Human Aspects in Root Cause Analysis that Technology Cannot Replace

Root cause analysis (RCA) is one of the fundamental aspects of problem solving in our drive for continuous improvement. Simply put, it is the process to determine the most basic cause of a problem or deviation. There are many tools and techniques available to conduct RCA, for instance the ‘Fishbone diagram’ and the ‘5xWhy’ tool to name a few. With the ever-increasing use of technology at our fingertips, there are now digital tools available to initiate and document the RCA, while facilitating remote collaboration between teams.

While technology is good to streamline workflows, the quality of the RCA still comes down to the human aspects – it is after all the human beings reviewing facts, determining the underlying cause, and generating effective corrective actions to mitigate and prevent the issue. Therefore, it is essential to understand the foundation principles upon which a good RCA practice is to be built in a manufacturing plant.

Examples of some bad practices are:

• The operator wasn’t aware of abnormalities (no top-down communication).

• The operator was aware of abnormalities but didn’t inform anyone (no bottom-up communication).

• Corrections were done without thorough RCA.

"If you wonder why you are facing repeat issues even though you have trained your management team on RCA techniques, and trained and retrained your line operators and supervisors on the revised SOPs, start with going to the production floor, and observe!"

• No cross-functional collaboration with other departments for RCA.

• No progress due to unclear responsibility.

• The deviation was handled without facts or going to Gemba.

In Suntory, we constantly use the term “Gemba”. This is a Japanese term which means “the place where value is created”. So gemba could mean the manufacturing line where product is produced. It could mean the convenience store where product is sold to consumer. What is not ‘gemba’ in this context, is for example, a meeting room! The quality of the RCA is reliant on the quality of the facts ascertained. So in order to gather the correct information, the value of going to the gemba cannot be overstated. In this context, we follow the principle of looking at what we call the ‘3Gen’:

Gemba: Spend time at the actual site of issue, not only in the meeting room

Gembutsu: Look at actual goods involved (machine, product etc)

Genjitsu: Gather facts- timelines, sequence of events etc

Remember: All information resides in the ‘3Gen’

This should be followed up with the ‘what/ where/ who/ when/ why’. Once the right information is obtained, it will aid in the 5xWhy, Fishbone analysis, or any other RCA techniques. Once you have established the root cause, then brainstorm to determine the corrective actions and preventive actions (CAPA). Put a plan in place to implement the CAPA while assigning clear roles and responsibilities with associated timelines. Finally, the case should not be closed until the effectiveness of the actions are verified over an appropriate period of time.

There is no substitute for walking the production areas, talking to the operators, and understanding how things are actually being done. Often, management assumes processes are done a certain way, while the reality on the production floor could be different. When such assumptions are made, it then leads to faulty RCAs. If you wonder why you are facing repeat issues even though you have trained your management team on RCA techniques, and trained and retrained your line operators and supervisors on the revised SOPs, start with going to the production floor, and observe!