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    Root cause

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    © All Rights Reserved
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    4 views31 pages

    Rootcause Analysis

    Uploaded by

    John P. Bandoquillo
    Root cause

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF or read online from Scribd
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    of 31
    ROOT CAUSE ANALYSIS A WAY TO EFFECTIVE PROBLEM SOLVING Presented to: Polyfoam ~ RGC International Corp. Valenzuela City March 12, 2010 a Root Cause Analysis — A Way to Effective Problem Solving QUAL CLS At the end of this training program, the participants shall be able to’ C Define the problem and describe the steps in problem solving process, and; Explain the different tools in root cause analysis and know how and when to use them. SECTION 1.. .. Effective Problem Solving Process SECTION 2 «s+... .. Problem Identification SECTION 3.. Containment Action SECTION 4.. Root Cause Analysis SECTION 5 wessee . Formulation and Evaluation of Corrective Action SECTION 6.. Implementation and Monitoring of Corrective Action SECTION 7... FMEA: A Preventive-Based Problem Solving Tool SECTION 8... . Conclusion and Final Challenge Root Cause Analysis ~ A Way to Effective Problem Solving QuaLTY ris SECTION 1: : EFFECTIVE PROBLEM SOLVING PROCESS THE ICEBERG O Weare by nature very myopic. We have a very real tendency to see just what's before our eyes, and seldom what's beyond the reflection or beneath the surface. We see what we choose to see. This myopic nature, coupled with our apparent penchant for reactive behaviour, results in our missing some of the greatest opportunities for achieving progress in difficult situations. O We seldom actually deal with or solve true problems. We generally treat the symptoms until they subside to an extent where we no longer feel we need to treat them-and we foolishly think we have solved the problem, when we have in fact never even really addressed the problem. We are marvellous at deceiving ourselves into seeing and believing just what we want to see and believe. O AProblemis.... Difficult issue needing solution ™ Deviation from the set standard tm Whatever that stop us from doing better ®@ An opportunity for improvement. CC Organization’s Response to a Problem ™ Problem Denying ™ Problem Accepting ™ Problem Solving aD Root Cause Analysis — A Way to Effective Problem Solving C1 Those problems that have IMPACT on: = =, ™ Safety @ Health ™ Quality Once ™ Reliability =o ™ Productivity - = Financial Losses > 6oe 2. 408 mismerc | 3 aniod Za 1 Imagine an occurrence during which an operator is instructed to close valve A; instead, the operator closes valve B, As a result of investigation, the supervisor concludes that the operator error was the cause. CO To address this problem, the supervisor takes the following corrective actions: ™ Retrain the operator on the procedure, and Remind all operators to be alert when manipulating valves or emphasize to all personnel that careful attention to the job should be maintained at all times. OA process to determine the problem, analyze its root causes and implement effective solution based on the root cause. ; » (ISO 9001:2008 Clause 8.5.2, 8.5.3) mT ™ PDCA Cycle Approach ™@ Six Sigma Approach 8D Approach a TTY PLUS Root Cause Analysis — A Way to Effective Problem Solving Qt PDCA CYLE 7 ac TO = Fishbone Diagram + Pareto Chart 4.Determine the problem + Control charts 2. Analyze the problem + Histogram PLAN 3. Identify cause = Graphs 4. Planiset counter measures |= Check Sheets = Scatter diagram = Flowchart/Process Mapping 5, Implement the po countermeasure ©. Confirm effectiveness ofthe |= Graphs CHECK | countermeasures = _ Pareto Chart Act | 7.Standardize and establish |» Control Chart control = Check Sheet © 8D isa problem-solving methodology for product and process improvement, It is structured into eight disciplines, emphasizing... TEAM SYNERGY C1 The team as a whole is better and smarter than the quality sum of the individuals. Each discipline is supported by a checklist of assessment questions, such as “what is wrong with what”, “what”, “when”, “where”, “how much”. Use Team Describe the Protsom Tmplement and Yeriy tntenion (Contaisinent) Actwons) Pd Root Cause Analysis — A Way to Effective Problem Solving "institutionalize improvement ‘ontrol Deployment " Quantify Financial Results “Present Final Projact Results and Lessons Learned "Close Project Control "Design Solution ~Pllor Solution “Implement Sol "Identify Root Causes “Quantity Root Causes Verily Root Causes Develop Charter and Business Care Map Exit Collect Voice of the Customer Specify CTOs / Requirements Measure cTQs / Requirements "Determine Procer: Stability “calulate Baseline Sigma Refine Peo TT C. Establish a small group of people with the: ™ Knowledge ™ Time ™ Authority ® Skill +sto solve the problem and implement corrective actions. C1 The group must select a team leader. aa QUAETY Pus Root Cause Analysis — A Way to Effective Problem Solving Sonar =) CO Team responsible to solve a problem in the organization. QUALITY CIRCLE © members coming from within the department or section ™@ SELF-DIRECTED TEAM * cross-functional/ members from different departments Eenaenane. cate CO The Power of the Team... T.E.A.M. WORK Together Each Achieves More WORK 1. IIMPLEMENTER ™ a practical person who likes to get things done 2. COORDINATOR ™ coordinates the team and facilitates progress towards its goals 3. IDEAS PERSON @ puts forward original ideas 4. RESOURCE INSTIGATOR ™@ good at finding resources in the external environment. 5. MONITOR EVALUATOR ™ evaluates ideas and proposals and monitors the progress of the team 6, COMPLETER ™@ concerned with details Root Cause Analysis — A Way to Effective Problem Solving 7. DRIVER im shapes the way the team works and can provide motivation and encouragement 8. SPECIALIST brings specialist knowledge of the team 9. TEAM WORKER quieter member of the team who is keen to promote team spirit C. Four Cornerstones of Good Teamwork ™ Communication Trust @ Support ™ Commitment TI What do you do if a member of your team is not doing what you have agreed to do? Think of the possible reasons in the following order: ™@ Don’t kno * Examine your communication. © Has it been clear and concise? ™ Can't do: * Do they need skills, tools, or access? @ Won't do ‘© What are the consequences for failure? * Are there rewards for good performance? Dann FF TALIA Root Cause Analysis — A Way to Effective Problem Solving SECTION 2: PROBLEM IDENTIFICATION (eis naadi kooastol:1 83mm 1 itis the first step in the problem solving process. C “A problem well stated is a problem half solved.” - John Dewey yah Aare ealol ees 1. The Pareto Principle 2. The Godzilla Principle 3. The Triple Constraints Principle 4. The Control Point Principle 5. The Pop-Up Principle 20% SIGNIFICANT FEW) CO The Godzilla Principle tells us that to solve problems easily, catch them early. 1 How do you do this? Identify the risks (possible problems). Monitor your plan and note any significant deviations. Reflect on past experiences (problems) and learn from them. slice a alae Se ee a ee aa QUALITY PLUS 9 _— — = — —— a Root Cause Analysis — A Way to Effective Problem Solving Quay nies 1s every “deviation from the expected” a problem? The “Triple Constraints” principle of Problem Solving suggests that something is a problem if: MERNS LAW TIME cost ae P (Make you late) (Increases cost) 17 ROUNS. Fe HEP THe PERFORMANCE —— (Cegrades performance) ype If none of these occur, it's NOT a problem, = 210 $ just a HINDRANCE. This principle means that you normally act on problems only during certain periods, O These control points are: When you first think of the problem. ™ When you get an early warning sign. m When it actually happens * This principle suggests that solutions yield problems of their own. PROBLEM 1 PROBLEM 2 PROBLEM 3 ‘Solution to ‘Solution to, aaRLERt Problem 1 Problem 2 PROBLEM 5 Root Cause Analysis — A Way to Effective Problem Solving QUATT EUs (huaceseaueaeaarer aon @ Flowcharting/ Process Mapping ™@ Check sheet ™ Pareto Chart O Aproblem solving tool used to identify where the problem ; occurs in the process. | atk ' 1 1 Process Flow Diagram Symbols Terminator | Process Decision box Corinector L Off-page Connector a Root Cause Analysis ~ A Way to Effective Problem Solving QUAUTY Rhus Not just a tool for organizing and collecting data, the tool is used to determine which among, the problems needs to be solved first. Day Backload 1 2 3 4 ‘Wrong Size ul wi 1 Wrong Order Taking W 1 W my Mishandling 7 mt W mi C1 Disadvantages of Check Sheets ™@ Do not show changes over time. ™@ More tedious to determine the trend. ™@ Possible to misinterpret data due to different influencing conditions present. ARETO CHART. 1 80-20 Rule: 80% of the problems are accounted to VITAL FEW causes; 20% of the problems are accounted to TRIVIAL MANY causes. C1 Sample Pareto Chart Types of Document Complaints. Fourth Quarter 2009 40 109% Significant 30 ‘ Bo% 20 | Trivial 40% Many 10 205 9 — ° Gusily Quality Imoiee Pacungist Wieng other certficate cerfcste anor attr quariy ence missing. Penn IZ eee El Root Cause Analysis — A Way to Effective Problem Solving QUALITY nus ® bigeaatesuaa ‘The 5W’s in Defining the Problem What is the problem? WHAT | What is the magnitude of the | QUANTIFY the problem problem? wen | When does the problem Define the FREQUENCY of occur? OCCURRENCE What PROCESS or were. |Where the does the problem | oor eation doce the occur? problem occur Quantify the IMPACT of the problem WHY | Whyis it a problem? WITH | Who are primarily affected by WHO _ | the problem? O wHat What is the problem? What is the magnitude of the problem? (therefore, QUANTIFY the problem) Example: Summary of QA Report shows that there are 20 occurrences of backload for 1 week (or 2% of the total delivery trips) were back loaded due to mishandling. CO WHEN m@ When does the problem occur? (define the frequency of occurrence) Example: Period: 5% rejection rate last December 2009. Data of previous months shows that rejection rate due to wrong size. is lower. (a graph may be shown here to support the problem) Pann tt a Root Cause Analysis — A Way to Effective Problem Solving QUALITY PLUS OO WHERE Where does the problem occur? (what process/ operation does the problem occur) Example: FG Inspection Area (you may use a flowchart to detail wherethe problem really occurs, especially if there are more activities or processes that contribute to the problem) O wny Why is ita problem? (quantify the IMPACT of the problem) Example: IMPACT: P 65,000.00 scrap cost (or loss due to scrap) O WITH WHO Who are primarily affected by the problem? Example: No specific person directly affected by the problem identified. mann 14 a Root Cause Analysis — A Way to Effective Problem Solving QUALITY PLUS SECTION 3: : \ CONTAINMENT ACTION =i C. Intermediate action/ quick-fix action. CO Necessary to temporarily address the PROBLEM, not the CAUSE of the problem. C Important to: ™@ Appease the customer. ™ Prevent further damage. ™@ Prevent possible damage to potential customer/ user. C_ Define and implement those intermediate actions that will protect the customer from the problem until permanent corrective action is implemented. Verify with data the effectiveness of these actions. What action can be taken immediately? Do we have stocks that need sorting? Are we still manufacturing parts with the problem? will the actions that we take cause other problems? ooaoa Product Segregation Product Recall Replacement with New Product Production Stoppage ooaogo = ei AE oo Root Cause Analysis — A Way to Effective Problem Solving SECTION 4: ROOT CAUSE ANALYSIS hae, uae O RCA is the process for identifying the basic or causal factors tl underlie variation in performance. Ci Very critical and vital stage in the problem solving process. 1 Determines the effectiveness of the solution to be formulated later. CO Poorly executed root cause analysis will result to recurrence of the problem in the future. © Focuses on systems, not people 2 Positive approach to system changes CO Multidisciplinary 1 RCA can help identify risk-prone or weak points in processes. Faxes iene es 1. Root causes are underlying causes. 1 Goal should be to identify specific underlying causes. Hi The more specific why an event occurred, the easier it will be to arrive at recommendations that will prevent recurrence. 2. Root causes are those that can reasonably be identified. Occurrence investigations must be-cost beneficial. ait not practical to keep valuable manpower occupied indefinitely searching for the root causes of occurrences. a QUALITY Pas AVANTE Root Cause Analysis ~ A Way to Effective Problem Solving Quartus 3. Root causes are those over which management has control. Avoid using general cause classifications such as operator error, equipment failure or external factor. Management needs to know exactly why a failure ‘occurred before action can be taken to prevent recurrence. 1 We must also identify a root cause that management can influence. 4, Root causes are those for which effective recommendations can be generated. ™@ Recommendations should address root causes identified. @ If the analysts arrive at vague recommendations such as, “Improve adherence to written policies and procedures,” then they probably have not found a basic and specific enough cause and need to expend more effort in the analysis process. C1 Step 1: Determine possible causes, Step 2: Decide on suspected causes O Step 3: Verify root causes o A technique for tapping creative thinking during the construction of cause and effect diagram Maximize the brainpower of a team Use to generate ideas/issues Use to clarify ideas/issues ooa a Root Cause Analysis — A Way to Effective Problem Solving ALITY MUS EPS IN BRAINSTORMING Identify a facilitator Clarify purpose of the session Review rules of brainstorming Generate ideas, taking turns Display ideas Review ideas for clarification ooo0000 CO Cause & Effect Diagram © Why-Why Technique -TAr/eH) pun OC A diagram used to organize a search for the cause (s) of a problem; also known as 4 FISHBONE DIAGRAM. Materials Machine ‘\ Methods. Pann 4B BR Root Cause Analysis ~ A Way to Effective Problem Solving Quauety Pus 1 Dispersion Analysis C Process Classification \ Noestablished °M +— Lackofprogiam Poorlayout —+ Noisywork é / \ \ Foe orgotto Poor concentration upload f rena status report ——_— rn Cploadedin a the website / roomany | ¢ in the report / a Method theprogam No regular PM Too many conversion v in data Forgot to |_ ‘System was S upload ~~ down for an hour N x Uploadin: Limitation in the present process Draw data from word file Wrong status report uploaded in the website Convert to excel file AN k < Noisy work area oa \ Poor concentration Poor layout a pm 19 a a Root Cause Analysis — A Way to Effective Problem Solving (QUaFHTY rus Cl PRoceDuRE: Take a selected course and use a Why-why Diagram to explore the underlying causes of the problem. Each divergent step of the Why-Why analysis is produced by asking “Why?” Flo upload mediately Noevidence wu? wie Wrong report Poor Standards Double handing fata] Nocuidre (2 Taiichi Ohno used a similar but less developed methodology called the “Five Why's” to uncover the root cause of a problem and to correct it. The whole Toyota system was built on the practice & evolution of this scientific approach. C The “Five Why's” is not a superficial tool but one that is, expected to dig down to “the ultimate cause - almost always an organizational problem”. C1 “Underneath the ‘cause’ of a problem, the real cause is hidden In every case, we must dig up the real cause by asking why, why, why, why, why. Otherwise, countermeasures cannot be taken and problems will not be truly solved.” HIN e209 a2 ry pres Root Cause Analysis — A Way to Effective Problem Solving STEP 2: DECIDE ON SUSPECTED ROOT CAUSES (Xo Vatolol ky O Multi-voting CO Nominal Group Technique 1D Description: MI Multi voting narrows a large list of possible causes toa smaller list of the top priorities or to a final selection. Multi-voting is preferable to straight voting because it allows an item that is favoured by all, but not the top choice of any, to rise to the top. Cl APPLICATION: After brainstorming or some other expansion tool has been used to generate a long list of possible causes, When the list must be narrowed down, and When the decision must be made by group judgment. CO PRoceDuRE: 1. Display the list of options. 2. Decide how many items must be on the final reduced list. Decide also how many choices each member will vote for. 3. Individually, each member selects whatever number of choices is allowed which he or she thinks are the causes. 4. Tally votes. 5. Ifa decision is clear, stop here. Otherwise, continue with a brief discussion of the vote. O Example: POSSIBLE CAUSES ace ao Limitation inthe system Nee MeNrelee Poor layout that is conducive to chatting NaS celestial. t No regular PM Nig LEN |eey N | pom 24 aN Root Cause Analysis — A Way to Effective Problem Solving NOMINAL GROUP TECHNIQUE (NG OO This technique is a structured variation of small group discussion methods. The process prevents the domination of discussion by a single person, encourages the more passive group members to participate, and results in a set of prioritized solutions or recommendations. CO steps: 1. Divide the people present into small groups of 5 or 6 members, preferably seated around a table. 2, State an open-ended question. 3. Have each person spend several minutes in silence individually brainstorming all the possible ideas and jot these 4, Have the groups, collect the ideas by sharing them round robin fashion (one response per person each time), while all are recorded in key term, ona flipchart. No criticism is allowed, but clarification in response to questions is encouraged. 5. Have each person evaluate the ideas and individually and anonymously vote for the best ones (for example, the, best idea gets Points, next best 4 Points, etc), 6. Share votes within the group and tabulate. A group report is prepared, showing the ideas receiving the most points. 7. Allow time for brief group presentations on their solutions. Root Cause Analysis — A Way to Effective Problem Solving QR Quay STEP 3: VERIFY ROOT CAUSES fiona ey O Validation Table SUSPECTED | VALIDATION | TOOLSUSEDFOR | — RESULT OF Roo causes | ACTIVITIES VALIDATION, VALIDATION imitation in the | Check procedure} System & Valid; existing system/procedure conducted = andsystem | Frocedure Review | double handling Interviews | Validsno record No regular PM | Check with IT Meio department visit, THR Reh Poors: = connctaven Tools Je SCATTERED DiKcAM 2. REERTIN 3. jusrecnsin YINPOTS'S TESTING ed AIMIIIIIH a Root Cause Analysis — A Way to Effective Problem Solving QUALITY Pus SECTION 5: FORMULATION AND EVALUATION OF CORRECTIVE ACTION Whew emer CO Identify various possible solutions and evaluate their effectiveness in solving the problem (Brainstorm all possible improvement solutions C1 Without any constraints, generate a list of possible solutions. Use Cost / Benefit Analysis. Choose the most suitable creativity technique for this purpose (I Evaluate and select the best improvement solution Fei eomalni won C. Used to evaluate in detail the idea of giving rebate if customers pay on time for those invoices with high peso values. Driving Forces + [5 >| <(=1- Restraining Forces + Increased cash flow of + An estimated Pxx will be about Pxx. incurred as rebates. + An estimated xx hrs of + Contribute Pxx to administrative efforts. financial benefits. An estimated total cost of Px will be incurred by the company Jey eh Aiding fine ingede~ cbsbutins Aight. ! a igs It ae wee B24 Root Cause Analysis ~ A Way to Effective Problem Solving RY OF ACTION PLAN Estimated Cost | Expected | Timeline/ Of Savings’ | Responsible Implementation | _ Benefits Person Hule pote, SECTION 6: IMPLEMENTATION & MONITORING O CORRECTIVE ACTION C1 Define and implement the permanent corrective actions needed. Choose on-going controls to ensure the root cause is eliminated. C1 Once in production, monitor the long-term effects and implement additional controls as necessary. heialaenae aio aaa O Way to minimize risk of financial losses. O Good venues to collect initial data to make sure the solutions are effective. Tools that are useful include Design of Experiment (DOE), Descriptive statistics, and process capability. BIINNININI 8

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