Case Study – Root Cause Analysis in the case of personnel qualification records are not maintained

Case Study

Problem description: During internal quality audit, it’s found that the competencies data of newly hired employee are not available and properly maintained in HR Dept.

Purpose / objective : How to follow up until closed out the Corrective Action Request

Background :

On one occasion to do an internal quality audit in HR Dept. , I found that the competencies data of newly hired employee are not available and properly maintained.

ISO 9001:2008 Clause 6.2.2.a requires the organization shall determine the necessary competence for personnel performing work.

The question is :
1 . How do I find the root of the problem ?
2 . What corrective action and recommendations for preventive actions?
3 . Quality Records ?

One technique to find the root of the problem is a ” 5 – Whys ” .

There are two primary techniques used to perform 5 Whys: the fishbone (or Ishikawa) diagram and a tabular format. These tools allow for analysis to be branched in order to provide multiple root causes.


Figure 1 – “5 Whys” Root Cause Analysis Technique

The 5 Whys is an iterative question-asking technique used to explore the cause-and-effect relationships underlying a particular problem.

The primary goal of the technique is to determine the root cause of a defect or problem. (The “5” in the name derives from an empirical observation on the number of iterations typically required to resolve the problem.)

The technique was originally developed by Sakichi Toyoda and was used within the Toyota Motor Corporation during the evolution of its manufacturing methodologies.


  • The vehicle will not start. (the problem)
  1. Why? – The battery is dead. (first why)
  2. Why? – The alternator is not functioning. (second why)
  3. Why? – The alternator belt has broken. (third why)
  4. Why? – The alternator belt was well beyond its useful service life and not replaced. (fourth why)
  5. Why? – The vehicle was not maintained according to the recommended service schedule. (fifth why, a root cause)

Here are the steps how to DEFINE ROOT CAUSE ( S )

Why 1 :  Qualification record is with individual section and compiled data is not available with HR Dept.

Why 2 : Personnel Requirement (Requisition) by Project Management Team through verbal and or e-mail (without using Manpower Requirement form).

Why 3 : Urgent personnel requirement to secure the execution of project works.

Why-4 : HR Staf on duty did not aware about the importance of personnel qualification records and did not know what & how.

Why-5 : HR Staf on duty has not been given Quality Management System (QMS) Awareness (Lack of training or awareness )

Based on the root of the problem, it is recommended:

Corrective Action (s)

1, Personnel Requirement (Requisition) Record to be maintained

2, Record of Personnel Qualification to be maintained

3. List of Recruitment to be maintained


1, Refreshment course on the requirements of recruitment and personnel qualification to be conducted for the HR dept. .

2. HR and QA jointly form a team to review and establish the New Human Resource, Admin & General Affairs System, as necessary.


Figure 1 – Example of Root Cause Analysis in the case of personnel qualification records are not maintained

Figure 2 – Example of Employee Recruitment List

CF-185B_Personnel QUALIFICATION - 2013_rev0

Figure 3 – Example of Personnel Qualification Record

Video: “Introduction to Root Cause Analysis Video Preview”

Uploaded in YouTube by patonprofessional on Mar  1, 2010

Video Description:

Do you have recurring problems that are costing you time and money? Unresolved problems do more than aggravate. They can increase costs, lower quality, and drive customers away. Plus, quality management processes, such as ISO 9001, require organizations to have a corrective and preventive action process in place. Root cause analysis is integral to the success of any corrective action or problem-solving process.
Unfortunately, root cause analysis is an often maligned, misunderstood, and misapplied process. Instead of viewing root cause analysis as an opportunity for improvement, many see it only as an admission that things have gone wrong. Root cause analysis should be seen as an opportunity, not a chore.
This preview provides a quick overview of Paton Professional’s in-depth video Introduction to Root Cause Analysis, hosted by Denise Robitaille. For more information or to order, visit

  • Category       : Education
  • License : Standard YouTube License



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