When problems occur in organisations, it is generally easiest to deal with the symptoms - for they are the
immediately obvious aspects of the problem, and dealing with them is what gets recognition. So that’s
exactly what we tend to do. If something doesn’t work, we fix it, replace it, or re-do it. Job done. Problem
solved. When something else goes wrong, once again we fix it, replace it, or re-do it. Job done. Problem
solved. Or is it? The more astute reader will already be noticing a trend, and an opportunity to be a little
more efficient. Perhaps we might benefit from an investigation or analysis of the root causes of problems or
events. Root cause analysis is based on the belief that problems are best solved by correcting or
eliminating their root causes, instead of simply responding to the symptoms. By identifying - and then
dealing with - root causes, the recurrence of problems will be minimized. Of course, it is not always possible
to ensure the complete prevention of recurrence with just one round of applying control measures. Root
cause analysis may need to be a re-iterative process.
Two of the more well-known tools used in root cause analysis are the 5 whys and cause and effect
The 5 Whys
The technique known as The 5 Whys is extremely simple yet can be very effective. It is repeatedly asking the
question "Why?" to gradually delve below the surface problem, and uncover its root causes. Of course, the
number of questions does not actually have to be 5 - that's just a generalisation. It might also take 3, 4, or 6
questions to get there.
Using the 5 Whys does not require any special resources - just persistence. As any parent knows, children
are naturally gifted at it!
Let’s take a look at an example.
The problem: An organisation that provides catering to functions is getting customer complaints that they are
not receiving the food they ordered. Sometimes it’s the wrong food, sometimes the wrong quantity,
sometimes too early or too late. Using the 5 Whys technique, we can drill down from the initial symptom to a
1. Why are they not receiving the food that they asked for?
Because the preparation team are working to a different list than the one that the customer
2. Why is the preparation team working to a different list than the one that the customer
Because the customer authorises items on our order form, which should get entered in our order
tracking software, but to save time, the sales person phones through the requirements – which are
then written down by hand. Sometimes there are misunderstandings over what is meant
3. Why does that save time – isn’t using the software quick enough?
It is in theory, but while management and the preparation team have been trained on its use. The
sales team haven’t been trained yet
4. Why haven’t the sales people had software training yet?
Because it’s in the budget for next year. Their training budget for this year has already been
allocated – mostly on courses related to lead generation and sales techniques
5. Considering that sending the wrong food is a source of customer complaints, why wasn’t
the training prioritised?
Because the Sales Manager chooses what to spend her training budget on, and didn’t know about
the problem of incorrect food deliveries – that’s not considered a sales issue, but a delivery issue.
So, drilling down from the initial symptoms is starting to reveal several root causes such as; the prioritisation
of training, perhaps a lack of information flow to management, perhaps even incorrect categorisation of
issues reported. We could of course, go further still. Hopefully, the above example clearly illustrates that the
5 Whys technique can be very useful in getting to the root causes of problems.
Cause and effect
Cause and effect diagram
The analysis is greatly assisted by using a Cause and Effect Diagram in the shape of a fish skeleton with
the stated problem as the head. This is otherwise known as the Ishikawa diagram (after its originator
Kaoru Ishikawa – one of the founding fathers of quality management) or Fishbone diagram. This
diagram helps the user to trace problems back to originating or root causes and therefore lead to
improvement from the bottom up.
The above illustration is from a template Word Document included in the Qudos Quality Manager and Safety
Manager toolkits. This example is based on the 4S model of cause and effect diagram - which considers 4 main
causal factors - Suppliers, Systems, Skills, and Surroundings. This model is typically used in service industries.
There are also many other models in use such as:
- 4M model for manufacturing companies - with factors: Manpower, Machines, Methods and Materials
- · 6 category model for manufacturing companies - with factors: Equipment, Process, People, Materials, Environment, and Management
- · 4 category model for service sector organisations - with factors: Policies, Procedures, People, and Equipment
- · 8P model for service sector organisations - with factors: Product, Price, Promotion, People, Processes, Place / Plant, Policies, Procedures·
Some of the listings may seem to be a little contrived. For example, the 8P model particularly struggles in
combining Place/Plant as one factor to keep the factors to an even number. Some of the labels also seem to
be interchangeable e.g. Machines/Equipment, People/Manpower etc. Anyone using this technique should not
feel constrained by any of these models, but use the number of categories and labels that best suit the
The Cause and Effect Diagram is probably best used by a group. Typically, the procedure is as follows:
1. The effect or problem is listed at the head of the fishbone
2. Decide on the primary-level causes or factors – use one of the models mentioned, or brainstorm your
3. Numerous secondary-level causes may be identified within each of the primary-level causes or factors
– once again, the brainstorming technique can be useful here
4. (Optional) use the 5 whys technique to identify deeper causes
5. Review as a group
6. Plan actions
In addition to ‘brainstorming’ and ‘the 5 whys’ as mentioned above, various other management systems
techniques may be used in conjunction with cause and effect analysis. For example, an Affinity diagram may
be used to help you select the primary-level factors.
One variation of the Cause and Effect Diagram is CEDAC (Cause and Effect Diagram with the Addition of
With this type of diagram, secondary-level causes are shown only on the left of the primary-cause 'bones'
(perhaps using one colour of card or text box) - with possible solutions being shown on the right (perhaps
using another colour). This tool was developed by Dr. Ryuji Fukuda – a leading expert in industrial engineering
and quality improvement. This team-orientated tool could be used in conjunction with two brainstorming
sessions - one to determine causes, and the second to determine possible solutions. One way to use the tool
would be for participants to write their idea for causes and then solutions on post-it notes or similar, and place
them on a white board adjacent to the primary-cause headers – for subsequent consideration by the group.
Knowledge is power
Of course, using the above techniques assumes that you are aware that there is a problem in the first place!
Many organisational problems that occur time and again may be widely distributed over time, and affect
various personnel in different departments and locations. If the organisation doesn’t have software to capture
relevant information, and make it available for easy searching, they are prone to keep addressing the
symptoms time and again without realising there is a systematic problem they could be looking at.
Those with management system software such as Qudos System 3 can quickly and easily run queries to
identify similar problems and trends. Search criteria in that application include:
- How was the problem raised (e.g. by a customer, by an employee, at an audit, meeting or risk assessment)
- What is the main issue or topic e.g. OHS, environment, quality or other compliance issue - or subcategoriesof them
- Time period (from/to dates)
- Relevant location
- Relevant business unit or department
- The person that action was assigned to
- Text-based search – this might include any information that was entered about the problem e.g. relevant customer, equipment etc.
Enough is enough
From a philosophical point of view, the question can always be asked; but have you got to the real root cause
yet? Given endless time and patience, a problem can be investigated on a deeper and deeper level.
Fortunately, those of us involved in business management don’t have to be too philosophical. Generally, we
only need to investigate down to the root cause level that we can do something about – what you might call
the ‘Fixable level’. We also need to consider the old see-saw of costs and benefits. From a risk management
point-of-view, is it better to eliminate the causes or just accept the problem? Will the fix cost more than the
problem, or even cause other problems? The answers will of course be varied, but a little knowledge of the
techniques mentioned in this article will hopefully assist you in getting to the root cause of at least some of the
problems that your organisation faces.
What the standards say
Just about all management system standards have some form of requirement to investigate the cause(s) of problems, and act to eliminate them.
QUALITY - ISO 9001:2015 - Clause 10. 2 NCONFORMITY AND CORRECTIVE ACTION
ENVIRONMENT - ISO 14001:2015 - Clause 10. 2 NCONFORMITY AND CORRECTIVE ACTION
OCCUPATIONAL HEALTH & SAFETY – OHSAS 18001:2007 – Clause 4.5.2 ACCIDENTS, INCIDENTS,
NONCONFORMANCES AND CORRECTIVE AND PREVENTIVE ACTION
OCCUPATIONAL HEALTH & SAFETY – AS/NZS 4801:2001 clause 4.5.2 INCIDENT INVESTIGATION,
CORRECTIVE AND PREVENTIVE ACTION
FOOD SAFETY - ISO 22000:2005 - Clause 8.5 IMPROVEMENT
INFORMATION SECURITY - ISO 27001:2013 - Clause 10. 1 NCONFORMITY AND CORRECTIVE ACTION
+ Various controls from Annex A.1 may be applicable e.g.
A.12.6.1 MANAGEMENT OF TECHNICAL VULNERABILITIES and
A.16.1.6 LEARNING FROM INFORMATION SECURITY INCIDENTS
At the time of writing this article, ISO 9001 was due to be updated. However, the principle relating to
investigation of problems is not greatly altered.
|Dr. Ryuji Fukuda - CEDAC - A Tool for Continuous Systematic Improvement (Productivity
Haoru Ishikawa - Guide to Quality Control
Richard Whiteley - The Customer Driven Company
Further discussion on improvement techniques and templates/examples are included in the
Qudos Quality Manager and Safety Manager toolkits.