ROOT CAUSE ANALYSIS TUTORIAL

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Ontic offers this brief tutorial to assist you in pursuing your Root Cause investigation associated with the product or process noted on the accompanying Supplier Corrective Action Request !he Root Cause Analysis method described in this tutorial is based on the premise that there are normally two avenues of investigation that must be pursued" !he Root Cause associated with the generation of the defect !he Root Cause associated with the escape of the defect to Ontic

!he first page of this tutorial displays a flowchart depicting the suggested general thought process that may be used during the #$efect%&scape' Root Cause Analysis Please note that some basic elements of the two parallel investigations may be interdependent (or e)ample* there may be an interlin+ed (ailure ,echanism -sometimes referred to as the $irect Cause. !his interdependency is especially common in the case of administrative process discrepancies that are under investigation !he second and third pages of this tutorial display detailed flowcharts illustrating each of the two parallel Root Cause investigations Please note that the e)ample (ailure ,odes and suggested associated $efects* (ailure ,echanisms* Root Causes and Preventive Actions are broad representations -investigation of real/life occurrences would uncover multiple potential (ailure ,echanisms* Root Causes* etc . !he fourth page of this tutorial is a more in/depth e)planation of the general terms used -i e (ailure ,ode* $efect* etc . 0our investigation should be enhanced if members of your investigating team fully understand the terms%concepts* and use the terms as a universal language during the investigation

ROOT CAUSE ANALYSIS FLOW Page 2 of 5 DEFECT GENERATION DEFECT ESCAPE

What is the SYMPTOM?

FAILURE MODE

FAILURE MODE

What is WRONG?

DEFECT

DEFECT

How did it HAPPEN?

FAILURE MECHANISM (DIRECT CAUSE)

FAILURE MECHANISM (DIRECT CAUSE)

What ALLOWED it to happe ?

ROOT CAUSE

ROOT CAUSE

What A!T"ON wi## $eep it f%o& happe i g?

PREVENTIVE ACTION

PREVENTIVE ACTION

ROOT CAUSE ANALYSIS FLOW (GENERATION OF THE DEFECT) Page ' of 5

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What is the SYMPTOM?

FAILURE MODE

*+

What is WRONG?

DEFECT

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How did it HAPPEN?

FAILURE MECHANISM (DIRECT CAUSE)

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What ALLOWED it to happe ?

ROOT CAUSE

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What A!T"ON wi## $eep it f%o& happe i g?

PREVENTIVE ACTION

ROOT CAUSE ANALYSIS FLOW (ESCAPE OF THE DEFECT) Page 2 of 5

E(a&p#es -o5se%4ed 56 3/sto&e%+) *+ ,ai#s Test -Low .o#tage O/tp/t+ 2+ Dia&ete% Tape%s to 0 de%si1e '+ Pai t ,#aw -R/ s+ 2+ ,A"R ot %e3ei4ed 56 *+ No <dete3tio of Test ,ai#/%e th%o/gh a## i te% a# 7/a#it6 !o t%o#s 2+ No <dete3tio of di&e sio a# dis3%epa 36 th%o/gh a## i te% a# 7/a#it6 !o t%o#s '+ No <dete3tio of !os&eti3 Att%i5/te th%o/gh a## i te% a# 7/a#it6 !o t%o#s 2+ ,A"R %epo%ti g %e:/i%e&e t ot dete3ted d/%i g !o t%a3t Re4iew P%o3ess

What is the SYMPTOM?

FAILURE MODE

What is WRONG?

DEFECT

How did it HAPPEN?

FAILURE MECHANISM (DIRECT CAUSE)

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*+ 2+ " s/ffi3ie t 7/a#it6 P#a i g p%o3ed/%e -test 3%ite%ia 4a#idatio ;test s/%4ei##a 3e+ " s/ffi3ie t 7/a#it6 P#a i g p%o3ed/%e -di&e sio a# *st pie3e= i <p%o3ess > fi a# i spe3tio + " s/ffi3ie t 7/a#it6 P#a i g p%o3ed/%e -.is/a# *st pie3e= i < p%o3ess > fi a# i spe3tio + " s/ffi3ie t !o t%a3t Re4iew p%o3ed/%e -de4e#op&e t of p%o3ess 3o t%o#s+

What ALLOWED it to happe ?

ROOT CAUSE

'+ 2+

What A!T"ON wi## $eep it f%o& happe i g?

PREVENTIVE ACTION

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EXPLANATION OF TERMS/CONCEPTS 5
FAILURE MODE:

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!he symptom or event that hints at the deeper problem -the $efect. !he observed failure%reduction in product performance or ability of the product to meet all specifications &)amples" 1nit fails test -low output voltage.* undersi2e diameter* late delivery to customer* blistered paint* reali2ed manufacturing cost e)ceeds estimated cost* etc

DEFECT: !he actual flaw in the product or process that is responsible for the (ailure ,ode 3hen dealing with special processes* machined parts -or other structural parts or assemblies.* the $efect can be identical to the (ailure ,ode -i e * undersi2e diameter* stoc+ material thic+ness oversi2e* sheet metal enclosure height undersi2e* etc . !he $efect identification must be as detailed as possible to facilitate the investigation

FAILURE MEC ANISM !DIRECT CAUSE": !he machine* hardware* or process discrepancy that results in the $efect -i e * bro+en tool bit* wor+ piece holding fi)ture misaligned* late delivery from supplier* machine tool program error* undefined manufacturing process* lac+ of in/process inspection process* etc . !here often e)ists multiple (ailure ,echanisms associated with a single defect4 each one should be prioriti2ed as to having the highest li+ely affect on the discrepant product%process !he identified (ailure ,echanism is sometimes mista+enly considered to be the Root Cause

ROOT CAUSE: !he systemic deficiency that allowed the (ailure ,echanism to occur* and to affect the product or process -i e * insufficient in/process inspection planning process* insufficient machine tool set/up instructions* insufficient manufacturing planning process* e)istence of undocumented manufacturing process%practices* etc . !he Root Cause is addressed through Preventive Actions aimed at eliminating the identified (ailure ,echanism-s.

PRE#ENTI#E ACTION: !he permanent systemic improvements that address the Root Cause and eliminate the (ailure ,echanism Preventive Actions can include procedural improvements* tooling redesign* mista+e proofing -through special tooling in the case of manufacturing processes* or the application of appropriate computer software in the case of administrative or document related events.* employee training per revised procedures* etc

Preventive Actions addressing the actual Root Cause are systemic in nature and transcend all immediate corrective actions%discrepant product containment actions related to a specific part number* discrete process* etc