Rca Training Rev 0

Editor's Notes

• #3: The training is educational but not academic in approach, rather it is done in in a practical way where one can learn to use RCAimmediately in real life situation.This training consists of:lectures,practices, androle plays that provide participants with an in-depth understanding of how to analyze a system in order to identify the root causes of problems.
• #4: The training is educational but not academic in approach, rather it is done in in a practical way where one can learn to use RCAimmediately in real life situation.This training consists of:lectures,practices, androle plays that provide participants with an in-depth understanding of how to analyze a system in order to identify the root causes of problems.
• #8: The presentation is organized in such a way that we can move from one part (module) of the presentation to another. Also included are two ice breakers during or after the scheduled coffee break. Application form each module is also included although in such a way that it can be part of each or both module, although the advance application will require module 2 to better understand its application.
• #12: Root Cause Analysis - structured and thorough review of problem designed to identify and verify what is causing the symptomsa process for understanding and solving a problem. Useful process for understanding and solving a problem. Root Cause AnalysisTracing a Problem to Its OriginsIn medicine, it's easy to understand the difference between treating symptoms and curing a medical condition. Sure, when you're in pain because you've broken your wrist, you WANT to have your symptoms treated – now! However, taking painkillers won't heal your wrist, and true healing is needed before the symptoms can disappear for good.But when you have a problem at work, how do you approach it? Do you jump in and start treating the symptoms? Or do you stop to consider whether there's actually a deeper problem that needs your attention?If you only fix the symptoms – what you see on the surface – the problem will almost certainly happen again. which will lead you to fix it, again, and again, and again. If, instead, you look deeper to figure out why the problem is occurring, you can fix the underlying systems and processes that cause the problem. Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why the problem occurred in the first place. Root Cause Analysis seeks to identify the origin of a problem. It uses a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:Determine what happened.Determine why it happened.Figure out what to do to reduce the likelihood that it will happen again. RCA assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, you can discover where the problem started and how it grew into the symptom you're now facing.You'll usually find three basic types of causes:Physical causes - Tangible, material items failed in some way (for example, a car's brakes stopped working). Human causes - People did something wrong. or did not doing something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing).Organizational causes - A system, process, or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid). Root Cause Analysis looks at all three types of causes. It involves investigating the patterns of negative effects, finding hidden flaws in the system, and discovering specific actions that contributed to the problem. This often means that RCA reveals more than one root cause.You can apply Root Cause Analysis to almost any situation. Determining how far to go in your investigation requires good judgment and common sense. Theoretically, you could continue to trace root causes back to the Stone Age, but the effort would serve no useful purpose. Be careful to understand when you've found a significant cause that can, in fact, be changed.
• #13: The Root Cause Analysis ProcessRoot Cause Analysis has five identifiable steps.Step One: Define the ProblemWhat do you see happening? What are the specific symptoms? Step Two: Collect DataWhat proof do you have that the problem exists?How long has the problem existed?What is the impact of the problem? You need to analyze a situation fully before you can move on to look at factors that contributed to the problem. To maximize the effectiveness of your Root Cause Analysis, get together everyone – experts and front line staff – who understands the situation. People who are most familiar with the problem can help lead you to a better understanding of the issues.A helpful tool at this stage is CATWOE. With this process, you look at the same situation from different perspectives: the Customers, the people (Actors) who implement the solutions, the Transformation process that's affected, the World view, the process Owner, and Environmental constraints. Step Three: Identify Possible Causal FactorsWhat sequence of events leads to the problem? What conditions allow the problem to occur?What other problems surround the occurrence of the central problem? During this stage, identify as many causal factors as possible. Too often, people identify one or two factors and then stop, but that's not sufficient. With RCA, you don't want to simply treat the most obvious causes - you want to dig deeper.Use these tools to help identify causal factors:Appreciation - Use the facts and ask "So what?" to determine all the possible consequences of a fact.5 Whys - Ask "Why?" until you get to the root of the problem. Drill Down - Break down a problem into small, detailed parts to better understand the big picture. Cause and Effect Diagrams - Create a chart of all of the possible causal factors, to see where the trouble may have begun. Step Four: Identify the Root Cause(s)Why does the causal factor exist?What is the real reason the problem occurred? Use the same tools you used to identify the causal factors (in Step Three) to look at the roots of each factor. These tools are designed to encourage you to dig deeper at each level of cause and effect. Step Five: Recommend and Implement SolutionsWhat can you do to prevent the problem from happening again?How will the solution be implemented?Who will be responsible for it?What are the risks of implementing the solution? Analyze your cause-and-effect process, and identify the changes needed for various systems. It's also important that you plan ahead to predict the effects of your solution. This way, you can spot potential failures before they happen.One way of doing this is to use Failure Mode and Effects Analysis (FMEA). This tool builds on the idea of risk analysis to identify points where a solution could fail. FMEA is also a great system to implement across your organization; the more systems and processes that use FMEA at the start, the less likely you are to have problems that need Root Cause Analysis in the future.Impact Analysis is another useful tool here. This helps you explore possible positive and negative consequences of a change on different parts of a system or organization.Another great strategy to adopt is Kaizen, or continuous improvement. This is the idea that continual small changes create better systems overall. Kaizen also emphasizes that the people closest to a process should identify places for improvement. Again, with kaizen alive and well in your company, the root causes of problems can be identified and resolved quickly and effectively. Key PointsRoot Cause Analysis is a useful process for understanding and solving a problem. Figure out what negative events are occurring. Then, look at the complex systems around those problems, and identify key points of failure. Finally, determine solutions to address those key points, or root causes. You can use many tools to support your Root Cause Analysis process. Cause and Effect Diagrams and 5 Whys are integral to the process itself, while FMEA and Kaizen help minimize the need for Root Cause Analysis in the future. As an analytical tool, Root Cause Analysis is an essential way to perform a comprehensive, system-wide review of significant problems as well as the events and factors leading to them.Why Do Root Cause Analysis?“Just fix it, there is too much to do.”“We don’t have time to think, we need results now.”Reality - fix symptoms without regard to actual causesRoot Cause Analysis - structured and thorough review of problem designed to identify and verify what is causing the symptoms
• #17: Pareto Analysis is used to record and analyse data relating to a problem in such a way as to highlight the most significant areas, inputs or issues. Pareto Analysis often reveals that a small number of failures are responsible for the bulk of quality costs, a phenomenon called the ‘Pareto Principle.’This pattern is also called the ‘80/20 rule’ and shows itself in many ways. For example: 80% of sales are generated by 20% of customers. 80% of Quality costs are caused by 20% of the problems. 20% of stock lines will account for 80% of the value of the stock.A Pareto diagram allows data to be displayed as a bar chart and enables the main contributors to a problem to be highlighted.As a basic Quality Improvement tool, Pareto Analysis can: define categories of defects which cause a particular output (product, service, unit) to be defective; count the frequency of occurrence of each defect; display graphically as a bar chart, sorted in descending order, by frequency of defect; use a second y axis to show the cumulative % of defects .Vilfredo Pareto was an economist who is credited with establishing what is now widely known as the Pareto Principle or 80/20 rule. When he discovered the principle, it established that 80% of the land in Italy was owned by 20% of the population. Later, he discovered that the pareto principle was valid in other parts of his life, such as gardening: 80% of his garden peas were produced by 20% of the peapods.Some Sample 80/20 Rule Applications· 80% of process defects arise from 20% of the process issues.· 20% of your sales force produces 80% of your company revenues.· 80% of delays in schedule arise from 20% of the possible causes of the delays.· 80% of customer complaints arise from 20% of your products or services.(The above examples are rough estimates.)
• #18: 1. Gather facts about the problem, using Check Sheets or Brainstorming, depending on the availability of information.2. Rank the contributions to the problem in order of frequency.3. Draw the value (errors, facts, etc) as a bar chart.4. It can also be helpful to add a line showing the cumulative percentage of errors as each category is added. This helps to identify the categories contributing to 80% of the problem. 5. Review the chart – if an 80/20 combination is not obvious, you may need to redefine your classifications and go back to Stage 1 or 2. Examples When possible, use Minitab’s version, as an industry standard, rather than creating one in Excel - refer to Example 1 in this section Use a series of Pareto charts to drill down to more detail - Example 2 Recognise the 80: 20 principle but if the original Pareto is very flat be prepared to cut the defects in a different way, say 40:60 - Example 3 Minitab gives an extra dimension to Pareto Analysis - Example 4
• #19: 1. Gather facts about the problem, using Check Sheets or Brainstorming, depending on the availability of information.2. Rank the contributions to the problem in order of frequency.3. Draw the value (errors, facts, etc) as a bar chart.4. It can also be helpful to add a line showing the cumulative percentage of errors as each category is added. This helps to identify the categories contributing to 80% of the problem. 5. Review the chart – if an 80/20 combination is not obvious, you may need to redefine your classifications and go back to Stage 1 or 2. Examples When possible, use Minitab’s version, as an industry standard, rather than creating one in Excel - refer to Example 1 in this section Use a series of Pareto charts to drill down to more detail - Example 2 Recognise the 80: 20 principle but if the original Pareto is very flat be prepared to cut the defects in a different way, say 40:60 - Example 3 Minitab gives an extra dimension to Pareto Analysis - Example 4
• #20: Construct the Pareto chart – Example 1Use a series of Pareto charts to drill down to more detail – Example 2 Recognise the 80: 20 principle but if the original Pareto is very flat be prepared to cut the defects in a different way, say 40:60 - Example 3 Create more Pareto by cutting across another variables- Example 4
• #22: At first glance, this looks unhelpful. But of 238 data points, most were counts of 1 or 2. A full Pareto would be very flat.Therefore after the first cumulative 42% of defects (100) , the balance of defects (138) are blocked together as “others”.This enables us to see that a “top 9” of defects can be analysed - most are “S-clip” problems (links between ICs and PCB
• #23: Examples of Unacceptable Root Cause- Operator Error- It was broken (equipment, gauge, tooling)The process didn’t do what it was supposed to doDidn’t know what to doIt only happened onceFrequent use of “not able to determine/unresolved”
• #28: valuable tool for: Focusing on causes not symptoms capturing the collective knowledge and experience of a group Providing a picture of why an effect is happening Establishing a sound basis for further data gathering and action Cause and Effect Analysis can also be used to identify all of the areas that need to be tackled to generate a positive effect.
• #30: 1. Identify the Problem/IssueSelect a particular problem, issue or effect. Make sure the problem is specific, tightly defined and relatively small in scope and that everyone participating understands exactly what is being analyzed. Write the problem definition at the top of the flip chart or whiteboard.2. Brainstorm Conduct a Brainstorm of all the possible causes of the effect, i.e., problem.Have a mixed team from different parts of the process (e.g., assemblers and testers).Get a “fresh pair of eyes” - from someone who is not too close to the process.Have a facilitator - an impartial referee.Everyone is an equal contributor (“leave stripes at the door”).Fast and furious - go for quantity rather than quality (of ideas) at first.Involve everyone, or question why he/she is here.Timing - set an upper limit and best time/day of the week.Offer an incentive (free lunch?).Know when to stop.Recognize that this is a snapshot of how the group thinks today.Re-visit the problem again.Refer also to the Process Mapping tool.Consider (how) should you involve your customer?Write each idea on a Post-It® to make it easy to transfer them onto the fishbone diagram later. Be careful not to muddle causes and solutions at this stage. It is important to brainstorm before identifying cause categories otherwise you can constrain the range of ideas. However, if ideas are slow in coming use questions such as, ‘what about?’, to prompt thoughts.3. Draw fishbone diagram Place the effect at the head of the “fish” Include the 6 recommended categories shown below
• #31: 4. Align Outputs with Cause CategoriesReview your brainstorm outputs and align with the recommended major cause categories, e.g., the People, Method, Machine, Material, Environment and Measurement System. Note:These may not fit every situation and different major categories might well be appropriate in some instances, however, the total should not exceed six. Other categories may include Communications, Policies, Customer/Supplier Issues etc.5. Allocate CausesTransfer the potential causes from the brainstorm to the diagram, placing each cause under the appropriate category.If causes seem to fit more than one category then it is acceptable to duplicate them. However, if this happens repeatedly it may be a clue that the categories are wrong and you should go back to step 4.Related causes are plotted as ‘twigs’ on the branches. Branches and twigs can be further developed by asking questions such as ‘what?’, ‘why?’ ‘how?’, ‘where?’ This avoids using broad statements that may in themselves be effects. Beware, however, of digging in and getting into bigger issues that are completely beyond the influence of the team.6. Analyze for Root CausesConsider which are the most likely root causes of the effect. This can be done in several ways:Through open discussion among participants, sharing views and experiences. This can be speeded up by using Consensus Decision Making.By looking for repeated causes or number of causes related to a particular category.By data gathering using Check Sheets, Process Maps, or customer surveys to test relative strengths through Pareto Analysis.Once a relatively small number of main causes have been agreed upon, Paired Comparisons, can be used to narrow down further.Some groups find it helpful to consider only those causes they can influence.7. Test for RealityTest the most likely causes by, e.g., data gathering and observation if this has not already been done.The diagram can be posted on a wall and added to / modified as further ideas are generated either by the team or by others who can review the teams' work.Cause and Effect Analysis can be combined with Process Mapping.A fishbone may be developed for each discrete activity within the process that is generating the output / effect so that causes are linked to particular steps in the process
• #32: Types of Questions that may be Asked Does the person have adequate supervision and support? Does the person know what he is expected to do in his job? How much experience does the person have? Does the person have the proper motivation to do his best work? Is the person satisfied or dissatisfied with his job?Is the person more- or less-productive at certain times of the day? Do physical conditions such as light or temperature affect their work? Does the person have the tools/equipment needed to do the job? Who does the person contact when problems arise? Is the work load reasonable?
• #33: Types of Questions that may be Asked How is the method used defined? Is the method regularly reviewed for adequacy? Is the method used affected by external factors? Have other methods been considered? How does the operator know if the method is operating effectively?Is statistical analysis used to verify the effectiveness of the method? What adjustments must the operator make during the process? Have any changes been made recently in the process?
• #34: Types of Questions that may be Asked How old is the equipment or machinery? Is it maintained regularly? Is the machine affected by heat or vibration or other physical factors? How does the operator know if the machine is operating correctly?Is statistical analysis used to verify the capability of the machine? What adjustments must the operator make during the process? Have any changes been made recently in the process?
• #35: Types of Questions that may be Asked How is the material produced? How is the material verified? How old is the material? How is quality judged prior to your operation? What is the level of quality?How is the material packaged? Can temperature, light or humidity affect the material quality? Who is the material supplier? Has there been a change in suppliers?
• #36: Types of Questions that may be Asked How are conditions monitored? How are conditions controlled? How is the control measuring equipment calibrated? Are there changes in conditions at different times of the day? How does change impact the processes being used? How does change impact the materials being used?
• #37: Types of Questions that may be Asked How frequently are products inspected? How is the measuring equipment calibrated? Are all products measured using the same tools or equipment? How are inspection results recorded? Do inspectors follow the same procedures? Do inspectors know how to use the test equipment?
• #38: A Cause and Effect diagram (also known as a Fishbone or Ishikawa diagram) graphically illustrates the results of the analysis and is constructed in steps. Cause and Effect Analysis is usually carried out by a group who all have experience and knowledge of the cause to be analyzed. Cause-and-Effect diagrams graphically display potential causes of a problem The layout shows Cause-and-Effect relationships between the potential causesAllow team members to specify where ideas fit into the diagramClarify the meaning of each idea using the group to refine the ideas. For example:Is also Called, “Fishbone" or "Ishikawa" diagram is named after its creator, Kaoru Ishikawa.Is used to systematically list all the different potential causes for a specific problem (or effect). Is often used to help identify the reasons why a process goes wrong.A Cause and Effect diagram graphically illustrates the results of the analysis and is constructed in steps. Cause and Effect Analysis is usually carried out by a group who all have experience and knowledge of the cause to be analyzed. Cause-and-Effect diagrams graphically display potential causes of a problem The layout shows Cause-and-Effect relationships between the potential causesThe Cause and Effect diagram is one of several charts used during Brainstorming to organizing ideas into common themes. This format helps with the process of distinguishing between alternatives, identifying common threads, and keeping the ideas flowing. This method also allows the team to easily divide up the ideas for further work.Organize the topic, team and write down the general categories on the chart. Brainstorm the ideas about the potential causes using good brainstorming practices (no bad ideas, everyone gets a voice). Illustrates how several potential causes may lead to the same effect. Generally takes on the shape of a fishbone.   Potential causes are organized under common headings such as Materials, Machinery, Methods, Environment, Process & Measurement It is common for people working on improvement efforts to jump to conclusions without studying the causes, target one possible cause while ignoring others, and take actions aimed at surface symptomsCause-and-effect diagrams are designed to:Stimulating thinking during a brainstorm of potential causesProviding a structure to understand the relationships between many possible causes of a problemGiving people a framework for planning what data to collectServing as a visual display of causes that have been studiedHelping team members communicate within the team and with the rest of the organization
• #44: The “Five Why’s” is a method for rapidly determining the root cause of a problem popularized by Taichi Ohno, the father of the Toyota Production System. His technique was to approach any problem and keep asking “Why” until he was satisfied that the answer showed him what was really the source of the problem. In doing so, he then had a good idea of what needed to be fixed to prevent the problem. He called it the “Five Why’s” because he found over time that by asking “why” five times he usually ended up with the right information to go and fix the problem. The Five Why’s should be used by individuals and teams when trying to quickly assess and determine source of problems. Most problems can be handled this way, however more complex or life/mission critical problems typically require a more formal root-cause methodology including documenting the analysis. However, even the formal methodology requires asking “why” over and over again.Why not just ask “Why”?Need to systematically organize and analyze dataFirst understand “What happened” then “Why”Typically multiple root causesBlame is an obstacleGuidance needed to investigate human performance problemsNeed to ask right questions to completely understand whySome RCA techniques may provide easy answers that are either incomplete or wrong (but easy to find)
• #52: Now that you have already learned the technique of finding out the root cause using any of the tools in Module 1 or Module 2 of this training, you are now going to apply the acquired skill in preparing the CA/PA request and report.However, please note the following.Examples of Acceptable Root CauseProcess- acceptance criteria is unclearSystem or process allows errors-enumerate themCommunication-specs/work instructions changed without being communicatedEmployees unaware of defects or the effects of the defectsEquipment part malfunction due to set-up issues; parameter change without evaluation/risk assessmentExamples of Unacceptable Root Cause- Operator Error- It was broken (equipment, gauge, tooling)The process didn’t do what it was supposed to doDidn’t know what to doIt only happened onceFrequent use of “not able to determine/unresolved”
• #53: Corrective, Preventive, or Continual Improvement? I find that some organizations are having trouble distinctly identifying the three types of improvement in clause 8.5: corrective, preventive, and continual. Fixing an actual, detected problem in such a way as to prevent its "recurrence" is corrective action. When you anticipate a potential problem (based on risk planning or trend analysis) and take action to prevent its "occurrence", that is preventive action. Some people think that by correcting a known problem so it is prevented from happening again, they have taken preventive action. No, that is just part of a full and complete corrective action. While ongoing corrective and preventive actions provide improvement, another type of improvement can be made to conforming processes and products. You may want to do things faster and better, not triggered by problems or expected problems, but based on your monitoring of quality objectives and suggestions for improvement. Continual improvement is a recurring, step-by-step, activity that increases the ability of an organization to meet requirements. Don't rely solely on corrective and preventive actions to improve your system. Continually seek to improve the effectiveness and efficiency of your processes; don't  wait for problems to reveal opportunities for improvement. Improvements can range from simple small-step improvements to strategic breakthrough projects. The key is to have a process in place to identify and manage the improvement activities. These improvements may result in changes to the product, processes, system, or even the organization. To set up a continual improvement process, read Annex B, Process for Continual Improvement, in ISO 9004:2000. Management review meetings cover process performance and product conformity, as well as, recommendations for improvement. These reviews should be the forum for identifying possible improvements and recording any decisions and actions. The results of planned improvements will be reviewed at future meetings and provide evidence of your continual improvement process. Corrective Action – the action taken to eliminate the root cause of an existing non-conformance andto prevent its recurrence. It is reactionary in naturePreventive Action – the action taken to eliminate a potential non-conformance and to prevent its occurrence. This is pro-active in nature.
• #55: OBJECTIVEProvide evidence that afterimplementation and overtime,the action works properlyand does not introducea new problem or effect.
• #56: 3 Steps in Verifying Effectiveness1. The “after” condition eliminates the problem.2. There is a difference between the “before” and “after” condition.3. The “after” condition does not create another effect
• #58: PROBLEM SOLVING FAILURE- JUMPING TO CONCLUSIONS,NO FACT FINDING- SHOTGUN ROOT CAUSE - FAILURE TO DEFINE THE PROBLEM- FAILURE TO FIND THE ROOT CAUSEWEAK PROBLEM SOLVING SKILL-NO EXECUTION OF CORRECTIVE ACTIONSACTION IS ONLY FOR THE SHOW NO COMMITMENT/OWNERSHIPTIME FACTOR- COST CONSTRAINTS
• #59: PROBLEM SOLVING SUCCESSProblem is clearly defined.Problem is acceptedAs an opportunity/challenge to improve- True root cause is found- Implemented an effective and irreversible corrective and preventive action- Problem did not re-occur
• #60: PROBLEM SOLVING SUCCESSProblem is clearly defined.Problem is acceptedAs an opportunity/challenge to improve- True root cause is found- Implemented an effective and irreversible corrective and preventive action- Problem did not re-occur
• #86: This is the end of the presentation , now let us practice what we have just learned
• #87: This is the end of the presentation , now let us practice what we have just learned