or external consultants who specialize in the problem area you’re investigating.

Confirm the Root Cause

Before you move on to finding a solution, make sure you’ve found the real root cause and not just a symptom of a deeper issue. Validate your findings by asking:

• Does this cause explain most or all of the problem?
• If we fix this, is it likely that the problem will be solved?
• Do most team members agree that this is the root cause?

Once you’ve determined the root cause, document it clearly. You’ll use this information in the next step to develop and implement a solution that addresses the issue at its core, ensuring it’s less likely to recur in the future.

Determining the Root Cause of our Example

Continuing with our example, the cross-functional team now shifts its focus to determining the root cause of the increased rejection rate for Widget A. Armed with their prioritized list of possible causes and the data gathered, they delve into the next step of the RCA process.

The team begins by revisiting the “suspect list” generated using the Fishbone Diagram. Machine-related factors, particularly temperature fluctuations, pressure inconsistencies, and cycle time variability, are at the top of this list, followed by material quality concerns. Analyze the Data Digging deeper into the data collected, the team finds that the temperature, pressure, and cycle time increases directly correlate with the spike in the ‘Cracked Surface’ defect type. They also note that the unusual noises observed by machine operators started to occur around the same time the defects increased. Conduct Tests or Experiments To validate these observations, the team decides to run the molding machine under controlled conditions, varying one parameter at a time while keeping the others constant. After a series of tests, they discover that an increase in temperature directly leads to the ‘Cracked Surface’ defects in the widgets. Use Logical Reasoning Using deductive reasoning, the team rules out other possible causes. For instance, since all operators have completed mandatory training and the material batches show no signs of contamination, these are less likely to be the root causes. Confirm the Root Cause After careful consideration and validation, the team reaches a consensus that the root cause of the problem is “Temperature Fluctuations in the Molding Machine.” This conclusion satisfies the criteria for root cause identification: It explains most, if not all, of the ‘Cracked Surface’ defects. Fixing this issue is likely to resolve the problem. Most team members agree that this is the root cause. The team documents this root cause clearly and prepares for the next step in the RCA process: developing and implementing a solution that will fix this issue at its core, thereby preventing its recurrence in the future.

Step 5: Implement and Monitor Solutions

Congratulations, you’ve identified the root cause! But your journey doesn’t end here. The whole point of Root Cause Analysis (RCA) is to not just find the root cause but to fix it so the problem doesn’t happen again. This is where Step 5 comes in, where you implement solutions and make sure they actually work. Here’s how to go about it:

Develop a Solution Plan

The first thing you need to do is come up with a plan for how you’re going to fix the root cause you’ve identified. This should include:

• What  needs to be done: The specific actions that will address the root cause.
• Who  will do it: The people responsible for each action.
• When  it will be done: A timeline for implementation.
• How  it will be done: The resources and methods needed to implement the solution.

Gain Approval and Support

Before you start making changes, make sure you have the necessary approvals. This might mean getting a budget approved or getting buy-in from key stakeholders. The more support you have, the smoother the implementation process will be.

Implement the Solution

Now it’s time to roll up your sleeves and get to work. Follow the plan you’ve developed, and start implementing the solution. This could involve anything from retraining staff and revising procedures to repairing equipment or introducing new technology.

Monitor Effectiveness

You can’t just implement a solution and walk away. You need to monitor how well it’s working. This means going back to the data you collected in Step 2 and continuing to track those metrics. Are they showing improvement? If not, you may need to revisit your solution or even go back to earlier steps in the RCA process.

Make Adjustments as Needed

Sometimes a solution that looks great on paper doesn’t work out as well in the real world. If you find that your solution isn’t as effective as you’d hoped, be prepared to make adjustments. This could mean tweaking your current solution or going back to the drawing board to identify a different root cause.

Document the Process

Don’t forget to document everything you’ve done, from the solutions you implemented to the results you achieved. This documentation can be invaluable for future problem-solving efforts and for creating a knowledge base that can help prevent similar problems in the future.

Implementing and monitoring solutions of our example

After identifying “Temperature Fluctuations in the Molding Machine” as the root cause, the team crafts a detailed solution plan: What Needs to Be Done : Overhaul the machine’s cooling system and recalibrate temperature settings. Who Will Do It : A dedicated team of production engineers and machine operators. When It Will Be Done : To be completed within a two-week timeframe. How It Will Be Done : Allocate necessary resources like new cooling components and software for recalibration.

Gain Approval and Support Before proceeding, the team prepares a budget proposal and secures approval from management. They also consult with the quality control team and machine operators to gain their buy-in, ensuring a smoother implementation process. Implement the Solution The team then sets out to execute the plan. The cooling system is overhauled, and the machine is recalibrated. A pilot run is conducted to ensure that the new settings are effective in maintaining consistent temperature levels. Monitor Effectiveness After implementing the changes, the team goes back to the data. They continue to monitor the same metrics—temperature, pressure, cycle time, and defect count. Initial results show a significant reduction in the ‘Cracked Surface’ defect type. The temperature fluctuations have notably decreased. Make Adjustments as Needed While the initial results are promising, the team remains vigilant. They agree to meet bi-weekly to review the data and make any necessary adjustments to the solution. So far, no further modifications are required. Document the Process The entire RCA process, from problem identification to solution implementation and monitoring, is meticulously documented. This documentation will serve as a valuable resource for future troubleshooting and continuous improvement initiatives. By diligently following this five-step RCA process, the team has not only identified the root cause of the problem but has also successfully implemented a solution to prevent its recurrence.

RCA is more than just a problem-solving method; it’s a strategic approach that dives deep into issues to eliminate them at their source. By following the Five-Step RCA Process, organizations can not only identify the real culprits behind their problems but also develop and implement long-lasting solutions. This guide walked you through each step in detail, from defining the problem to monitoring the effectiveness of your solutions. Remember, the quality of your RCA is as good as the effort and attention to detail you put into it. Whether you’re looking to improve product quality, enhance customer satisfaction, or increase cost-efficiency, a well-executed RCA can be a game-changing tool in your continuous improvement arsenal. It’s not just about fixing what’s broken; it’s about building something better for the long term.

• Williams, P.M., 2001, April. Techniques for root cause analysis . In  Baylor University Medical Center Proceedings  (Vol. 14, No. 2, pp. 154-157). Taylor & Francis.
• Gangidi, P., 2018. A systematic approach to root cause analysis using 3× 5 why’s technique.   International Journal of Lean Six Sigma ,  10 (1), pp.295-310.
• Wong, K.C., Woo, K.Z. and Woo, K.H., 2016. Ishikawa diagram.   Quality Improvement in Behavioral Health , pp.119-132.

Q: Why is Root Cause Analysis important?

A: Identifying and resolving the root cause of an issue is crucial for achieving sustainable improvements. Focusing only on symptoms can lead to temporary fixes that may mask the underlying problem. RCA helps you understand the systemic issues contributing to a problem, allowing you to put in place measures that result in lasting change.

Q: What are the common methods used for Root Cause Analysis?

A: Several methods are commonly used for Root Cause Analysis, including:

• 5 Whys : A simple technique that involves asking “why” multiple times until the root cause is identified.
• Fishbone Diagram (Ishikawa Diagram) : A visual tool used to categorize potential causes of a problem.
• Fault Tree Analysis : A graphical representation of various probable causes of an issue, arranged in a hierarchical manner.
• Pareto Analysis : Identifying the most significant factors contributing to a problem based on the Pareto principle.
• FMEA (Failure Modes and Effects Analysis) : A structured approach to identifying potential failure modes and their consequences.

Q: How do I start a Root Cause Analysis?

A: Initiating a Root Cause Analysis typically involves the following steps:

• Define the Problem : Clearly articulate what the issue is.
• Collect Data : Gather relevant information and evidence.
• Identify Possible Causes : List potential causes that could be contributing to the problem.
• Analyze : Use RCA methods like the 5 Whys or Fishbone Diagram to dig deeper.
• Identify Root Cause(s) : Through analysis, pinpoint the underlying cause(s).
• Develop and Implement Solutions : Create action plans to address the root cause(s).
• Review : Evaluate the effectiveness of the solutions and make adjustments as needed.

Q: Can Root Cause Analysis be applied to non-manufacturing sectors?

A: Absolutely, Root Cause Analysis is a versatile tool that can be applied in various sectors, including healthcare, IT, logistics, and even the public sector. The principles remain the same: identify the root cause to implement effective, long-term solutions.

Q: What are some common pitfalls to avoid in Root Cause Analysis?

A: Some common pitfalls to be aware of include:

• Rushing the Process : Skipping steps or rushing through them can lead to incorrect conclusions.
• Blaming Individuals : RCA should focus on systemic issues rather than blaming individual employees.
• Ignoring Data : Failing to consult data can result in assumptions that may not be accurate.
• Lack of Follow-Up : Without proper evaluation and adjustment, even good solutions may fail over time.

Daniel Croft is a seasoned continuous improvement manager with a Black Belt in Lean Six Sigma. With over 10 years of real-world application experience across diverse sectors, Daniel has a passion for optimizing processes and fostering a culture of efficiency. He's not just a practitioner but also an avid learner, constantly seeking to expand his knowledge. Outside of his professional life, Daniel has a keen Investing, statistics and knowledge-sharing, which led him to create the website learnleansigma.com, a platform dedicated to Lean Six Sigma and process improvement insights.

Free Lean Six Sigma Templates

Improve your Lean Six Sigma projects with our free templates. They're designed to make implementation and management easier, helping you achieve better results.

Other Guides

Was this helpful.

tableau.com is not available in your region.