ROOT CAUSE ANALYSIS

Submitted By:
Under the guidance of : Preeti Baheti (BFT/18/157)
Mr. Ankur Makhija Mohammed Rushnaiwala (BFT/18/92)
What is RCA?

• Root cause analysis (RCA) is a class of

problem solving methods aimed at
identifying the root causes of problems
or incidents.
• It is often considered to be an iterative
process, and is frequently viewed as a
tool of continuous improvement.
Origin
• In the early 1900s, textile factories installed power looms to
manufacture cloth.
• They were designed to automatically pull yam from spools and
weave it into cloth.
• However, if a spool emptied, the loom continued to weave.
• This irregular cloth became waste.
• A loom inventor, named Sakichi Toyoda, assessed the waste
problem and found a solution .
• He applied a principle called Jidoka, which means a machine
should stop itself when a problem occurs.
• Many consider this principle the origin of Root Cause Analysis
because his looms no longer produced waste from an empty spool.
• Mr. Toyoda later became the pioneer of Toyota Production
Systems.
 Concentrating on performance improvement evaluations at root
causes is more effective than only removing the symptoms of a
problem.

A successful RCA is performed systematically, with conclusions

and causes supported by real evidence.

The purpose of considering all possible solutions to a problem is

Principles to inhibit recurrence at the lowest cost and in the simplest way.
Thus, always the the simplest or lowest cost approach is
preferred.

Usually, there is more than one root cause for any problem.

Focusing on WHY the mistake happened instead of WHO made

it.
 Benefits of RCA

Convenience: RCA is already

Automation: Automated
a streamlined process —
RCA system can share Realistic solutions: The Cost savings: RCA can also
automating it makes it even
information across factories solutions RCA creates can help increase your revenue.
more efficient. You can
within the same company, last for years. You can Defects, downtime and
detect safety hazards before
allowing managers to record develop clear, step-by-step maintenance all affect how
they become a reality and
notes concerning a common processes that work every much money you bring in,
predict deviations in
root cause and take steps to time and offer you and the longer you’re out of
product quality, fixing those
prevent it from happening incredible ease of use. commission, the more you
issues before they reach
at their own plant. When Avoid struggling with lose. Reducing the
your consumers. Even
each facility shares data, producing a new solution occurrence of these issues
without an automated
every plant can work more every time a malfunction keeps your company active,
solution, you still gain the
efficiently and avoid costly occurs — plug in a tried and so you can maintain your
advantage of an arsenal of
downtime and reactive true formula, instead. revenue stream.
data you can use to stop
maintenance.
problems in their tracks.
Types of RCA
Safety-based RCA descends from the fields of accident analysis and occupational safety and health.

Production-based RCA has its origins in the field of quality control for industrial manufacturing.

Process-based RCA is basically a follow-on to production-based RCA, but with a scope that has been
expanded to include business processes.

Failure-based RCA is rooted in the practice of failure analysis as employed in engineering and
maintenance.

Systems-based RCA has emerged as an amalgamation of the preceding schools, along with ideas taken
from fields such as change management, risk management, and systems analysis.
Tools used in
RCA
Steps of RCA
 Step 1 - Define the problem
• To define the extent of the problem and its effects in quantifiable terms, resulting in a narrower focus
for containment and root cause-finding efforts.
• Use 5W2H tool.
• Make a proper team to carry out this process consiting of a team leader and 7-8 team members having good
knowledge concerning the problem.
Step 1 - 5W2H

Who ? Identify who is associated with the problem.

What ? Describe the problem adequately.

If the problem occurs on a part, where is the problem

Where?
located?

When? Identify the date and time when the problem started.

Define why this is a problem for the Customer or

Why?
organization.
Step 1

In what mode of operation was the problem

discovered?
How ? What procedures were being used?
What environmental conditions were present?

Quantify the extent and severity of the problem

How much? (quantity, percent, cost, etc)
 Step 2 Assembling the data and inputs
• You can’t find what you don’t know.
• One should gather enough information/evidence around the problem statement to understand the
problem comprehensively.
• Try to seek as much qualitative and quantitative data about the problem statement, as possible.
• This step will involve using the Root Cause Analysis tools and techniques like pareto analysis, Fish
bone Analysis or Ishikawa Diagram, 5 WHYs, Cause and effect analysis.
 Why-Why Analysis
• Why are people searching for root cause analysis on the internet?
• Because there is no database to search in on their computer and the boss wants answers now.
Why?

• Why is there no database on the computer to search from?

• Because these are computers produced in 2000 and a knowledge databasecannot be installed.
Why?

• Why don’t we have new computers that can hdon’t we have new computers that can hdon’t we have new computers that can have
databases installed?
Why? • The company is short in money.

• Why is there no money left to purchase computers?

• Because we have lost money on repeat incidents.
Why?

• Why do we have repeat incidents?

• Because we haven’t sent people to proper training sessions.
Why?
 Step 3 Locate the root causes
• With enough data available to you, now you should review each of the causes identified and try to pin-point
the underlined/root cause behind the issue using various Root cause analysis tools available.
• 5 common RCA tools-
a) Pareto Chart.
b) The 5 Whys.
c) Fishbone Diagram.
d) Scatter Diagram.
e) Failure Mode and Effects Analysis (FMEA)
 Step 4 – Find Solutions
• This step is about coming up with the resolution for the root cause identified. The solution could be:
• Corrective Solution: A short term or stopgap measure to tackle the problem at hand. This solution addresses
the ‘direct’ and ‘evident’ cause of the issue
• Preventive Solution: A more thought about and long term resolution that targets the ‘root cause’ and prevents
it from re-occurring
 Step – 5 Create actionable strategies to
implement the solution

• With the solution defined, it’s time to devise the plan to incorporate the solution, methodically.
• This step will involve identifying and recording:
a) activities required to implement the solution
b) resources needed for the activities
c) schedule of activities
d) users responsible for the activities
e) any additional aspects around the solution’s implementation
Corrective Action Plan

• Verification of the solution before implementation will eliminate the problem.

• Cleary decide factors like when the problem will be solved? , what actions will be taken to solve the
problem? , who is responsible for what?.
 • Immediate action
Action taken immediately to fix the problem.
Types of • Permanent root cause corrective action
Corrective Actions Action taken to eliminate the problem on the affected area.
• Preventive corrective action
Action taken to Prevent the problem from occuring again in
any area.
Step – 6 Monitor the solution and acknowledge the team
work.

Last and quite essential step in the RCA process is to regularly If the solution works and doesn’t create further problems,
monitor the solution post its implementation and ensure it stays always validate your employees and celebrate them and their
viable and doesn’t let the root cause to reoccur. success.
 Shortcomings of Traditional Root Cause
Analysis

It isn’t humanly possible to analyze all the combinations of all the data on a production line, all
the time.

Often, most RCA information isn’t shared across manufacturing sites, as manual analysis doesn’t
scale. This leaves factories of the same company – or even individual lines within the same
factory – to repeat each other’s mistakes, leading to losses that could have been avoided.

Manual RCA is conducted on an ad-hoc basis. But as manufacturing processes are dynamic, the
data is constantly changing, so the analysis can quickly become redundant.
The Power of Automated Root Cause Analysis
Automated root cause analysis harnesses the
power of Machine Learning – a subfield of
Artificial Intelligence that focuses on
developing and researching algorithms that
learn from data.
They take the task of analyzing and
interpreting data away from the people on
the factory floor, thereby enabling them to
focus on actually optimizing the processes
and improving performance.
Significant advances in machine learning and
Big Data analytics, root cause analysis can be
performed using automated methods -
unbiased and based purely upon historic and
real-time data from the production floor,
infused with process expertise.
If you had to summarize the value of machine
learning in root cause analysis, it would
be: Less time spent on figuring out the
problem, more time spent on fixing and
preventing it.
 • Root cause analysis is a powerful tool for finding the root

Relevance of cause for the occurrence of defects in any manufacturing of

production especially in garments manufacturing.
• Following two case studies show the relevance and significance
RCA in of Root Cause Analysis and its tools in Garment Industry -
• Case study 1 :Measurement & Analysis of Productivity
Apparel and Finding Solutions to Improve Productivity in a Garment
Factory in Bangladesh
Industry • Case study 2: An application of Pareto analysis and cause-and-
effect diagram (CED) to examine stoppage losses
Case Study - 1
Measurement & Analysis of Productivity and Finding Solutions to Improve Productivity
in a Garment Factory in Bangladesh
By - Muhammad Abdus Samad, Chowdhury Luthfur Rahman, Md. Toufiqur
Rahman,Md. Shafiqul Islam and Prodip Sarkar
Overview
• In this case study we have analyzed the productivity in sewing section of a garment factory.
• Labor productivity was measured and analyzed using Kurosawa’s structural approach.
• It was found that the labor productivity is not up to the standard level.
• The reasons that reduce labor productivity and the factors for improving labor productivity were identified
using questionnaires and observations.
• The focus of the study was labor productivity and defects in the production floor.
• Occurrence of defects was analyzed using Pareto analysis which helped to identify the vital defects.
• Using root cause analysis, cause and effect diagram was generated and the reasons of the defects were
identified. Based on that, the solutions for reducing those defects were recommended.
• Some of the techniques that the garment manufacturing factory can implement are six sigma, automation
and nominal group technique.
Methodology

Topic Selection Investigation Factory Selection Questionnaire Data Collection

Analyzing Current Analyzing

Root Cause Analysing Labor
Productivity Worker's Pareto Analysis
Analysis Productivity
Condition Response

Recommendation
for Improvement
Problem

• The employee of the sewing department was unable to meet the set target implies that
the manpower and other resources are not used efficiently and effectively.
• Since the sewing department is unable to achieve the targets, it means some proportion of
the resources are being wasted.
• Some reasons that we have identified for low productivity are:
a) Machine Breakdown
b) Absenteeism
c) Manual operation
d) Defective products and Rework
Solution Using RCA tools

• Pareto Analysis: to identify the vital few

defects that take up around 80% of the
total defect that occurred.
From the pareto analysis, the vital defects identified are:
a) Skip Stitch (16.39%)
b) Dirty Spot (14.71%)
c) Uncut Thread (12.65%)
d) Raw Edge Out (7.4%)
e) Open Seam (7.29%)
f) Pleat (7.05%)
g) Top Stitch (5.68%)
h) Broken Stitch (4.77%)
These occurrences of these 8 defects are more than 75%
of the total defects.
• Cause and effect diagram in Sewing department: Based on the cause and effect diagram, the root causes were identified
for the vital defects of the sewing section and their solutions are also given.
Cause and Effect Diagram for Low Productivity in the Garments Factory
Conclusion and Findings
• The result indicated that labor productivity is lower than the standard level.
• The occurrences of defects are also high. That means resources aren’t fully utilized.
• The main reasons of low productivity lie within management, machine breakdown,
defective products, and incentives.
• Working condition of the garments factory is relatively better but there is no suitable
incentive program.
• Planning department set target production based on market demand, past data,
employees’ capability etc.
• As the garment factory don’t fulfill target production quota, it means resources aren’t
fully utilized.
• Through pareto analysis and cause and effect diagram we could list down roots of the
defects that are causing the problem.
• Hence now we know the roots, we can take suitable actions to prevent the defects to
occur again.
 Case Study - 2
An application of Pareto analysis and cause-and-effect diagram (CED) to examine stoppage losses
By - Jamal Hossen, Nafis Ahmad & Syed Mithun Ali
Department of Textile Engineering, Ahsanullah University of Science and Technology, Dhaka,
Bangladesh
Department of Industrial and Production Engineering, Bangladesh University of Engineering
and Technology, Dhaka, Bangladesh
Overview

• Spinning industries are facing challenges of improving productivity in the competitive market nowadays.
• Ring spinning, the most widely used yarn manufacturing process for short staple spinning, uses several types of
machinery from blow room to ring frame for producing yarns from cotton fibers.
• An enterprise can improve utilization of resources by identifying unwanted machine stoppage and taking
corrective actions at different points in the production cycle.
• This study focuses on the major six stoppage losses that are used to calculate Overall Equipment Efficiency (OEE)
of ring frame section.
• The Pareto analysis reveals that idling and minor stoppage and breakdown losses are responsible 89.3% of total
stoppage losses.
• According to cause-and-effect analysis, root causes for the stoppage losses are: high doffing time, high traveler
changing time, broken end of yarn due to piles generation through the front roller, power failure and change in
Draft Change Pinion (DCP) due to breakage of teeth of the gear during starting of machine by operators before
lowering of ring rail and change of Twist Change Pinion (TCP) due to the displacement of TCP gear shaft.
• Recommendations are made to reduce stoppage losses and to increase the productivity of the ring frame
section.
 Distribution of
Selection of a specific Data collection based
stoppage losses by pie
ring frame on stoppage losses
chart

Construct cause-and Counter actions taking

Construction of a
Pareto Chart to identify
significant losses
effect diagram for
significant losses based
on their causes
to reduce stoppage
losses and smooth
running of machines
Methodology

Analysis and discussion

about counter actions
Problem

• The productivity of a yarn manufacturing factory is affected by several factors including stoppage
time losses, spindle speed, waste extraction percentage.
• The reduction of stoppage time is necessary to increase the productivity of ring frame in the textile
processing factory.
• The efficiency and productivity of a spinning mill reduced due to unwanted stoppage of machinery.
• It is necessary to reduce unwanted stoppage of machine or equipment for nonstop production to
meet the demand.
• The stoppage is categorized as major six losses which are used to calculate overall
equipment efficiency.
• The six big losses are equipment failure or breakdown losses, setup or adjustment losses, idling and
minor stoppage losses, reduced speed losses, yield losses, and quality defects or rework losses.
Solution using RCA tools
• Pareto analysis: It is seen that the
most significant source of loss is idling
and minor stoppage, which is 67.2% of
total losses, then the second is
breakdown stoppage losses amounting
22.1%. Here, the idling and minor
stoppage and breakdown losses are
vital few factors causing 89.3%
stoppage losses. Others stoppage
losses are yield losses (8.4%)
and reduced speed (2.3%).
Cause-and-effect diagram for idling and minor stoppage: Major root causes are identified for idling and minor
stoppage. By using this information we can take corrective actions and solve the problem.
Cause-and-effect diagram for breakdown loss: The reasons for breakdown stoppage loss are categorized on the
basis of the influence of man, machine, materials and measures. Due to lack of skills of the operator, breakage of
DCP gear. Machine-related factors are displacement of front roller, breakage of V-belt, displacement of TCP gear
shaft that occurred due to a loose connection between nuts and bolts. Due to the generation of piles through
the front roller, the wastage is increased.
Corrective actions for breakdown losses
S. No. Stoppage type Causes Corrective Actions

1 The main motor Breakage of V-belt A Broken belt is replaced

stops

2 TCP breaks • TCP gear shaft is displaced • TCP gear shaft is adjusted
• Loose connection between nuts • The connection between nuts and
and bolts bolts are adjusted

3 Front roller bearing • Generation of piles through front • The position of front roller is
breaks roller adjusted
• Displacement of front roller

4 DCP breaks • Operators are not awarded about • The DCP gear is replaced
switch on/off button • The training program should be
• Unskilled operator arranged to develop the skill of the
operator
Conclusion and Findings
• Stoppage time losses are one of the most common problems of yarn
manufacturing industry.
• It should be minimized to ensure the highest productivity level of the ring frame section.
• Pareto analysis and cause-and-effect diagram are used to identify and evaluate different
types of stoppage time losses that are occurred in the ring frame section.
• After Pareto analysis, it is found that idling and minor stoppage and breakdown
losses constitute 89.3% of total stoppage losses.
• Then root causes of the stoppage losses are analyzed using a cause-and-effect diagram.
• Six different major concerning areas that are responsible for stoppage losses are higher
doffing time, more time is required for traveler change, all ends are broken due to piles
generation through the front roller, power failure, DCP changes due to breakage and TCP
changes due to breakage.
• Since now we know the roots of the causes we can eliminate them by performing
corrective actions.
References
Articles and blogs :
• Back to basics - Collecting Data for Root Cause Analysis by James J. Rooney and Lee N. Vanden Heuvel.
• Back to basics - The Art of Root Cause Analysis Five whys analysis to ask the right questions at the right time by
Vidyasagar A
• Fact sheet OSHA - The Importance of Root Cause Analysis During Incident Investigation.
• https://mantec.org/root-cause-
analysis/#:~:text=Root%20cause%20analysis%20can%20offer,company%20on%20a%20large%20scale.
• https://www.seebo.com/root-cause-analysis-examples-in-
manufacturing/#:~:text=The%20term%20%E2%80%9Croot%20cause%E2%80%9D%20refers,and%20the%20%
E2%80%9C5%20Whys%E2%80%9D.
• http://www.asq0707.org/download/presentations/8D-Training-ASQ-Meeting2017-9-12.pdf
• https://www.onlineclothingstudy.com/2016/08/the-5-why-simple-process-to-understand.html
• https://bobsleanlearning.wordpress.com/2010/09/16/root-cause-analysis-overview/
• http://cbafaculty.org/DAU/CMQ220%20Root%20Cause%20Analysis/CMQ220%20Root%20Cause%20Analysis%
20L1%20Final.pdf
References
Case Studies:
• Measurement & Analysis of Productivity and Finding Solutions to Improve Productivity in a Garment Factory in
Bangladesh (By - Muhammad Abdus Samad, Chowdhury Luthfur Rahman, Md. Toufiqur Rahman,Md. Shafiqul Islam
and Prodip Sarkar )
• An application of Pareto analysis and cause-and-effect diagram (CED) to examine stoppage losses (By - Jamal Hossen,
Nafis Ahmad & Syed Mithun Ali , Department of Textile Engineering, Ahsanullah University of Science and Technology,
Dhaka, Bangladesh , Department of Industrial and Production Engineering, Bangladesh University of Engineering and
Technology, Dhaka, Bangladesh)
Links For Automated Root Cause Analysis Articles and Blogs:
• https://www.seebo.com/root-cause-analysis-examples-in-manufacturing/
• https://medium.com/datadriveninvestor/root-cause-analysis-in-the-age-of-industry-4-0-9516af5fb1d0
• https://www.researchgate.net/figure/Machine-Learning-workflow-for-automated-Root-Cause-Analysis-This-
procedure-rank-all_fig1_320089206
• https://lanalabs.com/en/automated-root-cause-
analysis/#:~:text=The%20automated%20root%20cause%20analysis,causes%20in%20an%20automated%20fashion.
Thankyou