APPENDICES 7：ROOT CAUSE GUIDENCE

EXAMPLE

Management identifies that workers not wearing their Personal Protective Equipment (PPE) is resulting in poor performance on customer audits. After collecting further information, a clear problem is defined: “Not using PPE is impacting worker health and reducing audit performance.”

IDENTIFY POSSIBLE CAUSE--CAUSE AND EFFECT ANALYSIS (FISHBONE DIAGRAM)

Follow these steps to solve a problem with Cause and effect analysis:

Step 1:

First, write down the exact problem you face Where appropriate, identify who is involved, what the problem is, and when and where it occurs then, write the problem statement in a box on the right hand side of a large sheet of paper, and draw a line across the paper horizontally from the box this arrangement, looking like the head and spine of a fish, gives you space to develop ideas.

Next, identify the factors that may be part of the problem these may be systems, equipment, materials, external forces, people involved with the problem, and so on then draw a line off the “spine” of the diagram for each factor, and label each line.

Management identifies three main factors affecting PPE use in the factory as: Workers, Supervisors and Machines.

Step 2:

Identify possible causes for each of the factors you considered in step 2, brainstorm possible causes of the problem that may be related to the factor Show these possible causes as shorter lines coming off the “bones” of the diagram Where a cause is large or complex, then it may be best to break it down into sub causes. Show these as lines coming off each cause line.

Based on further data collection, surveys and interviews, management identifies that workers feel that the PPE is uncomfortable and that not all workers have had appropriate PPE training or thought the PPE training was boring. It was also found that not all supervisors are enforcing the facilities PPE rules and some supervisors do not fully understand the principles of PPE use and think it is not needed. Additionally, it was noted that the machines do not have appropriate safety guards.

When the problem is large or very complex, it is likely that each of the factors may have several causes in these instances, it might be good to break factors down into another level We can do this by asking the question “why?” the answer to this “why” will probably uncover one or more reasons and generate other “whys ”.

How far to drill down? the more the better, but generally five iterations of asking why is sufficient to get to a root cause the last “why” of our list could be a root cause under that factor.

Be careful though, the answers to your “whys”should be:

• Based on facts or actual conditions as determinedby the teams further investigation, not on

 opinions or assumptions

• Be looking for a deeper cause

Making a mistake in any question or answer canproduce false or misleading results

Step 3:

Analyze Your diagram By this stage you should have a diagram showing all of the possible causes of the problem that you canthink of depending on the complexity and importance of the problem, you can now investigate the most likely causes further this may involve setting up investigations, carrying out surveys, and so on these will be designed to test which of these possible causes is actually contributing to the problem if the diagram gets too complicated, this could be a sign that thereis more than one problem if needed, the diagram can be split to focus on specific factors or causes.