June 25, 2007 | Mark Paradies

Lean Root Cause Analysis

Lean Root Cause Analysis

A two part series based on
a talk at the 2007 TapRooT® Summit
by Mark Paradies & Kevin McManus

Lean Intro

What is Lean? It starts with the Toyota Production System, a highly efficient, customer focused, streamlined manufacturing process that helped Toyota survive when faced with competition from GM and Ford after WW II. The Toyota Production System started with Sakichi Toyoda at his textile mills and at his son’s (Kiichiro Toyoda) company, Toyota Motor Corp. Much of the credit for developing Lean is given to a Toyota engineer, Taiichi Ohno, and a consultant, Shigeo Shingo.

The main goal of Lean is to drive waste (muda) out of the production system. The seven forms of “deadly waste” are:

• Overproduction
• Transportation
• Waiting
• Inventory
• Motion
• Over-Processing
• Defects

These types of waste should be reduced (or eliminated) through the application of systematic tools to improve efficiency and effectiveness. Some of the systematic tools that are commonly part of a Lean implementation are:

Value Stream Mapping
Poka-Yoke (mistake proofing)
Kanban (pull production)
Kaizen (change for the better)
Just-in-Time (inventory reduction)
Total Productive Maintenance
Quick Changeover
Cellular Manufacturing
5S (sort, set order, standardize, shine, and sustain)

These systematic manufacturing improvement tools are applied to provide the customer with what they want, when they want it. For details about the Toyota Production System, see Modern Approaches to Manufacturing Improvement: The Shingo System by Shigeo Shingo and Toyota Production System: Beyond Large-scale Production by Taiichi Ohno.

Who is the Customer?

Lean production gives the customer what they want, when they want it. This requires understanding of what adds value from the customer’s perspective. Waste comes from producing things that the customer doesn’t want. So the root cause analyst should ask:

Who is the customer for my root cause analysis?
What does the customer really want?

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Perhaps you have already determined that your customer is management. And we all know what management wants:

• STOP THE PROBLEM.
• Don’t spend much time.
• Everything should continue as normal without disrupting any work and without causing delays to the tasks that the investigators were assigned prior to the investigation.
• Don’t point blame at management (especially senior management).
• Don’t provide evidence for lawsuits or for fines by government regulators.
• Find a few simple, inexpensive fixes that can be implemented easily.

This is NOT a joke. These are the desires of many managers who ask for a root cause analysis. And who wouldn’t want something like this? The desire is completely unreasonable, but understandable.

Therefore, as the leader of a lean root cause analysis, you must manage your customer’s (management’s) expectations. Make sure that your customer knows what they are buying. Management must have a reasonable expectation as to the cost for a good root cause analysis. And they must understand that root cause analysis IS NOT a magic bullet to solve all problems with no investment. Rather, advanced root cause analysis is a sophisticated performance improvement tool that when applied with diligence and thought, can lead to excellent (but perhaps not perfect) performance.

More Customers

Before you think this is all that you have to do, you may need to think more about who the customer is. First, “management” isn’t a good enough definition. What level of management? What manager (or managers) in particular?

The need to manage expectations and competing priorities from several managers and different levels of management can complicate delivery of a root cause analysis that is “just what the customer ordered.”

This should focus the analyst on their MAIN objective – stopping the problem. If the problem doesn’t stop (if an effective fix isn’t found for a serious safety, environmental, production, maintenance, or quality issue), then no level of management will be happy for long.

Next, you need to think about another set of unintended customers. These unintended customers include:

• The Government Regulator
• Workers
• The General Public
• Critics
• The Press
• The Company’s Shareholders
• Financial Analysts
• The Plaintiff’s Attorney

You may not be able to produce a report that satisfies all of the customers, but you should make rational decisions about the competing priorities.

Working to produce what the customer wants can produce radical changes in your root cause analysis and the reasonable desires of the customer.

Now that the first source of waste has been removed by producing a root cause analysis that is in line with reasonable customer expectations, the analyst can look for other ways to streamline the root cause analysis process to make it even leaner.

The first of those ways may seem very simple:

Only Investigate Incidents Worth Investigating

This sounds easy enough, but many companies have started by investigating only the biggest problems and then gone to the extreme of:

Investigating Everything!

Using root cause analysis to improve performance makes sense. But you have to pick targets with value to realize a return on your investment. You don’t need to investigate every burnt out bulb.

We will complete this discussion of applying Lean principles to root cause analysis in the September Root Cause Network™ Newsletter. If you would like to subscribe, CLICK HERE.

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