Root Cause Techniques

Presentation
Prepared by: Engr. Mohsin
 SHARE RESULTS
Meetings/Discussions

RESULTS & DEFINE PROBLEM

Data & Facts
PROCESS
EVALUATION
PDSA Cycles

Steps of Root Cause

Analysis
DATA COLLECTION

TEST SOLUTIONS & & ANALYSIS

Pareto Chart
IMPLEMENTATION
Flow Chart
PDSA Cycles

ROOT CAUSE ANALYSIS

Fishbone Diagram
 Root Cause Analysis Methods

Casual Factor The 5 Whys

Management Failure Mode
Tree Analysis Effect Analysis
Oversight
Change
Analysis

Risk Tree

Fishbone
Diagram Fault-Tree
Barrier
Analysis
analysis
 Causal Factor Tree Analysis

Apparent Problem

Symptom of Problem Symptom of Problem Symptom of Problem

Possible Root Cause Possible Root Cause Possible Root Cause Possible Root Cause Possible Root Cause

ACTUAL ROOT CAUSE

 Fishbone Diagram

No job description Incorrect collection time Staff careless in storage

No written guideline Staff not well-trained Lack of motivation system

No procedure for order description No funds Lack of equality

No procedure for collection Wrong blood-coagulant ratio
Insufficient payment
No job variety Staff not trained

EFFECT
Staff performing
JOB EXPECTATION PERFORMANCE FEEDBACK SKILLS & KNOWLEDGE ENVIRONMENT & TOOLS MOTIVATION ORGANIZATIONAL SUPPORT
unnecessary repeat
lab tests

Poor disposable equipment

Irregularity of data Poor quality, no funds

No supervision system
Inadequate information Not properly selected

Material scanty Damaged equipment Lack of support in cont. Improvement

Not enough collected Poor maintenance Insufficient budget

No feedback Unskilled personnel, no funds No supervision system

 01
Incident
Situation Some Factors to Consider:

05 06
03 04 Integrate into
Who What Where When

Evaluate differences Work Conditions Triggering Events Resources

Compare Set down Differences Investigation
for effect on incident
Process
02 Management Control Procedures Tasks

Comparable
incident-free
situation

Evaluate by Asking These Questions:

Change Analysis
Why now and not before? Why here and not there?

What was Different about this time from all the other times the same hardware operated without a
problem or the same task or activity was carried out without error?

Technical Barrier
• Variation of reheating furnace type
• Long period installation
• Main component of RBCS still
import
• Lack of qualified engineers who
have expertise on RBC
Technology
Barrier Analysis
Economic & Financial
• High cost investment
• Revenue loss due to long time
furnace shutdown
• No financial mechanism for
RBCS technology implementation
Policy, Legal &
Regulatory
• Efficiency energy policy and
regulation only for industry that
used energy >6000 TOE
• Voluntary for <6000 TOE
Institutional & Capacity
of Organization
• Lack of institution which have
capacity to help industry to install
RBCS
• Lack of institution which have
capacity to do testing,
modification and innovation for
RBCS technology.
• Absence of standardization and
certification of equipment related
RBCS
 Why did this Why did problem go Why was the problem
problem occur? undetected? not prevented?

The main pulley responsible for

WHY
rotating the belt is not functioning Carelessness of the workers At this stage it was unavoidable
has the conveyor
belt stopped? properly.

WHY Because it’s not getting enough

Lack of clue There was no clue
is the main pulley not power from the motor

Five Why’s Analysis functioning correctly?

WHY Because the motor has stopped

Problem : The project supposed to be finished in 6 months but Unnoticed incident Incident was unnoticed
is it not getting enough power working
our company failed to meet the deadline. from the motor?

WHY Because the motor was loaded

Carelessness of the management Indifference to problem
has the motor beyond it’s capacity
stopped working?

Instructions about the motor’s

WHY Carelessness of the Lack of initiative of
maximum load weight was
was the motor management management
overloaded? missing.
 Five Why’s Analysis

DESCRIPTION POTENTIAL IMPACT

01 Why has the conveyor belt stopped?
The main pulley responsible for rotating the belt is not
The main machine might get crashed
functioning properly.

Why is the main pulley not functioning

02 correctly? Because it’s not getting enough power from the motor Decrease in number of output

Why is it not getting enough power from the

03 motor?
Because the motor has stopped working Fail to meet expected performance

Because the motor was loaded beyond it’s capacity Risk of failure in the operation
04 Why has the motor stopped working?

Instructions about the motor’s maximum load weight was

The machine will stop working
missing.

05 Why was the motor overloaded?

 Five Why’s Analysis
WHY? WHY?
ON THE SURFACE HUMANS
They fail to find the product market fit. Entrepreneurs don’t have enough time,
resources or experience to make it work
They fail to make money or raise
on time.
money
Customers are bombarded with many
competing products in the market &
won’t trust a starter brand easily.
Investors don’t bet on products that
show high growth and high ROI
potential.
WHY?
HARD TRUTH
Product or service that the startup is
offering is not something that the
market wants or needs.
Startup teams are unable to build a
product that is valuable for their target
market fast enough.
Startup teams fail to tell the story of
their product accurately to reach the
customers.
Competitors or established players steal
the new startup’s slice of the pie.
WHY?
STATUS QUO
Most startups don’t have enough time to
mature & self sustain before they can hit
desirable high growth matrices that the
current investor eco-system favors.
Startups by nature travel an uncharted
territory. There is no single formula to
success. Only guidance and anecdotes
from previous success and failure
stories.
WHY?
ORIGINS
Entrepreneurs jump into the startup
adventure with many unknowns and
limited resources.
Startups often fail to address the root
causes of their eco-system.
OPPORTUNITY
FOR SOLUTIONS
A centralized space for startups to
establish their business strategy from
the get go, follow the original visions
evolution and scale up with self-
awar3eness and control.
 Language Barrier Educational Level

Customs Barrier Pay & Benefit

Communication problem Personnel Quality
Legal systems differences Turnover

Technology Dedication

Funding Standard Cost itemization failure

Technology trends Elevated cost

Hardware Deficiency Cost Factor
Staff Knowledge International currency bottleneck

Management backing Inconvenient payment plans

Funding Logistics

Software trends Delivery companies

Staff Knowledge
Software Deficiency
Risk Tree Delivery Time
Adverse events

Management backing Alternate Delivery Methods

Education Reliability

Compensation Financial soundness

Managerial Quality Client Perceptions
Retention Relationship history

Commitment Public Relations

Growth rates Expansion Planning

Interest rates Recruitment

Macro Economic Factor Local Service Reps Missing
Commodity prices Turnover

Regulatory environment Compensation

 Fault-Tree Analysis
AUDIT FAILURE

OR

Audit Objective Failure Audit Process Failure Audit Resource Failure

OR OR OR

Objective Objective Failure of Audit Failure of Other

Objective Incorrect Type I Error Type II Error Audit Failure
Unattainable Unidentified Process Element Resources

OR AND AND OR

System System
Objective Objective Compliance/ Audit Process Compliance/ Audit Process Audit Process Audit Process
Ambiguous Obsolete Suitability Error Failure Suitability Error Failure Failure Failure
Doesn’t Exist Exists
 Q3

Procedures

Poor leadership or
management Q2

Inadequate
Extreme heat Maintenance Poor
(Environment) (Organization) communication of

Human Error and Lack of training Absence of

safety management

Management Oversight
(Organization) Warnings (Design)
Q1

Q1
No SOPs in place, no clear
EVENT Equipment malfunction/
Error/ Violation Occurred safety procedures, safety rules
adequacy of feedback
not enforced (Organization)
(Design)
Poor quality control
Q2 Human Factors Present

Poor teamwork, Safety Too many controls

rules ignored, poor record that contradict each
Q3 Root Cause Analysis
Poor safety culture keeping (Organization) Fatigue, high time on other (Design)
task, excessive time
pressure
(Organization)
Poor system
integration

Inadequate manning/
organization of personnel
resource
 Failure Mode Effect Analysis

May be a product, assembly, Initial Development of the Improvement Post-Improvement

subassembly, or part Failure Mode Effect Analysis Activities Activities

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

POTENTIAL POTENTIAL
PROCESS POTENTIAL CURRENT RISK PRIORITY ACTION RISK PRIORITY
FAILURE FAILURE SEVERITY OCCURRENCE DETECTION RESPONSIBLE ACTIONS TAKEN SEVERITY OCCURRENCE DETECTION
STEP/INPUT CAUSES CONTROLS NUMBER RECOMMENDED NUMBER
MODE EFFECTS

DET= Detection RPN= Risk Priority Number

OCC= Occurrence SEV= Severity
Resp= Responsible FMEA= Failure Mode Effect Analysis
 Failure Mode Effect Analysis: Three-
Path Model

PATH 01 PATH 02 PATH 03

What are the Functions, Features or

What are the causes? How can the causes / FM be detected?
Requirements?

• No Functions
Can this be prevented? What is the How good is this method at detecting
• Partial/Over Function/
occurrence? it?
Degraded Over Time
• Intermittent Function
• Unintended Function

What are the effect?

• Design Changes • Mistake Proofing

• Process Changes • Changes to Standards,
ACTIONS • Error Proofing Procedures, or Guides
How bad is it?
• Special Controls
 Root Cause Analysis Template

ISSUE LIKELY ROOT CAUSE POSSIBLE SOLLUTION

Description Source Criticality Description Likelihood Information Description Risks Measure of Success

Level (High/ Level (High/ Tests to

Rationale Description Likelihood Mitigation Test Results
Medium/ Low)) Medium/ Low)) Clarify

Does not affect Simplify info

Status reports not Agree detail level
Client not aware of delivery but Check with required for report Client feels report Check with client
Client Medium being issued High Medium for new report with TBA
project status damaging to program Office so less time lacks detail after four weeks
weekly clients
account consuming for PM

HR did not get the Makes it tough to Budget is not being Budget report HR did not get Budget to be sent to
HR Medium High Check with Finance High N/A TBA
budget yet meet deadline issued weekly prioritized budget report HR

Project report not Creates project Check with Project report to be Manager did not Report to be sent to
Manager High Management Fault High Medium Talk to Manager Report Sent
done weakness Management cleared get report Manager

Deadline couldn’t Client Check with Did not meet Talk to

Client High Management Fault High Client meeting High Project Prioritized TBA
be met Dissatisfaction Management deadline Management
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