Root Cause Analysis (RCA)

A TPM Tool for a Learning Organization

Course Topics:

This course will cover the following topics:

Why-Why RCA Process
Role of Why-Why Analysis in TPM
Application of Why Why
 Section 1
Why-Why Process
Causes of :Losses
Multiple Causes -
Need Complex
countermeasures combination
Single Cause - for each cause
Easy to discover of causes
& Address
cause Problem
cause
cause

cause cause cause

cause
Causes of Losses are Often Complicated :
Common Failure scenario:
1. Management system breakdown
2. Failure to implement counter-measures
3. Premature equipment failure
4. Employees fails to follow procedure
5. Failure to ID & Respond
6. Large Loss Results
Equipment failure
Mgmt
breakdown Failure to Follow
procedure

Loss
 The Loss Pyramid

m a jor
ca ll/ t
LTA Re efec
Traditional d
Programs R ie v al
r
Ret ct
Measures MT or k d e f e
w .
Reactions R e / m ed f e ct
First o ld r de
Aid n H
m ino S TD
O c / UB
e S
Near f S p N S,
Misse to TIO NS
s O u I A
EV TIO
AT R
IS K BE S S D ONDI
HAVI O CE C
OR P R
 TPM RCA is Proactive
Addresses the Underling Causes of Losses

• Why- Why identifies the Root Causes of Losses

• Supports Implementation of Countermeasures
• Promotes Transfer of Learning
 Steps in Why - Why RCA
1. Identify the Problem
– observe, gather facts
2. Understand Ideal Situation
3. Identify & Understand the Phenomenon
- answer 5 W’s & 1 H of incident (what, when, where, who,
which, how severe)
4. Ask Why loss occurred...
– Consider both equipment & behavioral branches
– Ask successive Why for each branch
– ID Root Causes
5. Implement Countermeasures
6. Standardize (One Point Lesson)
 Step 1 - Identify Problem
Exercise

Quantify
Loss
 How does it Work?

Step - 2 Understanding the Ideal Situation

• Draw a equip sketch
One needs to of all parts and
Where analysis understand equipment locations of the related
involves equipment functions, structures subjects.
and manufacturing and operational
principals • Learn operational
related matters principals
One needs to • Draw a work flow chart.
Where analysis understand flow of
work and what is • Gather together and know
involves operational what forms and papers
matters involved in each
situation there are to fill out
Step - 3 Identifying the Phenomenon

Problem Phenomenon Phenomenon Means:

• Observing the facts with
your own eyes & all senses
• The facts without
presumption

Complex
combination of
causes
Utilize 5W’s 1H When Identifying the Phenomenon

What Material/ Prod No’s Lots/Types

When Trend Continuous Rate
Time / Period Start-up On Processing
Where Process Line/ Equipment
Location Part /Range
Who Skill Level Shift / Experience
Which Trend Direction (+) (-)
How Status
How (many) % / Piece
 Step 4 - Ask Why...? (Ask Successive Whys)
(Follow Phenomenon - Factor Relationship)
Phenomenon Factor (Why)

Phenomenon Factor (Why)

Phenomenon Factor (Why)

Phenomenon Factor (Why)

Phenomenon
CAUSE
Develop a Cause Tree to Order your Thinking

(1.1.1)
(1.1) What triggered 1.1?
(1.1.2)
(1) What triggered 1? Why
(1.2.1)
(1.2) What triggered 1.2?
Why
(1.2.2)
Phenomenon What triggered this phenomenon?

(2.1)
: Last “why’s”
(2) What triggered 2? Why (original sources of factors
that had led to phenomenon)
(2.2)
5W1H
Root Cause Analysis - 5 Why
Plant (where):
Date (when):
Case / Injury (What): Loss / Problem
Who: #1 Why?
Which:
How severe:
Behavioral Branch
Equipment Branch

#2 Why? #2 Why?

#3 Why? #3 Why?

#4 Why? #4 Why?

#5 Why?

Recommendations:

1 2 3 4 5 6
 Causes to Consider

Equipment Branch
• Improper Equipment Ordered
• Poorly Designed Equipment
• Inadequate Maintenance
• Wear & Tear
• Abuse or Misuse
 Causes to Consider

Procedural Branch
• Lack of Procedures
• Inadequate Procedures
• Misunderstood Procedures
• Failure to Warn or Respond
Note: Large losses often occur because of failure to
take timely action
 Causes to Consider

Behavioral Branch
• Lack of Knowledge
• Lack of Skill
• Physically Incapable
• Lack of Motivation
Why - Why Steps 1- 4 –
1. Identify Problem 2. Identify & Draw
Ideal Situation

3. Identify Phenomenon 4. Follow Phenomenon-Factor

What: Relationship – Draw Cause
When: Tree (Ask Why?)
Where: WHY 1?
Who: WHY 2?
Which: WHY 3?
How Many: WHY 4?
WHY 5?
Phenomenon:
Step 5 - Countermeasures

Last “Why’s” Countermeasures

Lack of lubrication Prepare lubrication

standards standards

Material strength is not Strengthen

enough materials

Installation positions are Mark all positions where

not clear things are to be installed
Step 6 - Standardize
After improving work methods or equipment, it is
important to standardize them to prevent people from
slipping back into old habits.

Typical standards include the following:

•Cleaning, Inspection and Lubrication Standards
•Maintenance Standards
•Education Standards (i.e. One Point Lessons)
•Engineering Standards