Root causeanalysis1
- 1. Continuous Improvement Learning Organization ROOT CAUSE SYSTEMS PROCESSES SYSTEMS PROCESSES ANALYSIS and Continuous Improvement 1
- 2. Topics to be discussed • What is Root Cause Analysis? • Tools and Techniques • Step-by-Step Root Cause Analysis • Corrective Action Planning 2
- 3. Process Improvement Control System Forecast Forecast Monthly Monthly Action Action Action Action Review Review Log Log Log Log Meeting Meeting Process Process Master Master Schedule Schedule Daily Daily Weekly Weekly Weekly Weekly Review Review Operating Operating Meeting Weekly Report Meeting Report Planning Meeting ACTION 1 2 3 Action Daily Daily Action Weekly Short Short Review Log Weekly Interval Log Process Process Interval Meeting Plan Control Control Plan 3
- 4. Action Log Review at the beginning and end of every meeting Copy and distribute to all attendees before they leave GKN Sinter Metals ACTION LOG Meeting: Date: Sheet 1 of ___ Action Log completed by: Meeting attendees: Distribution: Attendees +: Listed below are the issues discussed and actions agreed at the above meeting. The actions assigned were committed to by the responsible parties. Relevant material presented or reviewed is attached or referenced in the text. # Issue Action Required / Status Responsible Date due Completed? NEVER ASSIGN RESPONSIBILITY TO SOMEONE WHO IS NOT AT THE MEETING 4
- 5. Process Failure and Waste 5
- 6. Interruptions in Process Flow Emergency Unforeseen and unplanned or uncontrolled quality defect or stoppage of the process that will adversely impact the delivery of value to the customer. Requires immediate, unscheduled response. Waste and Improvement Deterioration in process performance. Responses can be planned and scheduled. 6
- 7. Achieving Breakthrough Results SPORADIC departure from historic level HISTORIC LEVEL L o The difference between the HISTORIC s and OPTIMUM level represents a tremendous cost savings s OPTIMUM LEVEL time 7
- 8. What is “Failure”? It no longer achieves a desired standard of performance. We fail to achieve our plan. We fail to deliver value to our customer. 8
- 9. If it’s not adding value it is... is anything other than the minimum amount of equipment, materials, parts, space and employee’s time which are absolutely essential to add value to the product or service. 9
- 10. What is RCA? Root Cause Analysis is a process of analyzing the cause-effect relationships between events. DATA ACTION ANALYSIS DECISION It aims to identify and separate symptoms from the true cause of a problem, and to identify the actions necessary to ELIMINATE it. 10
- 11. Step-by-Step Root Cause Analysis 1. FORM / CONVENE THE TEAM 2. GATHER EXPERTS 3. INVESTIGATE AND GATHER DATA 4. DETERMINE SEQUENCE OF EVENTS 5. AGREE ON THE EFFECTS 6. SEVERITY-OCCURRENCE-DETECTION RANKING 7. CAUSE AND EFFECT DIAGRAM (Fishbone, Mind map) 8. DEVELOP CORRECTIVE ACTION PLAN AND TIMETABLE. ASSIGN RESPONSIBILITY 9. FOLLOW UP FOR COMPLETION OF ACTIONS 10. EVALUATE EFFECTIVENESS OF ACTIONS 11
- 12. 1. Form the Team • Appoint an RCA facilitator and Team Leader. Facilitator has been trained on leading an RCA. Team leader has the content expertise pertaining to the event. • Team Leader and Facilitator meet and identify data to be gathered and who should be on the team for this particular analysis. • Select meeting date, time and place and inform members. • Ask team members to bring data and a draft of the sequence of events. 12
- 13. 2. Gather Experts • Decide who should help determine the root cause in addition to the standing team. • Operators, supervisors, anyone who has knowledge of the specific event. • Experts who may not have “been there” but who have relevant experience are valuable resources, including manufacturers reps and contractors. 13
- 14. 3. Investigate and Gather Data •As soon as possible after the event, collect information, including control charts, operator notes, gage readings, data forms. Try to get data before, during and after the event. • Interview operators, supervisors and anyone who may have information about what happened. Ask questions about what they saw and heard. • WHO, WHAT, WHERE, AND WHEN 14
- 15. THE SEVEN QC TOOLS RUN CHART HISTOGRAM CONTROL CHARTS SCATTER DIAGRAM 10 10 UCL • • • • 5 X VARIABLE • 5 2 • • • LCL • • • 0 0 TIME X VARIABLE • 1 CAUSE AND EFFECT FLOWCHART PARETO CHART DIAGRAM MACHINE MEASUREMENT 10 METHOD 5 MATERIALS MAN 0 TYPE
- 16. Pareto Chart 3.1 Line, 331 Work order data Source: PMC work order data 10/09/00 Machine parts/subsystems with more than 1 work order Cumm % 10.9% Machine part/subsystem No. WO's Machine part/subsystem No. WO's % of Ttl 21.2% Load nest 3 Probe 17 10.9% 28.2% Prox 16 Prox 16 10.3% 34.0% Infeed gear box 1 Hydraulic 11 7.1% 39.7% Elec 3 Bushing 9 5.8% 44.9% Pivot stop 1 Clamps 9 5.8% 49.4% Sealtite connector 1 Swing clamp 8 5.1% 53.2% Program 3 Sideclamp 7 4.5% 57.1% Cylinders 1 Switch 6 3.8% 60.3% Hydraulic 11 Hardstop 6 3.8% 62.8% Valve 3 Split nuts 5 3.2% 64.7% 66.7% 68.6% 3.1 Line-Work Order Pareto 70.5% % of total Work 12.0% 72.4% 74.4% 10.0% 76.3% Orders 8.0% 78.2% 80.1% 6.0% 4.0% 2.0% 0.0% m p p ic e ps e ve or m ls ec to le ey lin ul ob ril m ot la ob al ds ra El K D be M Pr la ec V yd pr ar C Lu id H H o S N Subsystem/Machine Part 16
- 17. 4. Determine The Sequence of Events 1. • Develop a clear picture of what happened first, second, third, etc. 2. • Don’t try to determine root cause at this stage, just get the sequence of events right. 3. • Don’t “Rush to Judgement”. The obvious may not be the right answer. 17
- 18. 5. Agree On The Effects Use the results of the investigation and sequence of events • Brainstorm any other possibilities • Rank the effects using • Severity • Occurrence • Detection 18
- 19. 7. Cause and Effect Diagram AKA: Ishikawa or Fishbone Diagrams CAUSES EFFECT Manpower Method Last Minute rush to build Material Machinery 19
- 20. WHAT IS A CAUSE & EFFECT DIAGRAM ? • Also known as a “Fishbone” (Ishikawa diagram) or Mind Map • Shows the relationship between the Effect / Problem & possible causes. • Helps to differentiate between symptoms and primary causes • A problem / effect can have several causes. These can be identified and categorized. • Often emerges out of a Brainstorming session • A primary tool for Root Cause Determination 20
- 21. FISHBONE DIAGRAM THE EFFECT • Represented by the HEAD of the skeleton • The Effect should be stated in simple terms. • General Effects should be broken down into more specific Effects. THE CAUSES • Represented by the RIBS of the skeleton. • Use the “4M’s” / “4P’s” or others to categorize the causes. • Add the causes to the rib. • Add further riblets to show relationships between causes. 21
- 22. CAUSE & EFFECT DIAGRAM reminders The 4 ‘s The 4 ‘s anpower ersonnel achinery lant aterials olicies ethods rocedures 22
- 23. Cause & Effect Diagrams HOW TO CONSTRUCT A CAUSE & EFFECT DIAGRAM • STEP 1: Agree on one statement that describes the selected problem • STEP 2: Generate the causes needed to build up the problem • STEP 3: Construct the diagram • STEP 4: Interpretation 23
- 24. Cause & Effect Diagrams FISHBONE DIAGRAM CAUSES EFFECT Manpower Method Build on Rush To Complete Material Machinery 24
- 25. FISHBONE DIAGRAM - DAILY EXAMPLE METHODS MACHINERY No record Use wrong gears tire pressure Drive Fuel mix too too rich Under-inflated tires fast Poor hearing Mech. doesn’t Radio too loud have specs Poor design Always late POOR Can’t hear engine Carburetor Difficult air valve GAS Impatience adjustment stems MILEAGE Poor training Wrong gas No oil change Poor type maintenance $ No owner’s $ “When in Rome” manual Improper No awareness lubrication Don’t know Don’t know right oil recommended Poor driving petrol type Wrong oil No owner’s manual habits MANPOWER MATERIALS 25
- 26. Mind-mapping What is it? What value does it have? Where can it be used? 26
- 27. Mind Mapping An unstructured / creative tool Is an advanced form of Cause and Effect METHOD MANPOWER Rules of Mind Mapping No Operator Wrong start g procedure nin al u lan an Lost rm p Use a brainstorming base or Mowe • Op Po No es r fil No Lazy won’t start • Centralize the theme Pull rope broken Gas tank empty Di Fouled spark plugs pe dn g ro ’t nin ive Don’t question or judge ch • lea ec ct fe k rc De la gu MATERIAL MACHINERY re • Revisit the tool No • As many input sources as possible 27
- 28. 6. Ranking the Causes MIND MAP Process Name_______________________________ Severity Cause • Occurrence Ca us • Detection e Risk Priority No. = Effect (Severity) X (Occurrence) X (Detection) Subsystem / Part Severity Occurrence Detection RPN 28
- 29. SEVERITY EVALUATION CRITERIA 5 Very High Process Problem affects Quality of the Output 4 High Process Problem will likely impact the Quality of the Output 3 Moderate Process Problem may impact the Quality of the Output 2 Low Subsystem partially fails with a slight impact on quality performance 1 Minor Potential failure mode has no real affect on quality performance 29
- 30. OCCURRENCE EVALUATION CRITERIA Probability Frequency 5 Very High Failure is certain 1 Daily or every unit 4 High Failure is highly likely 1 Weekly 3 Moderate Occasional failure 1 Monthly 2 Low Failure not likely 1 Quarterly 1 Remote No failures recorded 1 Annual 30
- 31. Process Control Detection Criteria 5 Can not detect will not detect that the failure is occurring or will occur 4 Low have a poor chance of detecting the failure 3 Moderate may detect the failure 2 High have a good chance of detecting the failure 1 Very High will almost certainly detect the failure Risk Priority Number = Severity X Occurrence X Detection 31
- 32. GUIDELINES-Fish bones and Mind Maps 1. Make sure that everyone agrees completely on the problem statement 2. Construct carefully to achieve the best result 3. Do not be afraid to spread the diagram out. 4. Avoid using too many ideas under one main cause 5. If the problem is too complex, draw more than one diagram 6. Keep it simple 7. Ranking using Severity-Occurrence-Detection 8. Keep asking....WHY ?…5 times!!!!! ? 32
- 33. ASK “WHY?” WHY? FIVE TIMES!!!!! 33
- 34. CAUSE AND EFFECT DIAGRAM METHOD MANPOWER CAUSES EFFECT No Operator Wrong start procedure Manpower ng l Method ua ni Lost an an pl rm or PO5 STOPS No Op Po Solenoid valve Mower file Lazy No gone won’t s start Gas tank empty Material Pull rope broken Machinery Di Fouled spark plugs dn pe ’t ro ch g nin ive ec k ct lea fe rc De la gu MATERIAL MACHINERY re No KEEPING RECORDS Keep copies of the Cause & Effect diagrams. They can be used if a similar problem arises in the future. 34
- 35. 8. DEVELOP CORRECTIVE ACTION PLAN Recommended Corrective Action-Operations Who? When? Root Cause Analysis (RCA) Log Prepared By Date Maint Supv RCA No. ANALYSIS Recommended Corrective Action-Maintenance Who? When? Problem Description: What events lead to the above stated problem? Recommended Corrective Action-Engineering Who? When? Long term Analysis Assignment Who? When? Ask Why 5 Times! Why: Why: SIGNOFF: Why: Why: Maintenance Supv. Production Engineer Production Superintendent Why: 35
- 36. 9. Follow up on Completion CORRECTIVE ACTION LOG RCA No. Date: Corrective Action Date No. Date Location Equip/ Resp Due Detailed Description Compltd? 36
- 37. Human Error “Errors must be accepted as System flaws,not character flaws.” L. Leape The Root Cause of many failures may involve human error: • Poor training • Fatigue Don’t be afraid to identify Human error as a root cause. Errors can be addressed positively. Enter corrective actions involving Human Error in the Corrective Action Log and complete them with the same urgency as other “mechanical” corrective actions. 37
- 38. Evaluate Effectiveness Of Corrective Actions •After corrective actions are in place, evaluate failure history again. Look at the data! • Recalculate S.O.D. and compare with original number • Implement additional corrective actions as necessary 38
- 39. WHIDTMSIWNHA What It Will Have Never I Happen Done Again To Make Sure 39
- 40. Processes, Systems and the Tools Will Empower the Organization to Make It All Happen Corrective Action Log CORRECTIVE ACTION LOG RCA No. Date: Corrective Action Date No. Date Location Equip/ Resp Due Detailed Description Compltd? DATA Control the S ACTION whole... E MANALYSIS S T S Y ...by controlling the parts DECISION 40
Editor's Notes
- #2: SYSTEMS and PROCESS are the pillars of continuous improvement. SYSTEMS drive all improvement. PROCESS everything can be mapped as a process flow (HR, Customer Service) To be effective a process flow must reflect the “real life flow” of what happens. By identifying what actually is being done improvement can be made. Only those who are involved know what actually happens on a day to day basis. Can’t really problem solve until the process flow is defined. In a LEARNING ORGANIZATION there is degree of empowerment - so that people doing the work - the experts - are the ones from whom information is sought.. The old Boss/subordinate system is replaced with with a new system that solicits everyone's input.
- #3: AGENDA Recommended reading: Systems Thinking Peter Synge SPC for the Rest of Us - Root Cause Analysis - Quality Planning and Analysis - Juran & Gryna
- #4: Based on Demings’ PDCA 1. The Daily Plan Establish standards for process without waste. Determine how long before the process can run to this standard before it is out of control Determine what the process is suppose to be and compare this to what it actually is. Use examples from your own experiences When you talk about the process real time it is CONTROL - afterward it is an EXCUSE. 2. REVIEW MEETING - What do we do to make sure this never happens again? 3. ACTION LOG - What action has been taken? What still needs to be done. Who is going to do it?
- #5: Record both ACTION and ISSUES. Issues may not be resolved by the action taken.
- #6: This is a good opportunity to discuss the LEAN philosophy to control waste.
- #7: This is another good opportunity to draw on your personal experiences and relate EMERGENCY back to your audience. Use product or processes that they are familiar with.
- #8: This is a good chart to help people visualize the difference - the way they usually do things and how they could be doing them. Describe that determining the ROOT CAUSE of why is the catalyst to improvement. This chart can be use to create a dialogue between you and your audience about their particular functions. This can be a hunt to identify the frustrated and angry. They can lead you to more problems to solve.
- #10: The above definition of waste has become widely accepted as a main driver of the change process and LEAN Manufacturing. It states that the MINIMUM amount of resources should be used for each and every task throughout the company. Waste is everywhere and its elimination brings massive cost benefits. To create a dialogue with your audience ask for some examples of waste in their areas.
- #11: This is another example of Demings’ PDCA in action. Discuss that many time in an improvement process only certain elements are used resulting in continuous fire fighting rather than continuous improvement. Collecting DATA and Analyzing it without making a DECISION or taking ACTION does not improve the process. Collecting DATA, ANANLYZING that Data, making a DECISION,taking ACTION on the DECISION - then starting over again is the way to make incremental corrections to continually improve the way things are done at Sunrise Medical.
- #13: Everyone one on the team is a problem solver. The Facilitator and Team leader may be the same person - but whoever is appointed should be somewhat removed form the situation to maintain perspective. The main objective of the LEAD is to keep the team focused on the problem. The LEAD and FACILITATOR decide who should be on the team and what experts are required to solve problems. Publish an AGENDA ahead of time. Establish an environment to achieve the greatest discretionary effort from each individual.
- #14: It is KEY to identify the experts that should be on the team. Groups tend not to bring in experts and want to solve problems themselves. As a rule nobody does anything wrong because they want to do something wrong…it is generally the process
- #15: This is another good time for you to bring in examples from your experience where a SPORADIC EVENT caused a major quality problem and tie you experiences in with how you investigated and gathered data.
- #18: 1. Put things in a logical order - from start to finish - assure the order. This process is critical to ROOT CAUSE or you are dealing with symptoms. Don’t rush to judgement. Going through the process will provide valuable insights.
- #21: Separate cause from effect and get it all on paper.
- #22: The tendency is to grab hold of too large a problem - when that happens divide the problem. One suggestion is to start each session with a little training session to describe the intentions of the meeting and the expected outcomes. This assures that people know what to do and how to do it in each problem solving session. Be comfortable with silence. Learn to wait through the silence as people process information. The tendency is to start fixing. Remember in this situation there is no waste in process.
- #24: It is critical to agree and get consensus on STEP 1.
- #26: Get down every possible cause for the problem. Record jokes also…even if the finger is pointed at the Supervisor or another person. Things said in jest are often subconscious causes of the problem. Feelings are magical in that they identify things the brain hasn’t integrated.
- #27: When people have had allot of exposure to brainstorming - mind mapping can be another alternative to approach creative solutions to problems.
- #29: There is always the tendency not to establish the Risk priority. Ranking is very important to identify biggest problems. Ranking systems occurs on the following page.
- #31: Is the occurrence SPORADIC or CHRONIC? Walk your class through this ranking to identify frequency.
- #32: Use this formula for every problem identified on the FISHBONE to establish priority.
- #34: Give an example from your experience of how this has helped.
- #35: Keep your information - don’t throw it away - odds are you will not solve all of your problems the first time you use the CAUSE & EFFECT DIAGRAM.
- #39: S.O.D. Severity of Occurrence Detection
- #41: Without systems in place the process will drift away!