Root cause problem solving example
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Root Cause Problem Solving “The fire” May 5, 2006 This report is solely for the use of client personnel. No part of it may be circulated, quoted, or reproduced for distribution outside the client organization without prior written approval from McKinsey & Company. This material was used by McKinsey & Company during an oral presentation; it is not a complete record of the discussion. CONFIDENTIAL OPI Module #8
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An example for RCPS in illustrated story. Learn how to do root cause problem solving from the example given. Easy to use for teachers or learning facilitators.
Transcript of Root cause problem solving example
Root Cause Problem Solving
“The fire”
May 5, 2006
This report is solely for the use of client personnel. No part of it may be circulated, quoted, or reproduced for distribution outside the client organization without prior written approval from McKinsey & Company. This material was used by McKinsey & Company during an oral presentation; it is not a complete record of the discussion.
CONFIDENTIAL
OPI Module #8
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Two hours later …
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Fire
Fuel
Heat O2
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Fire
Fuel
Heat O2
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Fire
Fuel
Heat O2
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Two days later …
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Fire
Fuel
Heat O2
?
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Fire
Fuel
Heat O2
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Fire
Fuel
Heat O2
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Two months later …
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Fire
Fuel
Heat O2
?
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Fire
Fuel
Heat O2
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Fire
Fuel
Heat O2
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Root cause problem solving – 5 Why?
Why was there a fire?
Why was there oxygen?
Oxygen cannot be removed.
Why were people smoking?
Put non smoking sign!
Why was there a leak?
Why did they keep falling on the pipe-line?
Cut tree, eliminate the root cause!
Why did coco-nuts fall on the pipeline?
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Results of root cause analysis
5 Why? - Root cause analysis revealed falling objects (coconuts) as root cause for the pipeline leak and thus the fire
Implication
To prevent this from happening again:1) Cut tree2) Check for other falling objects3) Incorporate learning in SOP
Root Cause Problem Solving
“The fire”
May 5, 2006
This report is solely for the use of client personnel. No part of it may be circulated, quoted, or reproduced for distribution outside the client organization without prior written approval from McKinsey & Company. This material was used by McKinsey & Company during an oral presentation; it is not a complete record of the discussion.
CONFIDENTIAL
OPI Module #8
