Event Report: Root Cause Analysis and A3 thinking

The session started with an explanation of the 5 Whys, which Carlo likened to an annoying toddler. I had never thought of it that way – but it is very accurate!

In our groups we picked between 2 techniques: 5 whys and cause & effect diagrams, and applied them to an exercise – 3mile island. Reading about 3 mile island – you couldn’t help but be shocked and amused at the number of things that had to go wrong for disaster to occur – and how quickly they had happened.


During the exercise the parts that stuck out the most for me were:

  • Break the problem down to the human level, if you’re still at a machine level – dig deeper.
  • Each step can have action items, but you should expend most of your energy at the root level.
  • How you phrase your question is important, try various questions and see where their path leads you.
  • Try not to find THE root cause. There are usually many. Don’t worry if you don’t have clear 5 steps, most of us had tree’s.

Think of 5 whys and Cause & Effect diagrams as training wheels. Use them to practice the skill and discipline of asking questions and delving deeper into the problem. Another technique is a fishbone diagram – but I have no idea how that works.

We then looked at the A3 template: http://www.crisp.se/lean/a3-template. This is a techniques to force you to do more than just analyze the problem. Each A3 has both an owner and a mentor.

You look at the current condition, and explain the background – why is this important?

Root Cause analysis is one part of an A3 and should be done with the group closest to the problem – those involved.

Carlo mentioned some books to read for those interested:

Thank you to our sponsor, Alacrity for the snacks and drinks 🙂

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2 Responses to “Event Report: Root Cause Analysis and A3 thinking”

  1. Heidi Nieuwoudt 19 April 2012 at 12:22 # Reply

    Thanks for the summary and the links, Sam! I regrettably couldn’t make it to this event and especially found the PDF very useful.


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