RCA –

Why – Why Analysis

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Welcome to the session!

'Squeak video'

LEARINGS ????
o ONE SHOULD ANALYSE THE PROBLEM
o ONE SHOULD NOT SOLVE PROBLEM WITH PRE-ASSUMPTIONS
o ONE SHOULD TAKE INITIATIVE IN SOLVING PROBLEM

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Most factories fix problems temporarily to continue
operations, knowing fully well that the problem wil most
probably recur
3

FIX

1 2

OPERATE PROBLEM

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Most factories fix problems temporarily to continue operations,
knowing fully well that the problem wil most probably recur.
3

FIX

1 2

OPERATE PROBLEM

It is necessary to break this cycle, to get in control of

all losses by attacking the root causes.
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What do we mean by “Problem”
Technically, deviation from desired specification.
In general, deviation from expectation.

Example
1. Machine Breakdown
2. Efficiency less than standard
3. Delay in spares delivery
4. Deviations in Key Performance Indicator (KPI)
5. High level of defects
6. High consumption of consumables

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 Different tools are available to identify and action on causes which are of
varying complexity

Cause

Cause Cause

Cause

Single cause Multiple causes

Why –Why Analysis fishbone Diagram
Low Difficulty in pinpointing cause High

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What is “Why-Why analysis”
• It is a method of asking “Why” over and over again till one reaches a root cause.
i.e. ( What event triggers the cause)
• Normally, root cause gets identified within 5 times of asking “Why”

Do’s Dont’s

• To be done at work spot, right after • Not to be done by single function, but to
short term action is taken for a problem be done by cross functional team
• Identifying the symptoms after an • “May be” or “Could be” is not acceptable
abnormality is very important in a 5-why for analysis in 5-why
to arrive at the root cause

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When do we do “Why-Why analysis”
Sr. no. When there is a..
Problem ...Why
1 Quality failure
2 Equipment breakdown
Cause Why
3 Repetitive abnormalities/failures
4 Accidents/Incidents
5 Non achieved KPIs Why
because... Cause

Cause Why
because...

because... Cause Why

Root
because... Cause Why

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How is Why-Why analysis done in a systematic manner
• Clearly define the problem or issue
• Ask the cross functional group “WHY” it is a problem
• Capture each unique responses (possible causes)
• Eliminate them one by one either based on symptoms noticed by observer/shift person
OR after verification through Gemba audit
• For the remaining single cause again ask “WHY” it occurred
• Capture the responses and repeat the process till root cause is arrived at
Remember:

Problem "If you don't ask the right questions,

Symptom Verification you don't get the right answers”
Cause 1 Cause 2 Cause 3

Why 1

Why 2
Root
"If you don't ask the right questions, you don't get
Cause
Why 3 the right answers”

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Example 1 basic Why-Why analysis
PHENOMENON ANALYSIS FORM Ref No: PQ/0708/0010 Date: 01-Jan-2017
Describe the phenomenon clearly: Multiple coil failed in resistance test
Short term action: Coils discarded
Why-1 Wire diameter lesser than required in specification

Why-2 Wrong wire diameter (smaller) used as input material for lamination
W
H Why-3 Tension in the winding machine higher than normal
Y Why-4 The bearings for handling the wire in the winding machine is worn out

Why-5 There is no mechanism to replace the same periodically as part of the preventive maintenance regime

Is there anything else to be checked?

Proposed preventive countermeasures Resp Due Status
Dt
Change in work method Training for Operators to identify damaged bearings Ram 15-
/ training required Feb
Routine activity Replace all bearings based on lifecycle Shyam 15-
March
Predictive check

Preventive maintenance Create schedule for replacement of bearings and put in Ram 15-
place a check sheet to replace them on time Jun
Modification

Others
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Status Agreed Planned Implemented Effective
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Example 1
PROBLEM: Cylinder does not operate smoothly
WHY BECAUSE…
Why cylinder does not operate smoothly Strainer was clogged

Why Strainer was clogged Oil was dirty

Why oil was dirty Dirt entered the tank

Why does dirt get in Upper plate of tank has hole and gap

Why was hole made Repair work during maintainence work

Schedule repair work based on maintenance work.

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Example 1 Continued..
PROBLEM: Cylinder does not operate smoothly
WHY BECAUSE… ACTION
Why cylinder does not Strainer was clogged Clean the strainer
operate smoothly

Why Strainer was clogged Oil was dirty Replace oil

Why oil was dirty Dirt entered the tank Drain and clean the tank

Why does dirt get in Upper plate of tank has Plug hole and gap
hole and gap

Why was hole made Repair work during Schedule repair work based
maintainence work on maintenance work.

What is your immediate action? Cleaning the strainer

What is your final action ? Standardize repairs
After scheduling repair work based on maintenance work, Yes
is it OK
Preventive actions?
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 Why-Why analysis is not closed if the countermeasures do
not result in any of these or a combination of these actions
Why-Why Analysis should lead to

Checkpoint One Point Preventive/ Equipment System Visual Control/

addition in Lesson Predictive Modification Modification Mistake
CLTI Maintenance Proofing

Doing 5-why analysis will get imbibed into the culture only if the Manager
demands for the 5-Why document during review of any critical abnormality
(Breakdown, Quality complaint etc from the daily management team

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Incorrect Why Why | Why?
PHENOMENON ANALYSIS FORM Ref No: PQ/0708/0010 Date: 01-Jan-2017
Describe the phenomenon clearly: Multiple coil failed in resistance test
Short term action: Coils discarded
Why-1 Wire diameter lesser than required in specification

Why-2 Operator made the mistake of using wrong wire from the store
W
H Why-3 Ram is at fault
Y Why-4

Why-5

Is there anything else to be checked?

Proposed preventive countermeasures Resp Due Status
Dt
Change in work method Ram needs to be more careful Ram 02-
/ training required Jan
Routine activity
Predictive check

Preventive maintenance
Modification

Others

Status Agreed Planned Implemented Effective

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Common pitfalls observed while doing Why-Why Analysis
1. Assuming and stopping at “Operator error”
Try to understand “Why people don’t comply”
Is it because of
− Improper instructions
− Worn-out tools
− Improper training
− Lost expectations
2. Start the why-why with an end reason in sight

Some of the expectations while doing Why-Why Analysis’s

1. The process requires complete honesty and no predetermined assumptions
2. Follow the Data! Don’t try to lead it.
3. Why-Why should be done only with a cross functional team.

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RCA –
Fish Bone Analysis

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 Different tools are available to identify and action on causes which are of
varying complexity

Cause

Cause Cause

Cause

Single cause Multiple causes

Why –Why Analysis fishbone Diagram
Low Difficulty in pinpointing cause High

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If there are multiple causes which are affecting your problem then a
fishbone diagram or Cause and Effect Diagram is probably a good starting
point

Cause 5 Cause 3 Cause 1

Problem

Cause 6 Cause 4 Cause 2

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 What is a fishbone diagram?
• A visual tool for organizing information to establish and clarify the relationships between
an effect and its main causes
• Used to identify the potential root cause(s) of a problem so that collective actions can
be taken to eliminate their recurrence
• Assists in reaching a common understanding of a problem and its potential root
causes/drivers
• Known by several names (Ishikawa, fishbone, cause and effect)

Receipt process

Rushed salespeople

Hourly completion
required
Problem Unable to verify 40%
Causes Example Effect of January sales
Statement Rushed
receipts
Too many sales

Not enough sales

coverage at peak times

Salespeople

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At a high level, there are 3 steps required to construct an
fishbone diagram
Step 1:
Write the problem statement in the head of the “fish.”
Determine the major categories (causes) of the effect
Summarize causes under categories such as:
— people
— measurements
— methods
— machines
— material
— environment
Identify potential root causes

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Step 2: There are different approaches used to determine
the major categories of a fishbone diagram
The most common approach utilized is using “generic” categories:
• The 8 P’s
Procedures, People, Price, Promotion, Processes, Plant, Product and Policies

• The 6 M’s
Machinery, Materials, Maintenance, Methods, Mother Nature, and Man

• The 3 S’s
Skills, Systems and Suppliers.

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 Step 3: Once major categories are set up, a team should
begin to brainstorm causes by asking “why”
Begin the questioning process with the “most likely” major category.
Ask: “Why does this defect occur or condition exist?
Rule of thumb is to ask “why” 3-5 times
— as questioning continues, it becomes progressively more difficult and a more thought
provoking assignment
— early questions are usually superficial, obvious; the later ones more substantive

Symptom 1

‘why’s’
Symptom 2

‘why’s’
Symptom 3

Why did ‘why’s’

this Symptom 4
And more Probable
happen?
‘why’s’ Root
Cause
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Benefits of fishbone diagram
• Involves the whole team and captures collective knowledge about the problem
• Helps to structure brainstorming around the root causes not the symptoms
• Channels the team to focus on the content of the problem, rather than the history
• Supports the team in the discovery of the root causes of a problem by identifying,
exploring and graphically displaying the potential causes in cascading levels
of detail.

Manpower
Measurement Machinery
(People)

Problem/Effect

Mother Nature
Materials Method
(Environment)

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 Understanding Severity, Occurrence and Detection of the causes and
prioritise causes to do Why-Why on
List all the causes along with the lever, then give a geometrical progression rating
(1,3,9) for Severity, Occurrence and Detection based on your operational
understanding. High scoring causes should be priotitised for why-why

Score = Severity X Occurrence X Detection

Severity
Relation between cause and effect and extent of the problem if the cause occurs
Occurrence Lever Cause Sevierity Occurance Detection SCORE
QC Nonstandard packing 9 3 9 243
How often the cause occurs 9 3 3 81
QC Improper sorting
Detection QC Unskilled man power 9 3 3 81
9 9 1 81
How easily the occurrence of QC High Bottle Temperature
QC infrastructure problem 9 3 1 27
Cause is detected. Easy detection Process defect identification and elimination 9 9 9 729
Process ware handling 9 9 3 243
scores low and vice-a-versa 9 9 1 81
Process swabbing method not proper
rated Process hot end sample checking not proper 9 3 3 81
Process Job setting not proper 9 3 3 81
Process Timing problem 3 3 1 9
Process Unskilled man power 3 3 1 9

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 A Pareto chart with data can also enables you to prioritise where to
focus efforts
Pareto chart of errors in exam form
What it is
(Example)
■ The Pareto principle is often described by the
‘80/20 rule’ No date of birth 45
■ This rule says that, in many situations, roughly
80% of the problems are caused by only 20% of
the contributors No signature 23

■ The Pareto principle implies that we can

frequently solve a problem by identifying and Incorrect case number 10
attacking its ‘vital few’ sources
■ Uses a bar chart to show frequency, cost or
Incorrect date of birth 7
severity of incidents (defects, problems,
accidents, etc.) in order from most frequent to
least frequent
Incomplete form 5

No fee 3

0 20 40 60

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 Generating solutions
Brainstorming can be used to generate solutions for the root cause problem

A team approach to generating ideas Rules for brainstorming

Go around the table and everyone makes a suggestion ■ No criticising

Keep the process rolling ■ Record all ideas on a flipchart

■ Do not analyse suggestions
A quick and fun way of getting solutions aired
■ Encourage wild ideas
Encourages free thinking and therefore creativity
■ Everyone participates
■ Build on ideas
Other types of brainstorming:
■ Have fun!
Silent – everyone writes ideas on ‘post its’ and pins them to a
board
Reverse – ask the opposite to the root cause solution (i.e., ‘What
would it take to make customer service worse?’)
Systematic – review a list of major issues and brainstorm each in
turn
Excursion – generate ideas through external stimulation

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 A Prioritisation matrix can be made to evaluate the possible
solutions
What it is Prioritisation matrix – example

■ A grid which maps

High
out decision options
based on a given
set of criteria – for ‘Do later’ – Easy to ‘Go for it’ – Easy to
example impact of implement, but implement and
an idea versus the limited financial significant financial
■ Ease of
speed/ease to benefit impact
implementation
implement the idea
■ Experience from
■ Rating of options previous initiatives
based on
experience, input ■ Input from
from stakeholders stakeholders ‘Don’t bother’ – ‘Do later’ – Hard to
and quick ‘back of (internal and Hard to implement implement, though
the envelope’ external) and limited financial reward is
calculations (if financial reward high
needed)
Low

Low High

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Complete Process | Developing a fishbone diagram
fishbone diagram procedure (Ishikawa or Cause and effect diagram)
Step 1: Capture issue or problem and represent that in a box. Problem

Step 2: Draw a line from the box across the paper or white
Problem
board (Forming the spine of the fishbone)

Category 3 Category 1
Step 3: Draw diagonal lines from the spine to represent
categories of potential causes. Problem

Category 4 Category 2

Category 3 Category 1
Step 4: Draw smaller lines connecting spine line to represent
deeper causes.
Problem

Step 5: Identify which cause has maximum impact

(Prioritize causes) Category 4 Category 2

Category 3 Category 1
Further Why-Why Analysis is needed to validate the actual
cause, ideally with data.
Problem
Note: Brainstorm potential solutions once the actual cause 20% of attributes
has been identified and prioritize them for contributing to
80% of the
action Category 4 Category 2
problem

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 Example 1: Ishikawa diagram used in determining root causes
for the problem of ‘Late Payment of Invoices’
Computer Internal mail
system system
Cost-reduction program
Older system

Excess One pick-up daily

demand Downtime
Manual sort Workspace Equipment
process
Access limitations Excess New maintenance
Lost/misplaced mail
demand contractor
Turnover
Low priority
Inexperienced staff WHY are
Hiring invoices paid
Turnover Audit recommendation late?
freeze
for tighter control
Access limitations Centralized
payment Manual Crowded
Maximize cash authorization files space
Low priority
Morale Payment Branch offices
Pay cuts delays forward payments weekly Missing documentation
Productivity Resigned
Reorganization
deadlines Increased
of purchase org. No limit manager
Overtime workload
reduced Missing
purchase orders

Finance
Staff Documentation
policy

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Exercise

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Thank You