Continuous Improvement

Through Effective
Root Cause & Corrective Action

Cedric Baker

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 Goals
Create an understanding of the concept of Root Cause
analysis

To impart a familiarity with analytical tools utilized in

the determination of Root Causes

To teach the members of this class how to effectively

analyze problems, determine their Root Causes and
define appropriate Corrective Actions

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 Agenda
What is Root Cause Analysis?
Why Do We Perform Root Cause Analysis?
Root Cause Analysis Philosophy
Symptom vs. Root Cause
Root Cause Analysis Process
Phase 1: Investigation
Phase 2: Analysis
Problem Solving Tools
Phase 3: Decision
Mistake Proofing
Case Study (Good RCA versus Bad RCA)
Summary (Principals or Root Cause Analysis)
Additional Resources

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 What is Root Cause Analysis?

Root Cause Analysis (RCA) Definition:

Methodology for finding and correcting the true
root cause(s) of a problem while implementing
corrective action to prevent recurrence.

Root Cause: The agent, failure, or fault, from

which a chain of effects or failures originates.

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 Why do we perform
Root Cause Analysis?
Design Where a defect is found
Component
Level
often has a correlation
to the cost of the
Assembly
defect!
During
Testing
By
Customer
The goal is to
eliminate the
defect as far up
stream as possible.
At the source!
?
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 Root Cause Analysis Philosophy

It is critical that everyone take a personal and active

role in improving quality
Each problem is an opportunity because it can tell a
story about why and how it occurred
To do this well, we must:
Understand true problem before taking action
Remain open-minded and avoid jumping to conclusions
Take action using sound judgment based on facts and data

If effective RCA is not performed, the problem is likely to reoccur

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 Symptom vs. Root Cause
Symptom Approach
Errors are often a result of
worker carelessness.
We need to train and
motivate workers to be more
careful.
We dont have the time or
resources to really get to the
bottom of this problem.
Avoid placing band-aids on the symptoms. Seek the real cause(s).
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Root Cause Approach
Errors are the result of
defects in the system.
People are only part of the
process.
We need to find out why
this is happening, and
implement mistake-proofs so
it wont happen again.
This is critical. We need to
fix it for good, or it will come
back and burn us.
 Root Cause Analysis Process

Phase 1: Investigation

Phase 2: Analysis

Phase 3: Decision

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 Root Cause Analysis Process
Phase 1: Investigation
Purpose: Gather a factual account of the defect/failure
Be as neutral as possible
What is the problem? Where is the problem? When did the problem
Verify non-compliance Factory first occur?
Defect Supplier Day, date
Failure Design Location
Test
Environment
Runtime of system

Product History What is the Impact to To what extent did the

Failure/Repair History the customer? problem occur?
Total runtime Cost Events leading up to the incident
Previous systems, environments, Schedule
tests Retrofit
Spares
Life Cycle Cost

Collect and review data for trends, process variation, and stability
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 Root Cause Analysis Process
Phase 1: Investigation

Document and track the nonconformance and associated

root cause analysis.

Examples of media used for documentation are:

Non-conformance Documents (DMR)
Corrective Action Request Form (CAR)
Supplier Corrective Action Request Form (SCAR)
Corrective Action Plan (CAP)

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 Phase 2: Analysis

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 Root Cause Analysis Process
Phase 2: Analysis

Purpose: To determine root cause(s), by identifying

reasons explaining WHY an incident occurred.

Step 1
Using the factual information gathered in the investigation
phase, determine the root cause(s) by identifying potential
causes of the problem using one or more structured problem
solving tools.

Utilize all stakeholders and subject matter experts

Avoid attempts to fix the issue during this phase

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Problem Solving Tools
Phase 2: Analysis

Fault Tree

5 Whys

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 5 Why Analysis
Phase 2: Analysis

The 5-Why analysis method is used to move beyond symptoms and

understand the true root cause of a problem.

It is said that by asking Why 5 times, successively, causes one to

understand the ultimate root cause.

This tool is often used to complement the analysis necessary to

complete a Cause & Effect (Fishbone) Diagram

Continue to ask why until the lowest level cause (s) are determined

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 Example: Jefferson Memorial
Phase 2: Analysis
The Jefferson Memorial is deteriorating
Why?
Too much washing
Why?
Excess bird droppings
Why?
Lots of spiders to eat
Why?
Lots of gnats to eat
Why?
We leave the lights on all the time
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Problem Solving Tools
Phase 2: Analysis

Fault Tree

5 Whys

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 Fault Tree Analysis
Phase 2: Analysis

Fault tree analysis is used to analyze failures in complex products,

processes, or systems.

Fault tree analysis enables teams to effectively evaluate the design

and operational performance of their process. As a result the team
is able to objectively view a process and identify areas where
problems may arise.

A basic fault tree starts with the undesirable condition or failure.

The contributing causes are branched out until the root cause(s) is
reached.

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 Fault Tree
Phase 2: Analysis

Bulb Fails

2.0 Mother 4.0

5.0 Machines/
1.0 Methods Nature 3.0 Manpower Measurements/ 6.0 Materials
Systems
(environment) Metrics

2.1 Power 6.2 Filament

5.1 No electricity 6.1 Glass Broken
Outage Broken

2.1.1 Extreme 5.1.1 Power Plant 5.1.2 Power Line 5.1.3 Connector
6.2.1 Impurities
Weather Anomaly Fails Fails Corroded

5.1.2.1 Wind 5.1.2.2 Tree 6.2.2 Vibrations

Breaks Line Breaks Line

6.2.3 Exceeded
Life Expectancy

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 Root Cause Analysis Process
Phase 2: Analysis

Step 2
Prioritize the potential causes and key
contributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine the

need for formal laboratory failure analysis

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 Root Cause Analysis Process
Phase 2: Analysis

Step 3
Finalize the analysis by identifying the root cause(s):

Reproduce the failure or demonstrate it by appropriate

simulation for verification purposes, if practical.

Re-evaluate problem containment steps to assure the

defect / failure mechanism has been effectively contained.

Output should be a finite set of root causes showing why the incident was inevitable.

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 Phase 3: Decision

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 Root Cause Analysis Process
Phase 3: Decision

Purpose: To implement corrective and preventive action

Definition of Corrective/Preventive Action: Improvements to an organizations
processes taken to eliminate and prevent causes or other undesirable situations.

Step 1
Brainstorm possible solutions for corrective and preventive action.

Approach corrective and preventive action with the use of mistake

proofing.

Other examples of corrective actions include visible or audible

alarms, process redesign, product redesign, training or work
instruction improvements, improvement to material handling or
storage

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 Mistake Proofing
Phase 3: Decision
When to use Mistake Proofing:
Human error can cause mistakes or defects to occur
The customer can make an error which affects the output
At a hand-off step in a process
Minor error early in the process causes major problems later in process
Consequences are expensive or dangerous

It follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehand.
[Shingo]

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 Root Cause Analysis Process
Phase 3: Decision

Step 2

Finalize a solution and determine if acceptable by considering

the following:
Will the solution cause new problems?
The level of difficulty of implementing the solution?
How much time will it take to implement?
What is the cost of implementation?
Is the solution transferable to other processes or areas?

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 Root Cause Analysis Process
Phase 3: Decision

Step 3
Objectively Verify:
1. Each action in the implementation plan has been
carried out and completed.
2. Each solution effectively resolves root cause(s), and
eliminates or significantly reduces recurrence.
3. All documentation is complete and properly archived
4. All necessary training is complete
5. Nonconformance tracking effort is adequately closed
(SCAR, CAR, CAP, DMR, etc)
6. Consider doing a 30-60-90 day follow-up to further
ensure effectiveness of corrective/preventative actions

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 Case Study
The "Case" of the Sidelined Spectacles

Situation: It's 3 p.m. and you have a 5 p.m. deadline. You are hurriedly reviewing a lengthy procedure
that needs to be amended and on the boss' desk by 5 p.m. when disaster strikes- the lens of your
glasses falls out again! What do you do?
Finding (Problem): Your glasses have broken several times within the last few weeks, which is
slowing your productivity.
Understanding the need to solve the problem immediately so that you can get on with your day as
well as to prevent it from happening again by implementing corrective action, you decide to take a root
cause analysis approach to problem solving.

Containment: Use clear adhesive tape to secure the lens in the frame.
Root Cause: The glasses keep breaking, causing me to miss deadlines.
Corrective Action: Use clear adhesive tape to secure the lens in the frame, each time they break;
ask boss for deadline extension.
REFLECTION: Why is this a poor example of root cause analysis?

The example illustrates poor root cause analysis by highlighting common mistakes that prevent clients
from identifying the true root cause and determining the proper systemic corrective action. The root
cause listed above is actually a symptom of the problem; it does not address the true problem in the
system. Also, the corrective action provided is an act of containment, not irreversible systemic
corrective action. In this example, the finding and the root cause are identical, which provides no value
to the system.

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 Case Study
The "Case" of the Sidelined Spectacles

Finding (Problem): Your glasses have broken several times within the last few weeks, which is slowing your
productivity.
Short-Term Containment: Use clear adhesive tape to secure the lens in the frame.
Root Cause Analysis: Methodology: 5-Why
Restate the finding: The lens keeps falling out of my eyeglasses.

1st Why: Why does the lens keep falling out of your glasses? - The frames are damaged

2nd Why: Why are the frames damaged? - I am not storing them in the case

3rd Why: Why are you not storing them in the case? - I lost the case

4th Why: Why did you lose the case? - I am not storing the case in the same place

Corrective Action: I will keep the case in the same place by tethering the case to the desk. This will prevent the
case from being lost and I will be able to store the glasses in their case in a clear area of my desk when I don't need to
wear them.
REFLECTION: Why is this a good example of root cause analysis?
The example illustrates good root cause analysis that will allow clients to identify the true root cause and determine
the proper systemic corrective action. The root cause listed above addresses the true problem in the system. Also,
the corrective action provided is not simply an act of containment; instead it provides systemic corrective action. In
this example, the client used the "5 Why Methodology" which is a helpful tool when analyzing your root cause.

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 Summary Principles of RCA
1. Define the problem

2. Gather data and evidence

3. Ask "why" and identify the root causes

4. Implement corrective/preventive action(s) that mistake-proofs root cause

5. Ensure effectiveness by observing the implemented corrective/preventive

actions

6. Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-looking

culture that solves problems before they occur or escalate. More
importantly, it reduces the frequency of problems occurring over time by
creating an environment of continuous improvement.

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 Additional Resources
Root Cause Analysis Training and Tools

Think Reliability
http://www.thinkreliability.com/
ASQ Learning Institute
http://asq.org/training/root-cause-analysis_RCA.html
Sologic(Formerly Apollo Associated Services)
http://www.sologic.com/
Lockheed Martin Supplier Corrective Action Process
https://embastion.external.lmco.com/qis/supplier_ca/
Washington Memorial Root Cause Example
http://www.youtube.com/watch?v=IETtnK7gzlE&noredirect=1

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 Credits
12 October 2011. Air University. 8 March 2012.
<http://www.au.af.mil/au/awc/awcgate/nasa/root_cause_analysis.pdf>.

2012. 8 March 2012. <http://www.pjr.com/root_cause/root_cause_scenario_1B.htm>.

Cook, Gregory and Yechiel Rosenfold. Roeing RCCA Introduction to Root Cause and Corrective
Action. n.d.

Kirupakar, B. R. Quality Risk Managment for Pharmaceutical Industry. February 2007. March
2012. <http://www.pharmainfo.net/reviews/quality-risk-management-pharmaceutical-
industry>.

Page, Jody. "Causal Analysis: Workshop Presentation." LMMFC RC RCA Worshop. Orlando, 2012.

Root Cause. 2012. 8 March 2012. <http://www.businessdictionary.com/definition/root-

cause.html>.

Root Cause Analysis. 8 March 2012. 8 March 2012.

<http://en.wikipedia.org/wiki/Root_cause_analysis>.

Tague, Nancy R. Mistake Proofing. 2004. 5 March 2012. <http://asq.org/learn-about-

quality/process-analysis-tools/overview/mistake-proofing.html>.

Wilson, Bill. 2010. Root Cause Analysis. 8 March 2012. <http://www.bill-wilson.net/root-cause-

analysis>.
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 Please send all questions to:
mfc.training.supplier@lmco.com

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