Root Cause Analysis: Coronet Foods Pvt. LTD

Root Cause Analysis
Coronet Foods Pvt. Ltd
1
Content
 Course Objectives
 What is Root Cause?
 Benefits
 The Problem Solving Process
 Examples and Exercises
2
Objectives
Upon completion of this training, participants should be able

to:
 Understand the importance of performing root cause analysis

 Identify the root cause of a problem using the problem solving process
 Understand the application of basic quality tools in the problem solving
process
3
What is a root cause?
ROOT CAUSE =
 The causal or contributing factors that, if corrected, would prevent
recurrence of the identified problem
 The “factor” that caused a a problem or defect and should be permanently

eliminated through process improvement
 The factor that sets in motion the cause and effect chain that creates a
problem
 The “true” reason that contributed to the creation of a problem, defect or

nonconformance
4
What is root cause analysis?
 A standard process of:
 identifying a problem
 containing and analyzing the problem
 defining the root cause
 defining and implementing the actions required to
eliminate the root cause
 validating that the corrective action prevented
recurrence of problem
5
Benefits
By eliminating the root cause…

You save time and money!
 Problems are not repeated
 Reduce rework, retest, re-inspect, poor quality costs, etc…
 Problems are prevented in other areas
 Communication improves between groups and
 Process cycle times improve (no rework loops)
 Secure long term company performance and profits
$$ Less rework = Increased profits! $$

6
Importance of the root cause
Not knowing the root cause can lead to costly band aids.
 The Washington Monument was degrading

Why? Use of harsh chemicals
Why? To clean up after pigeons
Why so many pigeons? They eat spiders and there are a lot of spiders at the
monument
Why so many spiders? They eat gnats and lots of gnats at the monument
Why so many gnats? They are attracted to the light at dusk.
Solution: Turn on the lights at a later time.
© 2004 Superfactory™. All Rights Reserved. 7

When should root cause analysis
be performed?
When PROBLEMS occur !!
8
How does it differ from what we do
now?
USUAL APPROACH
Firefighting! Problem
Problem
Immediate Containment reoccurs
Identified
Action Implemented elsewhere!
Find
someone to
blame!
PREFERRED APPROACH
Immediate Defined Solutions are
Solutions
Problem Containment Root Cause applied across
validated
Identified Action Analysis company and
with data
Implemented Process never return!
9
How does it work?
Defect found at “Customer”…

PROCESS PROCESS PROCESS PROCESS
A B C D
CUSTOMER
“Customer” can be
Internal or External
10
How does it work?
Contain the problem…

A B C D
CUSTOMER
Nothing is allowed to further

escape to the customer
11
How does it work?
Contain the root process…

A B C D
CUSTOMER
Nothing is allowed to further

escape to the next process
12
How does it work?
Prevent the problem…

A B C D
CUSTOMER
Corrective action implemented

so root cause of problem does
not occur again!
13
But who’s to blame?
 The “no blame” environment is critical

 Most human errors are due to a process error
 A sufficiently robust process can eliminate human errors
 Placing blame does not correct a root cause situation
 Is training appropriate and adequate?
 Is documentation available, correct, and clear?
 Are the right skillsets present?
14
Corrective Actions
3 types of Corrective Action:
 Immediate action
 The action taken to quickly fix the impact of the problem so the “customer” is
not further impacted
 Permanent root cause corrective action
 The action taken to eliminate the error on the affected process or product
 Preventive (Systemic) root cause corrective action
 The action taken to Prevent the error from recurring on any process or product
15
Examples of Corrective Actions
Immediate
All current batch of paperwork re-inspected by another
worker for same type of problem
Permanent
Form changed to mandate completion of certain fields
Preventive
Similar forms with same fields used all over in
company are changed to “mandatory”
If preventive not addressed, problem will return!!
16
Examples of Corrective Actions
Immediate
Part removed and replaced in product, retested
Permanent
Product redesigned to account for part variability
Preventive
Design process changed to require variation
analysis testing on similar supplier parts
If preventive not addressed, problem will return!!

The Difference between
Permanent vs. Preventive Corrective Actions
Permanent Preventive
 Trained employee on proper machine use  Made training a requirement to new employees working in that
area
 Changed product design to make parts easier to assemble  Changed design guidelines to not allow for use of part in full
manually scale production

 All documents that are critical to project are identified with red
 Specific customer document critical to project is identified with folders
red folder
 Check for those software bugs added to checklist and

 Update all customers with latest software revision to fix problem
performed prior to release of software
 Fallen patient given full-time assistant to provide help moving  Process developed to identify “at risk” patients for falls who
around hospital require assistant

 Ethics training developed and provided to all employees
 Employee fired for ethical violation
18
Problem Solving Process
Identify
8 Problem 2
Validate Identify
Team
7 3
Problem
Follow Up Immediate
Plan Solving Action
Process
Complete Root
Plan Cause
Action
6 Plan 4
5
19
Steps for RCA
Step # 1: Identify the Problem
 Clearly state the problem the team is to solve

 Teams should refer back to problem statement to avoid
getting off track
 Use 5W2H approach
 Who? What? Why? When? Where? How? How Many?
20
Step #1
5W2H
 Who? Individuals/customers associated with problem
 What? The problem statement or definition
 When? Date and time problem was identified
 Where? Location of complaints (area, facilities, customers)
 Why? Any previously known explanations

 How? How did the problem happen (root cause) and how will the problem
be corrected (corrective action)?
 How Many? Size and frequency of problem
21
Step #2
Identify Team
When a problem cannot be solved quickly by an individual, use a
team!
 Should consist of domain knowledge experts

 Small group of people (4-10) with process and product knowledge,
available time and authority to correct the problem
 Must be empowered to “change the rules”
 Should have a designated Champion
 Membership in team is always changing!

Step #2
Key Ideas for Team Success
 Define roles and responsibilities

 Identify external customer needs
 Identify internal customer needs
 Appropriate levels of organization present
 Clearly defined objectives and outputs
 Solicit input from everyone!
 Good meeting location
 near work area for easy access to info
 quiet for concentration and avoiding distractions

Step #2
Roles and Responsibilities
 Champion: Mentor, guide and direct teams, advocate to upper

management
 Leader: day-to-day authority, calls meetings, facilitation of team, reports
to Champion
 Record Keeper: Writes and publishes minutes
 Participants: Respect all ideas, keep an open mind, know their role
within team

Step #3
Immediate Action
 Must isolate effects of problem from customer

 Usually “Band-aid” fixes
 100% sorting of parts
 Re-inspection before shipping
 Rework
 Recall parts/documents from customer or from storage
 Only temporary until corrective action is implemented (very costly, but

necessary)
 Must also verify that immediate action is effective

Step #3
Verify Immediate Action
 Immediate action = activity implemented to screen, detect and/or

contain the problem

 Must verify that immediate action was effective
 Run Pilot Tests
 Make sure another problem does not arise from the temporary
solutions
 Ensure effective screens and detections are in place to prevent further

impact to customer until permanent solution is implemented.

Step #4
Root Cause
 Brainstorm possible causes of problem with team

 Organize causes with Cause and Effect Diagram (Fish Bone Diagram)
 “Pareto” the causes to identify those most likely or occurring most often
 Use 5 Why? method to further define the root cause of symptoms
 May involve additional research/analysis/investigation to get to each
“Why?”
 Must identify the process that caused the problem
 if root cause is company-wide, elevate these process issues (outside of
team control) to upper management to address
27
Step #4
5 Why’s
 Ask “Why?” five times

 Stop when the corrective actions do not change
 Stop when the answers become less important
 Stop when the root cause condition is isolated
28
What is a Cause-Effect Diagram?
 A Cause-Effect (also called “Ishikawa” or “Fishbone”) Diagram is a

Data Analysis/Process Management Tool used to:
 Organize and sort ideas about causes contributing to a

particular problem or issue
 Gather and group ideas
 Encourage creativity
 Breakdown communication barriers
 Encourage “ownership” of ideas
 Overcome infighting

Cause-Effect Diagram
 A Cause-Effect Diagram is typically generated in a group

meeting
 It is a graphical method for presenting and sorting ideas
about the causes of issues or problems
30
 Steps used to create a Cause-Effect Diagram:

 Define the issue or problem clearly
 Decide on the root causes of the observed issue or problem
 Brainstorm each of the cause categories
 Write ideas on the cause-effect diagram. A generic example is shown
below:
Materials Methods
Environment Effect
Equipment People
NOTE: Causes are not limited to the 5 listed categories, but serve as a starting point
31
 Allow team members to specify where ideas fit into the diagram
 Clarify the meaning of each idea using the group to refine the ideas. For
example:
Materials Methods
Incorrect Quantity Late Dispatch

Spillage
Incorrect BOL Shipping Delay
Wrong Destination
Traffic Delays
Shipping
Environment
Wrong Equipment
Problems
Weather Driver
Dispatcher Attitude
Breakdown Dirty Equipment Wrong Directions
Equipment People

 After completing the Cause-Effect Diagram, take the following

actions:
 Rank the ideas from the most likely to the least likely cause cause
of the problem or issue
 Develop action plans for identifying the essential data, resources
and tools

Expected Outcome
• Individuals have become part of a problem solving team

 The sources of problems and other issues have been identified using
a systematic process
 Team members see issues from a similar perspective
 Ideas and solutions are documented
 Communication is improved
 Team members assume ownership

Step #5
Corrective Action Plan
 Must verify the solution will eliminate the problem

 Verification before implementation whenever possible
 Define exactly…
 What actions will be taken to eliminate the problem?
 Who is responsible?
 When will it be completed?
 Make certain customer is happy with actions

 Define how the effectiveness of the corrective action will be measured.

Step #5
Verification vs. Validation

(Before) (After)
 Verification
 Assures that at a point in time, the action taken will actually do what
is intended without causing another problem
 Validation
 Provides measurable evidence over time that the action taken worked
properly, and problem has not recurred

Step #6
Complete Action Plan
 Make certain all actions that are defined are completed as planned
 If one task is still open, verification and validation is pushed back
 If the plan is compromised, most likely the solution will not be as

effective

Step #7
Follow Up Plan
 What actions will be completed in the future to ensure that the root cause
has been eliminated by this corrective action?
 Who will look at what data?
 How long after the action plan will this be done?
 What criteria in the data results will determine that the problem has not
recurred?

Step #8
Validate and Celebrate
 What were the results of the follow up?
 If problem did reoccur, go back to Step #4 and re-evaluate root cause,

then re-evaluate corrective action in Step #5
 If problem did not reoccur, celebrate team success!
 Document savings to publicize team effort, obtain customer satisfaction

and continued management support of teams

What does a good RCA look like?
 The Root Cause is

 Internally Consistent ,
 Thorough, and
 Credible

The Complete Root Cause Analysis is

• inter-disciplinary, involving experts from the frontline services
• involving of those who are the most familiar with the situation
• continually digging deeper by asking why, why, why at each level of
cause and effect.
• a process that identifies changes that need to be made to systems
• a process that is as impartial as possible

To be thorough a Root Cause Analysis must include:

• determination of human & other factors
• determination of related processes and systems
• analysis of underlying cause and effect systems through a series of
why questions
• identification of risks & their potential contributions
 determination of potential improvement in processes or systems

To be Credible a Root Cause Analysis must:

• include participation by the leadership of the organization &
those most closely involved in the processes & systems
• be internally consistent

Hints about root causes
 One problem may have more than one root cause

 One root cause may be contributing to many problems
 When the root cause is not addressed, expect the problem
to reoccur
 Prevention is the key!

Review
 You learned:
 How to identify the root cause
 Why it is important
 The process for proper root cause analysis
 How basic quality tools can be applied to examples

Manufacturing
Root Cause Analysis

Example #1

Example #1
Identify Problem
Part polarity reversed on circuit board

Determine Team
 Team members:
 Team Leader – Terry
 Inspector – Jane
 Worker – Tammy
 Worker - Joe
 Quality Eng – Rob
 Engineer – Sally

Immediate Action
 Additional inspection added after this assembly process

step to check for reversed part defects
 Last 10 lots of printed circuit boards were re-inspected to

check for similar errors

Root Cause
Part reversed
Why?

Root Cause
Part reversed
Worker not sure of correct part orientation
Why?

Root Cause
Part reversed
Part is not marked properly
Why?

Root Cause
Part reversed
Engineering ordered it that way from vendor
Why?

Root Cause
Part reversed
Engineering ordered it that way from vendor
Process didn’t account for possible

manufacturing issues

Corrective Action
 Permanent – Changed part to one that can only be placed in correct

direction (Mistake proofed). Found other products with similar problem
and made same changes.
 Preventive - Required that any new parts selected must have

orientation marks on them.

Root Cause Analysis
Example #2

Example #2
Identify Problem
A manager walks past the assembly line and notices a puddle of

water on the floor. Knowing that the water is a safety hazard, she
asks the supervisor to have someone get a mop and clean up the
puddle. The manager is proud of herself for “fixing” a potential
safety problem.

Example #2
But What is the Root Cause?
The supervisor looks for a root cause by asking 'why?’

Immediate Action
Knowing that the water is a safety hazard, the manager asks the
supervisor to have someone get a mop and clean up the puddle.

Root Cause
Puddle of water on the floor
Why?

Root Cause
Leak in overhead pipe
Why?

Root Cause
Water pressure is set too high
Why?

Root Cause
Water pressure valve is faulty
Why?

Root Cause
Water pressure valve is faulty
Valve not in preventative maintenance program

Corrective Action
 Permanent – Water pressure valves placed in preventative

maintenance program.
 Preventive - Developed checklist form to ensure new

equipment is reviewed for possible inclusion in preventative
maintenance program.

Example #3
Root Cause Analysis

Example #3

Example #3
Identify Problem
Customers are unhappy because they are being shipped

products that don't meet their specifications.

Immediate Action
Inspect all finished and in-process product to ensure it meets

customer specifications.

Root Cause
Product doesn’t meet specifications
Why?

Root Cause
Manufacturing specification is different from

what customer and sales person agreed to
Why?

Root Cause

Sales person tries to expedite work by calling

head of manufacturing directly
Why?

Root Cause


Manufacturing schedule is not available for

sales person to provide realistic delivery date
Why?

Root Cause


Manufacturing schedule is not available for

sales person to provide realistic delivery date
Confidence in manufacturing schedule is not

high enough to release/link with order system

Root Cause
Why?

Root Cause
Parts sometimes not available thereby

creating schedule changes
Why?

Root Cause

Expediting and priority changes consume

parts not planned for
Why?

Root Cause


Manufacturing schedule does not reflect

realistic assembly and test time
Why?

Root Cause


Manufacturing schedule does not reflect

realistic assembly and test time
No ongoing review of manufacturing standards

Corrective Action
 Permanent – Manufacturing standards reviewed and

updated.
 Preventive - Regular ongoing review of actuals vs

standards is implemented.

Root Cause Analysis
Example #4

Example #4
Identify Problem
Department didn’t complete their project on time

Determine Team
 Team members:
 Boss – Jim
 Worker – Tom
 Worker - Karen
 Project Mgr – Bob
 Admin – Sally

Immediate Action
 Additional resources applied to help get the project team

back on schedule
 No new projects started until Root Cause Analysis

completed

Root Cause
Didn’t complete project on time
Why?

Cause and Effect
Procedures Personnel
Lack of worker
knowledge
Poor project plan
Poor project
mgmt skills Lack of resources
Didn’t complete
project on time
Inadequate Poor Inadequate

computer documentation computer system
programs
Materials Equipment

Cause and Effect
Procedures Personnel
Lack of worker
knowledge
Poor project plan
Poor project
mgmt skills Lack of resources
Didn’t complete
project on time
Inadequate Poor Inadequate

computer documentation computer system
programs
Materials Equipment

Root Cause
Resources unavailable when needed
Why?

Root Cause
Took too long to hire Project Manager
Why?

Root Cause
Lack of specifics given to

Human Resources Dept
Why?

Root Cause
Lack of specifics given to

Human Resources Dept
No formal process for submitting job opening

Corrective Action
 Permanent – Hired another worker to meet needs of next

project team
 Preventive - Developed checklist form with HR for

submitting job openings in the future

Example #5
Root Cause Analysis

Example #5

Example #5
Identify Problem
High pyrogen count on finished medical catheter product using

molded components.

Immediate Action
Immediate Action (and panic!)
 Quarantine all finished and in-process product

(over $2 million worth!)
 Analyze location of pyrogen to find common denominator

Panic-Driven Action
Panic-driven Immediate Reaction

(without root cause analysis)
 Pyrogen traced to molding cooling water leak

 Holy cow!… cooling water system hasn’t been cleaned in 15 years!
 Shut down 24/7 molding operation for 2 days to clean cooling water system
 Implement system for weekly analysis of cooling water for pyrogens
 Threaten to fire anyone who doesn’t report a cooling water leak

Panic-Driven Action - Results
Results of Panic-driven Immediate Reaction

(without root cause analysis)
 Day 1 after cooling water system cleaning: water tests clean of pyrogens
 Day 2: cooling water is saturated with pyrogens. Uh oh.
 All operators and technicians reporting “possible water leaks” on all presses, all molds, all shifts…
“just in case”.
 Molding operation shuts down. Operations manager nearly fired.
 “Help” flying in from corporate offices and other molding plants.
 Hourly conference calls to give status updates to executives.


Logic Returns
There must be a better way! How about trying something called

“Root Cause Analysis”?

Root Cause
Pyrogens on molded components
Why?

Root Cause
Parts released from molding even though they

had been sprayed with leaking cooling water
Why?

Root Cause

Disposition of contaminated parts procedure

does not discuss water
Why?

Root Cause


Oil, grease, dust, human contact believed to

be primary sources of contamination
Why?

Root Cause


Oil, grease, dust, human contact believed to

be primary sources of contamination
No formal evaluation of contamination sources,

types, severity, and disposition action.

Corrective Action
 Permanent – Disposition of contaminated parts procedure

re-written to include water.
 Preventive - Formal study of contamination sources,

consequences, and disposition requirements.

Root Cause Analysis: Coronet Foods Pvt. LTD

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Root Cause Analysis: Coronet Foods Pvt. LTD

Uploaded by

Copyright:

Available Formats

Root Cause Analysis

Coronet Foods Pvt. Ltd

 Examples and Exercises

Upon completion of this training, participants should be able

 Understand the importance of performing root cause analysis

 The “factor” that caused a a problem or defect and should be permanently

 The “true” reason that contributed to the creation of a problem, defect or

 A standard process of:

By eliminating the root cause…

$$ Less rework = Increased profits! $$

 The Washington Monument was degrading

© 2004 Superfactory™. All Rights Reserved. 7

Defect found at “Customer”…

Contain the problem…

Nothing is allowed to further

Contain the root process…

Nothing is allowed to further

Prevent the problem…

Corrective action implemented

 The “no blame” environment is critical

 Is documentation available, correct, and clear?

 Are the right skillsets present?

3 types of Corrective Action:

 Permanent root cause corrective action

 Preventive (Systemic) root cause corrective action

If preventive not addressed, problem will return!!

If preventive not addressed, problem will return!!

© 2004 Superfactory™. All Rights Reserved. 17

 Check for those software bugs added to checklist and

Step # 1: Identify the Problem

 Clearly state the problem the team is to solve

 Why? Any previously known explanations

 Should consist of domain knowledge experts

© 2004 Superfactory™. All Rights Reserved. 22

Key Ideas for Team Success

 Define roles and responsibilities

© 2004 Superfactory™. All Rights Reserved. 23

Roles and Responsibilities

 Champion: Mentor, guide and direct teams, advocate to upper

© 2004 Superfactory™. All Rights Reserved. 24

 Must isolate effects of problem from customer

 Re-inspection before shipping

 Recall parts/documents from customer or from storage

 Only temporary until corrective action is implemented (very costly, but

© 2004 Superfactory™. All Rights Reserved. 25

Verify Immediate Action

 Immediate action = activity implemented to screen, detect and/or

 Ensure effective screens and detections are in place to prevent further

© 2004 Superfactory™. All Rights Reserved. 26

 Brainstorm possible causes of problem with team

 Ask “Why?” five times

 A Cause-Effect (also called “Ishikawa” or “Fishbone”) Diagram is a

 Organize and sort ideas about causes contributing to a

© 2004 Superfactory™. All Rights Reserved. 29

 A Cause-Effect Diagram is typically generated in a group

 Steps used to create a Cause-Effect Diagram:

Incorrect Quantity Late Dispatch

© 2004 Superfactory™. All Rights Reserved. 32

 After completing the Cause-Effect Diagram, take the following

© 2004 Superfactory™. All Rights Reserved. 33

• Individuals have become part of a problem solving team

© 2004 Superfactory™. All Rights Reserved. 34

Corrective Action Plan