Most problems are dealt with in superficial ways.  Very few people and organizations actually arrive at the root cause of their problems.  At Toyota, they employ Root Cause analysis in almost everything they do.  One problem solving approach they employ is the A3 Process.

A3 is a paper size, typically 11" x 17".  There are actually several A3-type paper sizes, and Toyota believes that when you structure your problem solving around 1 page of paper, then your thinking is focused and structured.  

Below are the steps of the A3 process, followed by a real-world example of an A3 collaborative problem solving that I was a part of while I spent a short time at Toyota.  The steps below are taken from Dr. Durward Sobek’s very informative site:

Identify Problem or Need

Whenever the way work happens is not ideal, or when a goal or objective is not being met, you have a problem (or, if you prefer, a need).  The best problems to work on are those that arise in day-to-day work and prevent you from doing your best.

Understand Current Situation

Before a problem can be properly addressed, one must have a firm grasp of the current situation.  To do this, Toyota suggests that problem-solvers:

• Observe the work processes first hand, and document one’s observations.
• Create a diagram that shows how the work is currently done.  Any number of formal process charting or mapping tools can be used, but often simple stick figures and arrows will do the trick.
• Quantify the magnitude of the problem (e.g., % of customer deliveries that are late, # of stock outs in a month, # of errors reported per quarter, % of work time that is value-added); if possible, represent the data graphically.

Root Cause Analysis

Once you have a good understanding of how the process (i.e., the one that needs to be fixed) currently works, it’s time to figure out what the root causes are to the errors or inefficiency.  To accomplish this, first make a list of the main problem(s). Next, ask the appropriate “why?” questions until you reach the root cause. A good rule-of-thumb is that you haven’t reached the root cause until you’ve asked “why?” at least five times in series.

A common tool used in Root Cause Analysis is the Ishikawa Diagram, which is depicted below:

Main Components of an Ishikawa Diagram

1. At the head of the Fishbone is the defect or effect, stated in the form of a question.
2. The major bones are the capstones, or main groupings of causes.
3. The minor bones are detailed items under each capstone.
4. There are common capstones, but they may or may not apply to your specific problem. The common ones are:

• People
• Equipment
• Material
• Information
• Methods/Procedures
• Measurement
• Environment

After completing your Fishbone Diagram excercise as a group, it is helpful to test your logic by working the bones: top-down OR bottom-up like:

this happens because of g; g happens because of f; f happens because of e; e happens because of d; d happens because of c; c happens because of b; b happens because of a.

The excercise above is crucially important — you must test your logic so that it makes pragmatic sense and that the atomic root cause is actionable — that is, you can do something to correct it, reduce it, or eliminate the root cause.

Once you or your team arrive at a root cause for a specific capstone, then you typically “cloud” it to identify it as a root cause. A good rule is that there is typically *NOT* 1 root cause for a problem, but potentially several. Below is a diagram of one fishbone, decomposed:

Countermeasures

Once the current situation is fully understood and the root cause(s) for the main problem(s) has been unveiled, it’s time to devise some countermeasures. Countermeasures are the changes to be made to the work processes that will move the organization closer to ideal, or make the process more efficient, by addressing root causes.  Generally speaking, we recommend that countermeasures help the process conform to three “rules” borrowed from Steven Spear and Kent Bowen and slightly expanded: 

• Specify the outcome, content, sequence, and task of work activities.
• Create clear, direct connections between requestors and suppliers of goods and services.
• Eliminate loops, workarounds, and delays

Develop the Target State

The countermeasure(s) addressing the root cause(s) of the problem will lead to new ways of getting the work done, what we call the target condition or target state. It describes how the work will get done with the proposed countermeasures in place.  In the A3 report, the target condition should be a diagram (similar to the current condition) that illustrates how the new proposed process will work.  The specific countermeasures should be noted or listed, and the expected improvement should be predicted specifically and quantitatively.

Implementation Plan

In order to reach the target state, one needs a well thought-out and workable implementation plan. The implementation plan should include a list of the actions that need to be done to get the countermeasures in place and realize the target condition, along with the individual responsible for each task and a due date. Other relevant items, such as cost, may also be added.

A3 Example

Below is an example from an A3 project.  The context for the A3 Report below is around the question "Why was the end-of-shift clean-up not being completed?"  This question drove the team to follow the A3 method and subsequent root cause analysis to arrive at the root causes and implement solutions.  This activity below was done proactively done by the team with full support from management. 

Click on the image for a larger view.

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For articles on queueing theory, time-traps, operations, lean and six sigma, please visit the links below:

• The Gemba is the Dojo

• Managing Constraints Under Peak Volumes

• Order Pipeline of Events

• Variation for Dummies

• On Game Theory

• Series on Queueing Theory

• Applied Regression Analysis

• 5S

• Click-to-Ship Processes

• Kanban Sizing and "Pull"

• Lean at Krispy Kreme

• Theory of Constraints and Camping

• Lean for Software Development

• Don’t Waste the Customer’s Time

• Featuritis and the Focus on the Customer