Root Cause Analysis: A Framework For Tool Selection
See discussions, stats, and author profiles for this publication at: oot Cause Analysis: A Framework for Tool SelectionArticle in Quality Management Journal · January 2006DOI: 10.1080/10686967.2005.11919269 · Source: OAICITATIONSREADS656,9451 author:Mark DoggettWestern Kentucky University27 PUBLICATIONS 155 CITATIONSSEE PROFILESome of the authors of this publication are also working on these related projects:Four Pillars of Manufacturing View projectMedical Technology View projectAll content following this page was uploaded by Mark Doggett on 05 May 2014.The user has requested enhancement of the downloaded file.
Doggett9/22/051:53 PMPage 34Root Cause Analysis:A Framework for Tool SelectionA. MARK DOGGETT, HUMBOLDT STATE UNIVERSITY 2005, ASQThis article provides a framework for analyzing theperformance of three popular root cause analysistools: the cause-and-effect diagram, the interrelationship diagram, and the current reality tree. The literature confirmed that these tools have the capacity tofind root causes with varying degrees of accuracy andquality. The literature, however, lacks a means forselecting the appropriate root cause analysis toolbased upon objective performance criteria. Some ofthe important performance characteristics of rootcause analysis tools include the ability to find rootcauses, causal interdependencies, factor relationships,and cause categories. Root cause analysis tools mustalso promote focus, stimulate discussion, be readablewhen complete, and have mechanisms for evaluatingthe integrity of group findings. This analysis foundthat each tool has advantages and disadvantages,with varying levels of causal yield and selected causalfactor integrity. This framework provides decisionmakers with the knowledge of root cause analysis performance characteristics so they can better understand the underlying assumptions of a recommendedsolution.Key words: collaboration, decision making, problemsolving, quality methods34 QMJ VOL. 12, NO. 4/ 2005, ASQINTRODUCTIONBeneath every problem is a cause for that problem. Inorder to solve a problem one must identify the cause ofthe problem and take steps to eliminate the cause. Ifthe root cause of a problem is not identified, then oneis merely addressing the symptoms and the problemwill continue to exist. For this reason, identifying andeliminating root causes of problems is of utmostimportance (Andersen and Fagerhaug 2000; Dew1991; Sproull 2001).Tools that help groups and individuals identifypotential root causes of problems are known as rootcause analysis tools. The cause-and-effect diagram(CED), the interrelationship diagram (ID), and thecurrent reality tree (CRT) are three root cause analysistools frequently identified in the literature as viablemechanisms for solving problems and making decisions. The literature provides detailed descriptions, recommendations, and instructions for their constructionand use. Furthermore, the literature is quite detailed inproviding colorful and illustrative examples for each ofthe tools so they can be quickly learned and applied. Insummary, the literature confirms that these three toolsare capable of finding potential root causes.Conversely, although there is much informationabout the individual attributes of these root causeanalysis tools, there is little information regarding theperformance of these tools relative to each other. Thus,problem solvers and decision makers are likely to selecta tool based on convenience rather than on its actualperformance characteristics. Thus, the purpose of thisarticle is to explore and synthesize the current literaturefor a head-to-head performance analysis of the CED,ID, and CRT. The intent is to provide problem solverswith a mechanism that can be used to select the appropriate root cause analysis tool for the specific problem.
9/22/051:53 PMPage 35Root Cause Analysis: A Framework for Tool SelectionThe first section of this article presents an overviewand a background of the CED, ID, and CRT. For eachtool, there is a brief history, a presentation of variousconstruction techniques, and a summary of the tool’sadvantages and disadvantages. The second sectionreviews published articles that compare these tools.The third section analyzes the literature and provides aconceptual framework with a head-to-head comparison for problem-solving practitioners and decisionmakers. The final section concludes with implicationsand recommendations for management.Figure 1 Steps in building a cause-and-effectdiagram.Characteristicor effectA. Write the characteristic to be improved.CauseCharacteristicor effectCauseAN OVERVIEW OF ROOT CAUSEANALYSIS TOOLSCause-and-Effect Diagram (CED)The CED was designed to sort the potential causes of aproblem while organizing the causal relationships.Professor Kaoru Ishikawa developed this tool in 1943 toexplain to a group of engineers at Kawasaki Steel Workshow various manufacturing factors could be sorted andinterrelated. The original intent of the CED was to solvequality-related problems in products caused by statistical variation, but Ishikawa quickly realized it could beused for solving other types of problems as well. The toollater came into widespread use for quality controlthroughout Japanese industry (Ishikawa 1982). As itsuse spread to other countries, it became known as theIshikawa diagram, or more informally, the “fishbone”because of its appearance once complete (Arcaro 1997;Moran, Talbot, and Benson 1990; Sproull 2001).Brassard and Ritter (1994, 23) assert that the CED“enables a team to focus on the content of the problem,not on the history of the problem or differing personalinterests of team members.” Andersen and Fagerhaug(2000, 14) write that the CED is “an easily applied toolused to analyze possible causes to a problem,” whileWilson, Dell, and Anderson (1993, 195) call it a “highlyvisual technique which aids the process of defining theelements of a problem or event and determining how itprobably occurred.”CEDs are drawn primarily to illustrate the possiblecauses of a particular problem by sorting and relatingCauseCauseB. Add the main factor branches.CauseCauseCharacteristicor effectMinorcausesCauseCauseC. Add the detailed causal factors as twigs.them using a classification schema. The constructionand study of the diagram is intended to stimulateknowledge acquisition and promote discussion, but itcan also educate others about a process or problem.The CED encourages data collection by highlightingareas of expertise or by showing where knowledge islacking. Fredendall et al. (2002, 51) calls the CEDprocess “an exercise in structured brainstorming.” Thelogic of the CED is that one cannot act until the relationship between the cause and effect of a problem isknown. Consequently, the CED attempts to show relatedcauses so action can be taken.Ishikawa (1982) outlines the following steps forconstructing a CED. Step 1: Decide on the problem to improve or control. Step 2: Write the problem on the right side and drawan arrow from the left to the right side, as shown inFigure 1(A). Step 3: Write the main factors that may be causingthe problem by drawing major branch arrows to themain arrow. Primary causal factors of the problemwww.asq.org 35 2005, ASQDoggett
Doggett9/22/051:53 PMPage 36Root Cause Analysis: A Framework for Tool Selectioncan be grouped into items with each forming amajor branch, as shown in Figure 1(B). Step 4: For each major branch, detailed causal factors are written as twigs on each major branch of thediagram. On the twigs, still more detailed causalfactors are written to make smaller twigs, as shownin Figure 1(C). Step 5: Ensure all the items that may be causing theproblem are included in the diagram.Major cause category branches can be initially identified using the four Ms: material, methods, machines,and manpower, or more correctly, the four Ps: parts(raw materials), procedures, plant (equipment), andpeople. Categories can also be tailored depending on theproblem (Moran, Talbot, and Benson 1990; Scholtes1988; Sproull 2001). Sometimes measurement or environment is the fifth category. Arcaro (1997) suggestsusing no more than eight major categories.There are various types of CEDs. The dispersionCED develops groups of probable causes as the mainbranches. Participants are asked to identify why dispersions (or variations) in the problem occur. The reasonsfor the dispersions are then drawn as twigs on thebranches (Ishikawa 1982; Sproull 2001). The advantage of this method is that breaking down causes intomore detail helps organize and relate the factors. Thedisadvantage is that the final form is highly dependenton the person or group constructing it, and smallcauses of variation may be overlooked (Andersen andFagerhaug 2000).The process classification CED lists all theprocess steps on the main arrow. Factors that mayaffect that particular process step are added asbranches or drawn as individual CEDs. This type ofdiagram is like an assembly line with each processstep drawn on the main arrow with detailed branchesadded. The advantage of this method is that it is easyto understand because it follows the sequence of theprocess. The disadvantage is that similar causes mayappear repeatedly, while causes due to interdependentfactors are difficult to illustrate (Andersen andFagerhaug 2000; Ishikawa 1982).The cause enumeration CED simply lists all proposed possible causes of the problem and organizes36 QMJ VOL. 12, NO. 4/ 2005, ASQthem according to their relationship to the problemand each other. The advantage of this method is thatall proposed causes are listed and solutions are encouraged without confining thinking, with the resultingdiagram being quite complete. The disadvantage isthat it may be difficult to establish a direct relationshipbetween any given cause and the final effect (Andersenand Fagerhaug 2000; Ishikawa 1982).A thoroughly completed CED looks rather complicated with many branches, twigs, and smaller twigs.Conversely, too simple a diagram generally indicatesthat knowledge of the process or problem is shallowand requires further investigation (Ishikawa 1982).Also, the CED may highlight knowledge gaps throughthe lack of probable causes on a particular categorybranch.A drawback to using the CED is that there is nospecific mechanism for identifying a particular rootcause once complete. One technique is to look on thediagram for causes that appear repeatedly within oracross major categories. Selecting a single root cause,however, may prove difficult unless the characteristicsof the problem are well known or documented. As alast resort, groups can select a root cause throughunstructured group consensus or a structured technique such as multivoting or nominal group technique(Brassard and Ritter 1994).Overall, the advantage of the CED is that it is easy touse, it promotes structure while allowing some creativity, and it works best when the problem is well definedand data driven (Scholtes 1988). The disadvantage ofthe CED is that it is heavily dependent on detailedknowledge of the problem and it only identifies possiblecauses (Sproull 2001). Bhote (1988) criticizes theCED as ineffective, saying it is a hit-and-miss processthat may take months or years to find root causesbecause it tends to emphasize opinions and overlookcausal interactions.Interrelationship Diagram (ID)The ID, originally known as the relations diagram,was developed by the Society of Quality ControlTechnique Development in association with the Unionof Japanese Scientists and Engineers (JUSE) in 1976.
Doggett9/22/051:53 PMPage 37Root Cause Analysis: A Framework for Tool SelectionThe relations diagram was part of a toolset known asthe seven new quality control (7 new QC) tools. It wasdesigned to clarify the intertwined causal relationshipsof a complex problem in order to identify an appropriate solution. The relations diagram evolved into aproblem-solving and decision-making method frommanagement indicator relational analysis, a methodfor economic planning and engineering. Originalrelations diagrams analyzed cause-and-effect relationships using complex calculations for each factor(Mizuno 1988).In 1984, GOAL/QPC, an educational consultingcompany, formed the Statistical Resource Committee toresearch, review, and redesign its training materials forstatistical process control (SPC). The result of the committee’s work is a practitioner’s handbook, TheMemory Jogger, which describes the various SPC toolsfor practitioners and front-line managers. These toolsare known as the seven quality control (7QC) tools andinclude the CED. During the development of the handbook, the authors at GOAL/QPC became aware of theseven new QC tools as proposed and published byMizuno. After translating a working version ofMizuno’s book, which was not published in Englishuntil 1988, the Statistical Resource Committee refinedMizuno’s tools into another toolset called the sevenmanagement and planning (7MP) tools. The committee developed the term 7MP to indicate that this was nota “new” toolset to replace the “old” QC set of tools, butrather supplement them and more accurately describetheir intended application (Brassard 1996). As an outcome, GOAL/QPC published the Memory Jogger Plus in 1989, which features the 7MP tools and a variationof Mizuno’s relations diagram called the interrelationship digraph. A digraph is a combination of the wordsdiagram and graph (Moran, Talbot, and Benson1990). Thus, the terms interrelationship digraph,interrelationship diagram, and relations diagram aregenerally used interchangeably.The interrelationship diagram “ takes complex,multivariable problems and explores and displays all ofthe interrelated factors involved. It graphically showsthe logical (and often causal) relationships betweenfactors” (Brassard 1996, 5). Andersen and Fagerhaug(2000, 14, 19) state that the ID is “a tool used to identifylogical relationships between different ideas or issues ina complex or confusing situation” and “borders onbeing a tool for cause-and-effect analysis.” Brassardand Ritter (1994) state that the ID allows groups toidentify, analyze, and classify the cause-and-effect relationships that exist among all critical issues so that keyfactors can be part of an effective solution. The intentof the ID is to encourage practitioners to think in multiple directions rather than linearly so that criticalissues can emerge naturally rather than follow personal agendas. The ID assists in systematically surfacingbasic assumptions and reasons for those assumptions.In summary, the ID helps identify root causes.The ID uses arrows to show cause-and-effect relationships among a number of potential problem factors. Short sentences or phrases expressing the factorare enclosed in rectangles or ovals. Whether phrases orsentences are used is a group decision, but authors recommend the use of at least a noun and a verb(Brassard 1996; Brassard and Ritter 1994). Arrowsdrawn between the factors represent a relationship. As arule, the arrow points from the cause to the effect orfrom the means to the objective. The arrow, however,may be reversed if it suits the purpose of the analysis(Mizuno 1988).The format of the ID is generally unrestricted withseveral variants. The centrally converging ID placesthe major problem in the center with closely relatedfactors arranged around it to indicate a close relationship. The directionally intense ID places the problemto one side of the diagram and arranges the factorsaccording to their cause-and-effect relationships onthe other side. The applications format ID can beunrestricted, centrally converging, or directionallyintense, but adds additional structure based on factorssuch as organizational configuration, processes, orsystems.The ID may use either quantitative or qualitativeformats. In the qualitative format, the factors are simply connected to each other and the root cause isidentified based on intuitive understanding. In thequantitative format, numeric identifiers are used todetermine the strength of relations between factorsand the root cause is identified based on the numericvalue (Andersen and Fagerhaug 2000).www.asq.org 37
9/22/051:53 PMPage 38Root Cause Analysis: A Framework for Tool SelectionFigure 2 Example of an interrelationship diagram.IN OUT61IN OUT01ScheduledappointmentsIN OUT22EmergencyappointmentsPay levelsIN OUT03IN OUT31Equipmentquality andavailabilityAdministrativeworkloadIN OUT13IN OUT41SupportfunctionsavailabilityChanges ityIN OUT15Mizuno (1988) recommends the following whencreating a relations diagram: Step 1: Collect information from a variety of sources. Step 2: Use concise phrases or sentences as opposedto isolated words. Step 3: Draw diagrams only after group consensus isreached. Step 4: Rewrite diagrams several times to identifyand separate critical items. Step 5: Do not be distracted by intermediate factorsthat do not directly influence the root causes.Mizuno recommends asking why questions to surface true cause-and-effect relationships and to slowthe process so participants can critically evaluate,revise, examine, or discard factors.Andersen and Fagerhaug (2000) write that thefirst step for using an ID is to determine and label the38 QMJ VOL. 12, NO. 4/ 2005, ASQfactors, then place them on an easel or whiteboard ina circular shape and assess the relationship of eachfactor on other factors using arrows. After all relationships have been assessed, count the number of arrowspointing into or out of each factor. A factor with more“out” arrows than “in” arrows is a cause, while a factor with more “in” arrows than “out” arrows is aneffect. The causal factors form the starting point foranalysis. Figure 2 shows an example of an unrestricted quantitative interrelationship diagram.A variant of the ID is the ID matrix, which placesall the factors on the first column and row of amatrix. This format creates a more orderly displayand prevents the tool from becoming too chaoticwhen there are many factors. The strength and direction of the relationships can be represented througharrows, numbers, or other symbols placed in the cellsof the matrix. Brassard (1996) and Brassard andRitter (1994) argue that users become careless with 2005, ASQDoggett
Doggett9/22/051:53 PMPage 39Root Cause Analysis: A Framework for Tool Selectionlarge, complicated diagrams, so the ID matrix is agood technique to force participants to pay attentionto each factor in a more systematic fashion.A particular concern of the ID is that it does nothave a mechanism for evaluating the integrity of theselected root cause. In using the quantitative or qualitative method, practitioners must be able to assessthe validity of their choices and the strength of thefactor relationships. Some users may simply countthe number of arrows and select a root cause withoutthoroughly analyzing or testing their assumptionsabout the problem.Overall, the ID’s strength is that it is a structuredapproach that provides for the analysis of complexrelationships using a nonlinear approach. The disadvantage is that it may rely too heavily on the subjectivejudgments about factor relationships and can becomequite complex or hard to read (Andersen andFagerhaug 2000).Current Reality Tree (CRT)Goldratt (1990, 3) promotes the idea that the factorsof problems are interdependent and result from a fewcore (root) causes. Goldratt asserts, “We grosslyunderestimate the power of our intuition.” Intuitively,most people know how to solve problems, but areunable to because they have no method of focusingtheir intuition. Without a means to focus, people willdo the opposite of what they really believe and will“ play a lot of games with numbers and words.”Goldratt expands on the idea of problem solvingthrough focused intuition in the book It’s Not Luck(Goldratt 1994), which introduces the CRT. The CRTis one of five thinking process (TP) tools, a toolsetthat Goldratt developed for implementing the theoryof constraints (TOC).The CRT addresses problems by relating multiplefactors rather than isolated events. Its purpose is to helppractitioners find the links between symptomaticfactors, called undesirable effects (UDEs), of the coreproblem. The CRT was designed to show the currentstate of reality as it exists in a system. It reflects themost probable chain of cause-and-effect factors thatcontribute to a specific set of circumstances and createsa basis for understanding complex systems (Dettmer1997). Schragenheim (1998, 19-20) writes, “Thecurrent reality tree depicts the current state of anorganization with the objective of identifying a rootcause .” Scheinkopf (1999, 144) states that the CRT“is used to pinpoint a core driver—a common causefor many effects.” The CRT assumes that all systemsare subject to interdependencies among the factorcomponents. Therefore, related causes must be identified and isolated before they can be addressed.Like the other tools, the CRT uses entities andarrows to describe a system. Entities are statementswithin some kind of geometric figure, usually a rectangle with smooth or sharp corners. An entity isexpressed as a complete statement that conveys anidea. An entity can be a cause, an effect, or both(Dettmer 1997). Arrows in the CRT signify a sufficiency relationship between the entities. Sufficiencyimplies that the cause is, in fact, enough to create theeffect. Entities that do not meet the sufficiency criteria are not connected. The relationship between twoentities is read as an “if-then” statement such as,“If [cause statement entity], then [effect statemententity]” (Dettmer 1997; Scheinkopf 1999).In addition, the CRT uses a unique symbol, the ovalor ellipse, to show relationships between interdependentcauses. The literature distinguishes between interrelationship and interdependency using sufficient causelogic such that effects due to interdependency areattributed to multiple and related causal factors.Because the CRT is based on sufficiency, there may becases where one cause is not sufficient by itself to createthe proposed effect. Thus, the ellipse shows that multiple causes are required for the produced effect. Thesecauses are contributive in nature such that they mustall be present for the effect to take place. If one of theinterdependent causes is removed, the effect will disappear. Relationships that contain an ellipse are readas, “If [first contributing cause entity] and [secondcontributing cause entity], then [effect entity].”Figure 3 shows an example of a CRT.The CRT also allows for looping conventions thateither positively or negatively amplify the effect. In thissituation, an arrow is drawn from the last entity backto one of the earlier causes. If the original core causewww.asq.org 39
9/22/051:53 PMPage 40Root Cause Analysis: A Framework for Tool SelectionFigure 3 Example of a current reality tree.Operators do not usestandard practicesOperators view standard practicesas a tool for inexperienced andincompetent operatorsCompetent and experiencedoperators do not needstandard practicesCompany does not enforcethe use of standard practicesOperators want to beviewed as experiencedand competentSome standard practicesare incorrectSome operations do nothave standard practicesStandard practices arenot updated regularlyThe company does not have adefined system for creating andupdating standard practicesStandardization of practicesis not a company valuecreates a negative reinforcing loop, but can bechanged to a positive, the entire system will be reinforced with a desirable effect (Dettmer 1997). Althoughconstructed from the top, starting with effects, thenworking down to causes, the CRT is read from bottomto top using “if-then” statements. The arrows leadfrom the cause upward (Gattiker and Boyd 1999).The procedure for constructing a CRT was firstdescribed by Goldratt (1994) via narrative format inthe book It’s Not Luck. Cox and Spencer (1998) lateroutline the paraphrased procedure:1. List between five and 10 problems or UDEs relatedto the situation.2. Test each UDE for clarity and search for a causalrelationship between any two UDEs.3. Determine which UDE is the cause and which is theeffect.4. Test the relationship using categories of legitimatereservation (CLRs). (These are rules for evaluatingassumptions and logic and are described later.)40 QMJ VOL. 12, NO. 4/ 2005, ASQ5. Continue the process of connecting the UDEs using“if-then” logic until all the UDEs are connected.6. Sometimes the cause by itself may not seem to beenough to create the effect. Additional dependentcauses can be shown using the “and” connector.7. Logical relationships can be strengthened usingwords like some, few, many, frequently, andsometimes.This process continues as entities are added downward and chained together. At some point no othercauses can be established or connected to the tree. Theconstruction is complete when all UDEs are connectedto very few root causes, which do not have precedingcausal entities (Cox et al. 1998; Dettmer 1997). Thefinal step in the construction of the CRT is to review allthe connections and test the logic of the diagram.Branches that do not connect to UDEs can be prunedor separated for later analysis.The assumptions and logic of the CRT are evaluatedusing rules called CLRs. These rules ensure rigor in 2005, ASQDoggett
Doggett9/22/051:53 PMPage 41Root Cause Analysis: A Framework for Tool Selectionthe CRT process and are the criteria for verifying, validating, and agreeing upon the connections betweenfactors. They are also used to facilitate discussion,communicate disagreement, reduce animosity, andfoster collaboration (Scheinkopf 1999). The CLRsconsist of six tests or proofs: clarity, entity existence,causality existence, cause insufficiency, additionalcause, and predicted effect (Dettmer 1997).Clarity, causality existence, and entity existence arethe first level of reservation and are used to clarifymeaning and question relationships or the existence ofentities. The second level of reservation includes causeinsufficiency, additional cause, and predicted effect.They are secondary because they are used when questions remain after addressing first-level reservations.Second-level reservations look for missing or additionalcauses and additional or invalid effects (Dettmer 1997;Scheinkopf 1999).Variations are the use of the CRT to identify business constraints as part of TOC or to persuade others totake a particular course of action (Cox et al. 1998;Goldratt 1990; Lepore and Cohen 1999; Smith 2000).When used as a persuasion tool, it is known as thecommunication CRT. When used to identify businessconstraints, it becomes one of the five TP tools used inthe TOC process (Scheinkopf 1999).A particular concern of the CRT is its complexity ofconstruction and rigorous logic system. Practitionersmay find the application of the CRT too difficult ortime consuming. Conversely, the strength of the CRT isthe rigor of the CLR mechanism that encouragesattention to detail, ongoing evaluation, and integrityof output.PREVIOUS COMPARISONS OFTHE TOOLSFredendall et al. (2002), in a comparison of the CEDwith the CRT, declare that they use much of the samecausal logic and can be used in tandem. For example,a group may use the CED to brainstorm possible causesand then use the CED output to develop a list of UDEsfor the CRT. There are, however, some critical differences between the two approaches.First, the physical layout of the tools is different.The CED is horizontal and reads from left to right,while the CRT is vertical and reads from bottom to top.Second, the CED does not easily show systematic causesof an effect, while the CRT shows “if-then” logic moreprecisely. Third, practitioners may find the strict application of the CRT logic intimidating and resent havingto phrase their suggestions or objections as CLRs.Consequently, most people view the CED as easierbecause it requires less training and is quicker to construct. Fourth, the CED does not quickly identify theroot cause of the problem, while the CRT is structuredso that it visually points to it, which then leads moreprecisely to finding a potential permanent solution(Fredendall et al. 2002).Pasquarella, Mitchell, and Suerken (1997) presenta detailed comparison of the tools in a three-part proceedings article, with each author writing a section.Suerken does not compare the tools, but recommendsusing the TP tools, including the CRT, in educationalsettings. Pasquarella’s section compares the TP tools to10 quality control tools (adding three more tools to the7QC tools), including the CED. Pasquarella also compares the TP tools to the 7MP tools, including the ID.In comparing both sets of tools to the TP tools,Pasquarella comes to three conclusions. First, organizational managers will choose simple methods whenconfronted with too many tools or if they perceive atool as too complex. Thus, most managers will choosethe CED because it fits their perception of a simpleanalysis tool. Second, simple methods are heavilyinfluenced by the emotions of the people using them.Conversely, complicated methods require a degree ofexpertise and facilitation. Therefore, managers willagain choose the CED despite its subjective naturebecause they are reluctant to assign groups complexmethods. Third, most tools do not address systemwideproblems unless they can be integrated and rigorouslyapplied. In other words, most tools cannot be used inisolation to solve larger systemic problems.Consequently, organization managers tend to usesimple tools that do not solve systematic problems.Pasquarella claims the TP tools superior for thefollowing reasons:www.asq.org 41
Doggett9/22/051:53 PMPage 42Root Cause Analysis: A Framework for Tool Selection1. They are logical, simple, and there are less of themto consider.2. The TP tools capitalize on intuition and emotionwithout skewing the process because th
and recommendations for management. AN OVERVIEW OF ROOT CAUSE ANALYSIS TOOLS Cause-and-Effect Diagram (CED) The CED was designed to sort the potential causes of a problem while organizing the causal relationships. Professor Kaoru Ishikawa developed this tool in 1943 t
USING SAP ROOT CAUSE ANALYSIS & SYSTEM MONITORING FOR SYBASE UNWIRED PLATFORM 6 2. ROOT CAUSE ANALYSIS FOR SUP IN SOLUTION MANAGER After SMD Managed System Setup and Configuration, the Root Cause Analysis features of SAP Solution Manager Diagnostics are available in the Root Cause Analysis work center of SAP Solution Manager. Find further information about End-to-End Root Cause Analysis on SAP .
ROOT CAUSE ANALYSIS AND ACTION PLAN FRAMEWORK TEMPLATE The Joint Commission Root Cause Analysis and Action Plan tool has 24 analysis questions. The following framework is intended to provide a template for answering the analysis questions and aid organizing the steps in a root cause analysis
WHAT IS ROOT CAUSE ANALYSIS? 2 Root cause analysis (RCA), is a structural step by step technique that focuses on finding the real cause of a problem and deals with it. Root Cause Analysis is a procedure for ascertaining and analyzing the cause of problems, to determine how these problems can be solved or be prevented from occurring. 8.6.2014
"Fishbone" Diagram: Measures Top Primary Root-Cause Primary Root-Cause Second level Root-Cause Third level Root-Cause Fourth level Root-Cause Measures Education & Training To Recognize Fatigue Failure Of IRS Fatigue Management Systems Political Will Regulation & Policy Under-Reporting Hours Of Service (HOS) Recording Device
ROOT CAUSE ANALYSIS GUIDANCE DOCUMENT. 1. SUMMARY. This document is a guide for root cause analysis specified by DOE Order 5000.3A, "Occurrence Reporting and Processing of Operations Information."Causal factors identify program control deficiencies and guide early corrective actions.As such, root cause analysis is central to DOE Order 5000.3A.
The Problem with Root Cause Analysis Method A Method B Method C Method G Method E Method H Method J Method F Method D Method I No‐one can agree on "what is a root cause." Everyone says they do "root cause analysis,"yet everyone is doing something different!
It can be used on its own or in conjunction with the fishbone diagram analysis in moving from the chosen root cause to the true root cause. Simply ask Why 5 times starting with the effect of the problem. 5 Whys focuses the investigation toward true root cause
2013-11-05 Root Cause Analysis Beginner LISA 2013 Stuart Kendrick 16 Why No Root Cause? Why do I claim there is no such thing as a Root Cause? Consider the server which goes down; your monitoring system pages you; you investigate. Turns out the power supply died -you replace the power supply, the server reboots, everyone is happy again.
