Root Cause Analysis

Case Study
Definition of Terms:
A root cause is defined as a factor that caused a nonconformance
and should be permanently eliminated through process
improvement. The root cause is the core issue—the highest-level
cause—that sets in motion the entire cause-and-effect reaction that
ultimately leads to the problem(s).

Root cause analysis (RCA) is defined as a collective term that

describes a wide range of approaches, tools, and techniques used
to uncover causes of problems.

https://asq.org/quality-resources/root-cause-
analysis#approaches
We use Fishbone diagram

5 M – Manpower,
Materials, Method,
Machine and Money.
Case Study 1
School X offers chemistry classes to undergraduate
students, servicing laboratory subjects to different
colleges. During the conduct of the experiments, student
X spilled the chemicals on the sink and flushed with
water.
Case Study 2
Company X has been processing precious metals in its
operation. One of the laboratory procedures is crushing and
grinding of sample ores. During the process, particulates are
emitted to the atmosphere and proximity in nearest surroundings.
There was a dust scrubber installed only to found out that the
suction is not sufficiently enough to collect dust.
Case Study 3
Student X enters his laboratory classroom. He usually sorts out
his things before performing the experiment. The task on the
experiment includes techniques in using Bunsen burners. On the
course of the experiment, one of his classmates points the mouth
of the test tube to him and a sudden projectile shoot on his face.
To attend the need, he was assisted to wash his face, but was of
difficulty using the standard faucet.
Case Study 4
Worker X was doing a gravimetric analysis on the determination
of total solids (TS) on the monthly waste water samples. He
followed the protocols on his work to finish the analysis. He went
to seat and do the evaluation of the results for the first constant
weighing (24 hours drying). He logged the data and return he
samples in the oven for drying. After two hours, he transferred
the sample to desiccator and waited for 15 minutes. He recorded
the data. He did two more constant weighing and recorded again
the data. During the evaluation, he observed that the results were
erratic, that it should follow a downward trend. Walking in the
balance room, he noticed that the calibration certificate was
outdated.
Case Study 5
Worker X reported to his duty at morning shift (7:00-3:00 PM).
One of his duties was drying of ore samples. The samples arrived
at around 10 AM and he received a total of 50 samples. He
checked one at a time and affixed his signature on the waybill to
receive a total of 50 samples. He placed the ores on metal pans,
spreading evenly for quicker drying. He transferred all the pans to
the trays and closed the dryer. Upon closing of the dryer, his
supervisor called him to process samples for AAS. He followed
suit. At around 1:30 PM, he checked his samples. The samples
were still wet, not even hot. The switch was still OFF. Anxiety
rushed on him; he overturned the maximum temperature to
compensate the drying time. Hours passed by a fire broke out.
Case Study 6
Office X of a pharmaceutical company is currently doing an
inventory of all the chemicals, so to compensate the materials
and supply and consumption. A worker was tasked to back track
all the pertinent data on all the chemicals. He was overwhelmed
with tons of boxes of papers, some of which are chemicals with
no permit.
Case Study 7
Company X is producing meat canned goods as their
mainstream product. The process involves a batch process of
mixing all the ingredients and filling in cans. The cans were
packaged accordingly. The batch were tagged with
manufacturing date and batch number. After a month, a
salmonella incident was flashed on the news, affected individuals
were reported to have consumed the product.
Case Study 8
A sale of ergonomic chair was launched by Company X. Due to
high demand; a number were produced to sustain the sale for
two weeks. Office X procured the item and joyfully distributed to
their units. A month later, workers productivity was declining.
Backlogs were piling up, pain relievers were out of stock in the
clinic.
What to do?
1. Identify the problem.
2. Identify the root cause of the problem.
3. Identify corrective actions to eliminate the problem.