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Problem Solving
using
Root Cause Analysis
Franck Vermet
Why do we need Root Cause Analysis?
Because it works!
Works for all types of problems
solving (HSE, Quality, etc.)
Needs a paradigm shift:
from “Who” to “Why”
What are problems?
Opportunities
Symptoms
What are problems?
Problem solving
To be efficient:
-Systemic analysis
-Action
Problem solving time effectUntouched 0
Leaf 1
Small Branch 2
Master Branch 3
Trunk 4
Roots 5
Time before
it grows again
The deeper we cut into the
problem, the longer it takes to
reappear.
Solving any complex
problem simply.
Solution not guaranteed.
RCA techniques: Level 0
Surface understanding
Why
Because
RCA techniques: Level 1
Linear chain of cause and effect
My car will not start. (the problem)
1.The battery is dead.
2.The alternator is not functioning.
3.The alternator belt has broken.
4.The alternator belt was well beyond its useful
service life and has never been replaced.
5.I have not been maintaining my car according to
the recommended service schedule.
Why
Why
Why
Why
Why
RCA
Worksheet Description
Reference
Who When
Why - 1
Why - 2
Why - 3
Why - 4
Why - 5
Who When
1What
toexplain
5Why's
tounderstand
1How
toresolve
Guess
Opinion
Fact?
What
5 Why’s example: Manufacturing
1. “Why did the robot stop?”
The circuit has overloaded, causing a fuse to blow.
2. “Why is the circuit overloaded?”
There was insufficient lubrication on the bearings, so they locked up.
3. “Why was there insufficient lubrication on the bearings?”
The oil pump on the robot is not circulating sufficient oil.
4. “Why is the pump not circulating sufficient oil?”
The pump intake is clogged with metal shavings.
5. “Why is the intake clogged with metal shavings?”
Because there is no filter on the pump.
Taiichi Ohno
Questioning technique: Design
1 Why do we use twin booster rockets for the Challenger space
shuttle?
They are made by Thiokol at their factory at Utah. The railroad line
from the factory runs through a mountain tunnel which is slightly wider
than the railroad track. The US gauge (standard distance between the
rails) is 4 feet, 8.5 inches.
2 Why was that gauge used and not something larger?
Because that's the way they built them in England, and English
expatriates built the US Railroads.
3 Why did the English build them like that?
Because the first rail lines were built by the same people who built the
pre-railroad tramways, and that's the gauge they used.
4 Why did they use that gauge then?
Because the people who built the tramways used the same jigs and
tools that they used for building wagons, which used that wheel
spacing.
Questioning technique: Design
5 Why did the wagons have that particular odd wheel spacing?
If they used any other spacing, the wagon wheels would break on some
of the old, long distance roads in England, because that's the spacing of
the wheel ruts.
6 Why is it the spacing of the wheel ruts?
Imperial Rome built the first long distance roads in England for their
legions nearly 2000 years ago. Roman war chariots formed the initial
ruts, which everyone else had to match for fear of destroying their
wagon wheels. Since the chariots were made for (or by) Imperial Rome,
they were all alike in the matter of wheel spacing.
7 Why did Rome choose this spacing for their chariots?
The Imperial Roman war chariots were just wide enough to
accommodate the back ends of two war horses. A major design feature
of what is arguably the world's most advanced transportation system
was determined over two thousand years ago by the width of a horse's
ass.
Courtesy of Mark Warren
Symptom
Reference (SN, PN, SO,
PO, eQ#, Quest #)
Investigator(s)
Date
5 Why's
to understand
Occurrence
Guess
Opinion
Fact
Root Cause
Identified?
5 Why's
to understand
Non detection
Guess
Opinion
Fact
Root Cause
Identified?
Why - 1 Why - 1
Why - 2 Why - 2
Why - 3 Why - 3
Why - 4 Why - 4
Why - 5 Why - 5
1 How
to resolve
1 How
to resolve
Who When Who WhenWhat + Quest# What + Quest#
Manufacturing
Process
Tests
RCA technique: Level 1.2
Why why (occurrence and detection)
RCA techniques: Level 2
Logic tree
Symptom Why?
Root
Cause
Root
Cause
Root
Cause
Root
Cause
Root
Cause
• The 5 enablers (5Ms) of a production system are used as a checklist
• Helps brainstorming potential branches of a logic tree
• Can be very time consuming
• Can be frustrating as only a few branches as picked (usually by the manager)
RCA techniques: Fishbone diagram
Symptom
Man Machinery
Methods MaterialsMother Nature
Key to make it work:
Take action Be Accountable
Key to make it work: attitude
• No finger pointing / no blame
culture
• from 1 Who
• to 5 Why’s + 1 How
• Open communication
• Become a GOFer (Guess,
Opinion, Fact:
Validate your answer)
Conclusion: 5 why’s examples
You do not have any good 5 Why’s examples.
1. Your brain just isn't coming up with any ones I've used in the past.
2. Those examples were too long ago, with no current examples.
3. The method is not used consistently in your problem solving process.
4. It is not integrated into your process for handling root cause analysis and problem
solving.
5. You have not been trained on how to do so, or it has not been a priority (until
now).
From the web
Remember these things…
• Root cause analysis can be simple and fun
• Five-Why’s is quick and efficient
• Kill the system’s root – kill the problem tree

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Problem solving using root cause analysis

  • 1. Problem Solving using Root Cause Analysis Franck Vermet
  • 2. Why do we need Root Cause Analysis? Because it works! Works for all types of problems solving (HSE, Quality, etc.) Needs a paradigm shift: from “Who” to “Why”
  • 5. Problem solving To be efficient: -Systemic analysis -Action
  • 6. Problem solving time effectUntouched 0 Leaf 1 Small Branch 2 Master Branch 3 Trunk 4 Roots 5 Time before it grows again The deeper we cut into the problem, the longer it takes to reappear.
  • 7. Solving any complex problem simply. Solution not guaranteed. RCA techniques: Level 0 Surface understanding Why Because
  • 8. RCA techniques: Level 1 Linear chain of cause and effect My car will not start. (the problem) 1.The battery is dead. 2.The alternator is not functioning. 3.The alternator belt has broken. 4.The alternator belt was well beyond its useful service life and has never been replaced. 5.I have not been maintaining my car according to the recommended service schedule. Why Why Why Why Why
  • 9. RCA Worksheet Description Reference Who When Why - 1 Why - 2 Why - 3 Why - 4 Why - 5 Who When 1What toexplain 5Why's tounderstand 1How toresolve Guess Opinion Fact? What
  • 10. 5 Why’s example: Manufacturing 1. “Why did the robot stop?” The circuit has overloaded, causing a fuse to blow. 2. “Why is the circuit overloaded?” There was insufficient lubrication on the bearings, so they locked up. 3. “Why was there insufficient lubrication on the bearings?” The oil pump on the robot is not circulating sufficient oil. 4. “Why is the pump not circulating sufficient oil?” The pump intake is clogged with metal shavings. 5. “Why is the intake clogged with metal shavings?” Because there is no filter on the pump. Taiichi Ohno
  • 11. Questioning technique: Design 1 Why do we use twin booster rockets for the Challenger space shuttle? They are made by Thiokol at their factory at Utah. The railroad line from the factory runs through a mountain tunnel which is slightly wider than the railroad track. The US gauge (standard distance between the rails) is 4 feet, 8.5 inches. 2 Why was that gauge used and not something larger? Because that's the way they built them in England, and English expatriates built the US Railroads. 3 Why did the English build them like that? Because the first rail lines were built by the same people who built the pre-railroad tramways, and that's the gauge they used. 4 Why did they use that gauge then? Because the people who built the tramways used the same jigs and tools that they used for building wagons, which used that wheel spacing.
  • 12. Questioning technique: Design 5 Why did the wagons have that particular odd wheel spacing? If they used any other spacing, the wagon wheels would break on some of the old, long distance roads in England, because that's the spacing of the wheel ruts. 6 Why is it the spacing of the wheel ruts? Imperial Rome built the first long distance roads in England for their legions nearly 2000 years ago. Roman war chariots formed the initial ruts, which everyone else had to match for fear of destroying their wagon wheels. Since the chariots were made for (or by) Imperial Rome, they were all alike in the matter of wheel spacing. 7 Why did Rome choose this spacing for their chariots? The Imperial Roman war chariots were just wide enough to accommodate the back ends of two war horses. A major design feature of what is arguably the world's most advanced transportation system was determined over two thousand years ago by the width of a horse's ass. Courtesy of Mark Warren
  • 13. Symptom Reference (SN, PN, SO, PO, eQ#, Quest #) Investigator(s) Date 5 Why's to understand Occurrence Guess Opinion Fact Root Cause Identified? 5 Why's to understand Non detection Guess Opinion Fact Root Cause Identified? Why - 1 Why - 1 Why - 2 Why - 2 Why - 3 Why - 3 Why - 4 Why - 4 Why - 5 Why - 5 1 How to resolve 1 How to resolve Who When Who WhenWhat + Quest# What + Quest# Manufacturing Process Tests RCA technique: Level 1.2 Why why (occurrence and detection)
  • 14. RCA techniques: Level 2 Logic tree Symptom Why? Root Cause Root Cause Root Cause Root Cause Root Cause
  • 15. • The 5 enablers (5Ms) of a production system are used as a checklist • Helps brainstorming potential branches of a logic tree • Can be very time consuming • Can be frustrating as only a few branches as picked (usually by the manager) RCA techniques: Fishbone diagram Symptom Man Machinery Methods MaterialsMother Nature
  • 16. Key to make it work: Take action Be Accountable
  • 17. Key to make it work: attitude • No finger pointing / no blame culture • from 1 Who • to 5 Why’s + 1 How • Open communication • Become a GOFer (Guess, Opinion, Fact: Validate your answer)
  • 18. Conclusion: 5 why’s examples You do not have any good 5 Why’s examples. 1. Your brain just isn't coming up with any ones I've used in the past. 2. Those examples were too long ago, with no current examples. 3. The method is not used consistently in your problem solving process. 4. It is not integrated into your process for handling root cause analysis and problem solving. 5. You have not been trained on how to do so, or it has not been a priority (until now). From the web
  • 19. Remember these things… • Root cause analysis can be simple and fun • Five-Why’s is quick and efficient • Kill the system’s root – kill the problem tree