“When solving problems, dig at the roots instead of just hacking at the leaves”.
ANTHONY J. D’ANGELO
In manufacturing companies where the situation in the shopfloor is dynamic and constantly evolving, the use of Root Cause Analysis as a problem-solving method to identify the underlying reason for any issue newly encountered or repeatedly occurring. The goal is basically to prevent recurrence, not just fix symptoms.
There are a lot of techniques developed through the years and may have been conceptualized based on actual problems faced & continue to face. And so with methods or techniques being used based on required effort, complexity and the expected output which will serve as a guide in the course of corrective & preventive actions derived from.
For simple or single cause problems, the 5 Why method is the most appropriate to be used. The chain of “asks” will lead to identifying the root cause while for simple yet multi factor problems that require brainstorming, the Fishbone Diagram (also known as Ishikawa) is desired because it categorizes the causes of the problem which could either be one or a combination of People, Process, Machine, Material &/or Environment.
When prioritizing defects above all factors, Process and/or Quality Engineers, the Pareto Analysis is the go to Root Cause Analysis tool. This requires an above than average effort compared to 5 Why or the Ishikawa Diagram because it prioritizes the defect above all other factors which must be shown through a graph; only the “vital few” instead of being beclouded by “trivial many”.
In the Japanese & American companies where I spent almost three decades of my professional career, when mapping failures or major problems that are repetitively encountered despite all the effort, time & resources spent, because they are safety critical, the Fault Tree Analysis (FTA) is being used. It is actually a logic diagram that maps failure paths with gates.
As customer is king, when there are recurring customer complaints such as quality issues, the 8D or Eight Discipline, a formal corrective action report with containment, root cause & preventive actions are recommended & put into action then disseminated to cross functional teams. Note that this is also being used by companies when supplier issues are also encountered.
And lastly, among the methods I always hear is the FMEA (Failure Mode & Effects Analysis). Because it proactively ranks risks before they occur then through a system of table in scoring risks by showing the severity × occurrence × detection (RPN). It aims to identify which risks that should be avoided.
And many other methods that solely aim to identify, solve and prevent the recurrence of problems encountered.
Last weekend, I needed to intervene in a case in a company that I currently help, the recurring problem of warehouse stocks inventory inaccuracy & data timeliness inconsistencywhich has been hounding both their operations but also their market stake.
Being an HR & Organization Development advocate first & foremost, I relied on my past experience when I used of one of the RCA tools in solving recurring behavioral & complicated work–related issues. To me, the 5 Why method was simple yet quite effective. If I were a QA person or an Process Engineer, I would have used PFMEA, 8D etc.
Gathering all stakeholders (warehouse clerk, warehouse manager, checkers, forklift operators, dispatchers etc), for a quick learning session, I gave a simple rundown of Root Cause Analysis (RCA) methods & in prior to the workshop proper then I requested the group to practice the use 5 Whyon relevant that daily household issues which will reasonably resonate with them that they want to look, use the root causeanalysis method & hopefully effectively resolve it.
I was thinking maybe they will use water shortage as the topic for RCA but maybe due to the non–stop rains and seemingly trapped flood waters threatening not only the homes of these employees & their livelihood. The constant common inconvenience & disruption to their lives, theychose the to try the 5 Why on the FLOODS as a practice problem.
So when I challenged the group as part of making this learning session effective, to imagine themselves as government officials & LGU heads when going through this short exercise, which has affected everybody including myself, the frequent flooding that occurs in Pampangadisrupts communities, businesses, and infrastructure.
Here is the gist of the exercise on the use of 5 Whys Analysiswhich I translated in English but have chosen not to disclose the answers to the “whys” that the participants were able to come up with “angrily”.
1st Why does flooding occur in Pampanga?
2nd Why do Pampanga’s rivers and drainage systems overflow?
3rd Why are waterways clogged with silt and garbage?
4th Why is there poor waste management and deforestation?
5th Why is enforcement weak and strong flood control systems lacking?
After just a few minutes, corrections derived for the short-term were a combination of the intensification of community clean-up drives & enforce additional strict anti-dumping ordinances. The timely desilting of rivers and drainage canals should be done before the start of the rainy season.
For the medium term, to reduce upstream erosion, the implementation of reforestation programs & the introduction of localized flood barriers plus pumping stations in low lying areas and high-risk barangays should be pursued.
Finally, the long term is to Invest in comprehensive flood control infrastructure (dikes, retention basins, modern drainage). Strengthen LGU capacity for environmental law enforcement and disaster preparedness. Ensure that those that will implement the flood control infrastructure should be properly vetted, projects closely monitored & inspected, holding accountable those that are proven to have been remiss in whatever capacity (as an contractor, government official and private contractor).
Looking at all of the discussion & inputs, even if the group warehouse stakeholders were not experienced government engineers, government bureaucrats, LGU officials and private contractors, because they were a group of affected locals, the established Root Cause came ot naturally (systemic gap in environmental management, waste disposal, and insufficient flood control infrastructure investment & poor project implementation etc).
So when I praised the participants for their inputs about the 5 Why learning exercise, referring to our practice topic, one of the participants, in his almost shrieking voice, asked a very surprising yet valid question nonetheless.
“Shouldn’t there be a rule, that must exclude any person/s from participating in the RCA, specially those who are perceived to have conflict of interests or will primarily benefitting when the implementation of such corrective/preventive actions is adapted? “
When I asked why? I was simply told, “look at what happened to us”…. then just told myself, “malalim ang hugot…singlalim ng baha sa barangay nila”.
This is contrary to manufacturing because in solving problems in the shopfloor, the best person to engage & seek advise on how to make things better is the directly involvedor the one who actually does the work.
When the discussion became less comfortable and became more passionate & emotional, maybe due to anecdotes & actual experience that the flooding made, I reminded everybody that “warm up lang yan”…our main issue is to help resolve through this RCA learning session, the daily warehouse inventory which is at times not 100% accurate & not timely as well.
So we went on with the workshop exercise for the problem at hand, still felt the same level of passion though thankfully with less sarcasm. The 5 Whys method had effectively looked at the systemic root cause. The real workshop exercise “discrepancies in warehouse inventory & the effective and timely use of the data to come up with good decisions was our end goal.
As we overshot the workshop time, key takeaways were extracted from the groups. One of the gaps seen was when a forklift operator who is primarily in charge of the storage and proper placement of stocks but also does the checking of his own work, not by the designated checker, was the root cause of the problem. Worst, even if it cost the integrity of the warehouse inventory, there was no sanction or penalty imposed on the accountable person. Not to be outdone, somebody again reverted to the floodings….the immediate implementation of the flood control corrective & preventive actions should not be lead, implemented by anybody that is part of the decision making body, the oversight in charge or even the audit committee.
I had to excuse myself for a scheduled family dinner so that the session could end on a happy note or I’ll have to use 5 Why explaining to my wife why I was late.
One thing is for sure, for the floodings, we should NEVER stop asking WHY while our feet are still soaked but these murky water.
AUTHOR is 30 plus years HR stalwart & Organizational Development practitioner, BCP expert, company executive, Motivational Speaker & Writer, Social Entrepreneur, Community Leader, Univ. of the Phils. Alumni Governor & Fraternity Elder, successfully married & father of three boys, fondly called “Ninongng Bayan”, Respectful Workplace advocate and author of “Good Morning Hardworking People” weekly FB posts…