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ROOT CAUSE ANALYSIS (RCA)

<PROJECT NAME>

COMPANY NAME STREET ADDRESS CITY, STATE ZIP CODE

DATE

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TA*LE O+ CONTENTS
$ntroduction......................................................................................................................................% &'ent "escription.............................................................................................................................% Chronology of &'ents ( Timeline.....................................................................................................) $n'estigati'e Team and !ethod.......................................................................................................* +indings and Root Cause.................................................................................................................* Correcti'e Action.............................................................................................................................,

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INTRODUCTION
This section highlights the purpose and importance of the root cause analysis (RCA). $t pro'ides a discussion of the approach ta.en to identify and document the root cause of a particular pro lem and the follow/up actions necessary to properly address the root cause. $t also highlights what root causes should(should not consist of. The purpose of this root cause analysis (RCA) is to determine the causes that contri uted to the recent fi er optic ca le project0s material failure in the research la . +rom this RCA we will determine e1actly what happened during the failure e'ent2 how it happened2 and why it happened. $n order to accomplish this2 a formal in'estigation will ta.e place among an in'estigati'e team assigned y the 3ice President of Technology. 4nce the team identified what2 how2 and why this e'ent occurred2 a list of root causes will e de'eloped. This list of root causes will then e used to implement any changes necessary in order to pre'ent another similar failure. $t is important to note that for the purpose of this RCA2 root causes should e# / As specific as possi le / Reasona ly identifia le / A le to e managed(controlled Careful consideration must e gi'en to all findings related to this RCA as these findings2 as well as their correcti'e measures2 will impact the TruWa'e project. +ormal communication with the TruWa'e project team must e conducted throughout and upon completion of this RCA.

E,ENT DESCRIPTION
This section pro'ides a description of the e'ent that is eing analyzed. $t pro'ides a clear and concise description of the pro lem that triggered this Root Cause Analysis. $t should state the date2 time2 detailed description of the e'ent(pro lem2 who detected the pro lem2 who it affected2 and how it affected them. $t is important that the descriptions are as detailed as possi le since this pro lem is the source of the entire RCA. 4n +riday morning2 5une -2 %611 at 7#-8am a failure occurred on ca le line 9% during the trial run of our new fi er optic ca le product2 TruWa'e. The line technician on duty2 5oe :mith2 noticed that the polyethylene ca le jac.eting was deformed as it e1ited the e1trusion de'ice. $nstead of a uniform distri ution of the jac.eting material2 the jac.eting material was thic.er in some areas and thinner in others. The technician also noted that there were significant tears in the material and other areas with no jac.eting lea'ing the ca le core e1posed. !r. :mith immediately shut the ca ling line down2 preser'ed all of the data in the ca ling line computer2 and notified his super'isor2 5anet ;rown2 per company procedure. This e'ent affects the entire TruWa'e project team and sta.eholders as it may re<uire changes in the scope2 cost2 and(or schedule of the project. This in'estigation may result in the need to ma.e design changes2 process changes2 or other modifications that may delay project completion and product release currently scheduled for 4cto er -2 %611 and 5anuary -2 %6-6 respecti'ely. As pre'iously stated2 all findings and correcti'e actions must e formally communicated with the project team.

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C-RONOLO.Y O+ E,ENTS / TIMELINE

$n this section you are to pro'ide a detailed chronology of the e'ents leading up to2 and following2 the pro lem. This is an important piece of the RCA as the chronology of e'ents may lead to clues in determining how or why the pro lem occurred. ;e sure to include names2 times and detailed descriptions of all acti'ities. 7#66 A! / +riday 5une -st %611 Ca ling line 9% was powered up in the research la y technician 5oe :mith.

7#6% A! / +riday 5une -st %611 Technician 5oe :mith manually enters process data and parameters for e1perimental ca ling run of TruWa'e product. 7#6= A! > +riday 5une -st %611 Technician 5oe :mith completes loading of ca le core material onto feeder spool and awaits ca ling line computer ac.nowledgement that the line components ha'e reached all temperatures and are ready for operation. 7#-) A! > +riday 5une -st %611 Technician 5oe :mith recei'es ac.nowledgement that the line is ready for operation and initiates ca ling start. 7#-? A! > +riday 5une -st %611 Technician 5oe :mith notices the first anomalies in the ca le jac.eting as it e1its the e1trusion de'ice. @o steps are ta.en as it is considered normal for there to e a high degree of deformity within the first %6/)6 meters of a ca le run. 7#-8 A! > +riday 5une -st %611 Technician 5oe :mith notices that the deformity is still present eyond any reasona ly e1pected length of a ca le run. Ae immediately initiates the shutdown se<uence of the ca le line which includes preser'ing all data in the computer for any follow on in'estigation. 7#%6 A! > +riday 5une -st %611 Technician 5oe :mith completes line shutdown procedures and data preser'ation and immediately notifies his super'isor2 5anet ;rown. 7#%% A! > +riday 5une -st %611 :uper'isor 5anet ;rown arri'es at ca ling line 9% and 'erifies that all shutdown se<uences and data preser'ation ha'e een performed. :he spea.s with Technician 5oe :mith and records his 'ersion of the e'ent. :he then assigns technician 5oe :mith to another tas. and reports the incident to the TruWa'e Project !anager2 "an White.

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IN,ESTI.ATI,E TEAM AND MET-OD

This section should descri e how the in'estigati'e team is assem led2 who it consists of2 and how it gathers the data to e used in the analysis. As with any process2 it is important in the RCA that clear roles and methodologies e esta lished in order to allow for the process to mo'e in a controlled and deli erate manner. This is also an important part of the RCA ecause a majority of time spent in RCA is gathering data a out the e'ent(pro lem. The in'estigati'e team for this RCA has een selected y the 3ice President of Technology who o'ersees all research and de'elopment projects. The following indi'iduals comprise the team# !arcy ;lac. > Bead !aterial &ngineer and RCA Team Bead 5ohn White > Bead Process &ngineer "a'id Creen > Bead "esign &ngineer 5ane ;rown > Duality Assurance &ngineer +or this RCA the in'estigati'e team will use inter'iews with employees in'ol'ed in the e'ent. The team will also download and analyze the process data from the ca ling line 9% computer that was preser'ed immediately following the e'ent. The team will utilize other tools and techni<ues at its discretion ased on the comple1ity of the data and e'ent (e.g. $shi.awa diagram). 4nce the findings and root cause(s) are determined and the correcti'e actions are identified2 this analysis will e communicated to the TruWa'e project team. The purpose of this is to allow the project team to implement correcti'e actions2 ma.e appropriate changes to the project plan and schedule as well as other project documentation2 and communicate these changes to the appropriate sta.eholders. This will also ser'e as a lessons/learned and e archi'ed for reference on future ca le de'elopment projects so this root cause does not occur again.

+INDIN.S AND ROOT CAUSE

This section should descri e the findings of the in'estigation and e1plain the root cause(s) ased on these findings. $t is possi le that a RCA results in findings that are not directly related to the root cause of the pro lem. These should also e captured as product(process impro'ement steps in an effort to impro'e the product(project. $t is important to note that this section does not descri e the correcti'e actions to e ta.en as a result of identifying root cause. Correcti'e action will e discussed separately in the ne1t paragraph. All findings must e formally communicated with the project team in order to ensure any project changes can e made in accordance with the project0s change management process. ;ased on the in'estigation conducted for the TruWa'e ca le failure e'ent on 5une -st %6112 the team has determined se'eral findings regarding this e'ent# -) The temperature of the e1trusion de'ice was found to e too low at *66 degrees + instead of the appro'ed ,%, degrees +. %) The low e1trusion temperature did not melt the polyethylene properly to ensure uniform distri ution along the ca le length.

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)) The technician2 5oe :mith2 manually entered the temperature as well as other process parameters. According to the computer log he manually entered ,%, degrees + ut did not hit the E&nterF .ey and after -6 seconds the computer defaulted ac. to the *66 degree + temperature. *) Technician 5oe :mith performed all shut down and data preser'ation procedures correctly and notified his super'isor within an appropriate amount of time. ,) All other ca le products ha'e process profiles uilt into the lines to pre'ent any manual entry of process and temperature data. This safeguards against any operator error in manually entering process parameters. ;ased on the a o'e findings the in'estigati'e team has determined that the root cause for the TruWa'e trial ca le failure was operator error in that the manual temperature setting for the e1trusion de'ice was incorrect. While the operator attempted to set the temperature correctly2 he did not hit the E&nterF .ey after setting the temperature and did not ensure all settings were correct efore initiating the ca le run.

CORRECTI,E ACTION
As the purpose of the RCA is to determine the root cause of a pro lem2 it should result in some correcti'e actions that may e ta.en to ensure the same pro lem is not repeated. 4ften2 these correcti'e actions will result in changes to a project0s scope2 schedule2 or cost. $t is imperati'e that all of the findings and correcti'e actions are detailed and formally communicated with the project team so changes can go through the change management process and e implemented in the project plan upon appro'al. ;ased on the findings of the TruWa'e ca le failure e'ent on 5une -st2 %611 the RCA team has determined the following correcti'e action to pre'ent a repeat of this incident# All project teams esta lish process parameters within which their trial ca les must e uilt on the ca ling line. Pre'iously2 line technicians would manually enter process parameters into the line computer since these ca les were not yet part of production. The RCA team proposes that process parameters for trial run ca les also e pre/programmed into the line computers prior to trial runs in order to pre'ent entering incorrect data as a result of human error. Gnder this new process line technicians would simply select the correct pre/programmed file name associated with the trial ca le instead of manually entering )6 lines of process parameters. The e1pected result of this correcti'e action is the elimination of human error associated with future trial ca les runs.

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SPONSOR ACCEPTANCE
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