If your organization is experiencing repeated errors and corrective actions have not eliminated the occurrences you have not addressed the root cause.
As I left off in my post about checklist (5/8/2015 below) as quality tools, root cause analysis may be required to determine the correct line item to place on a check list.
One method used for arriving at the root cause of a problem is referred to as The 5 Whys. It could be 3 or 4 or even 7 or 8 but 5 Whys is the accepted term. After an error occurs we often stop at the first why, put the fix into place and are surprised that it happens again despite actions taken.
Investigations into aviation accidents are very thorough. Fortunately most of us don’t deal with that serious of an error. These very detailed investigations are like a 10,000 Why system. But one repeated finding is that the big "error" resulted from a series of small errors all of which seem insignificant and could have not caused an incident on their own. The fact that a series of events led to the problem is not exclusive to aviation accidents so it should come as no surprise that the first cause we find may not be the root cause for your problem.
Many examples exist for the 5 Whys. Some get complicated and deter its use. I provide one simple example below and a link to more detailed explanations. But what is most important is to remember most root causes of errors are at the end of a series of events. Don’t stop at the first thing you find wrong.
Example: A part is manufactured incorrectly after months of producing the part with no defects. Investigation finds the usual machine operator was on vacation. Corrective action is to retrain the relief man. Or perhaps the usual guy will be back before another part is made – case closed. But if the 5 Whys were applied you may find that the new guy made the part to the latest released drawing. When you speak to the normal operator he pulls out a hand mark-up someone provided. You interview the author of the marked drawing and he said there was an unexpected change to the mating purchased part and the in-house part needed an immediate change. There are some reasons why the change never gets incorporated and officially released and so on…Keep asking why and you will find the root cause(s).
These examples always sound a bit hokey but when you apply them to your real world problem you realize how vulnerable your systems are. For many operations just a little more inquiry – a few more Whys – may save your organization a lot of wasted time and avoid unhappy clients.
If you give this method a try I would be eager to hear how it worked for you. JoeG@JAGEngingrg.com
Other links on the subject (you may need to cut and paste the links)
http://www.isixsigma.com/tools-templates/cause-effect/determine-root-cause-5-whys/
http://qualitycommunityschools.weebly.com/uploads/4/1/6/1/41611
/how_to_use_the_5-whys_for_root_cause_analysis.pdf
As I left off in my post about checklist (5/8/2015 below) as quality tools, root cause analysis may be required to determine the correct line item to place on a check list.
One method used for arriving at the root cause of a problem is referred to as The 5 Whys. It could be 3 or 4 or even 7 or 8 but 5 Whys is the accepted term. After an error occurs we often stop at the first why, put the fix into place and are surprised that it happens again despite actions taken.
Investigations into aviation accidents are very thorough. Fortunately most of us don’t deal with that serious of an error. These very detailed investigations are like a 10,000 Why system. But one repeated finding is that the big "error" resulted from a series of small errors all of which seem insignificant and could have not caused an incident on their own. The fact that a series of events led to the problem is not exclusive to aviation accidents so it should come as no surprise that the first cause we find may not be the root cause for your problem.
Many examples exist for the 5 Whys. Some get complicated and deter its use. I provide one simple example below and a link to more detailed explanations. But what is most important is to remember most root causes of errors are at the end of a series of events. Don’t stop at the first thing you find wrong.
Example: A part is manufactured incorrectly after months of producing the part with no defects. Investigation finds the usual machine operator was on vacation. Corrective action is to retrain the relief man. Or perhaps the usual guy will be back before another part is made – case closed. But if the 5 Whys were applied you may find that the new guy made the part to the latest released drawing. When you speak to the normal operator he pulls out a hand mark-up someone provided. You interview the author of the marked drawing and he said there was an unexpected change to the mating purchased part and the in-house part needed an immediate change. There are some reasons why the change never gets incorporated and officially released and so on…Keep asking why and you will find the root cause(s).
These examples always sound a bit hokey but when you apply them to your real world problem you realize how vulnerable your systems are. For many operations just a little more inquiry – a few more Whys – may save your organization a lot of wasted time and avoid unhappy clients.
If you give this method a try I would be eager to hear how it worked for you. JoeG@JAGEngingrg.com
Other links on the subject (you may need to cut and paste the links)
http://www.isixsigma.com/tools-templates/cause-effect/determine-root-cause-5-whys/
http://qualitycommunityschools.weebly.com/uploads/4/1/6/1/41611
/how_to_use_the_5-whys_for_root_cause_analysis.pdf