Sunteți pe pagina 1din 31

Continuous Improvement Through Effective Root Cause & Corrective Action

Cedric Baker

Continuous Improvement Through Effective Root Cause & Corrective Action Cedric Baker 1
Continuous Improvement Through Effective Root Cause & Corrective Action Cedric Baker 1

1

Goals

Goals • Create an understanding of the concept of Root Cause analysis • To impart a

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

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

Solving Tools – Phase 3: Decision • Mistake Proofing • Case Study (Good RCA versus Bad

Case Study (Good RCA versus Bad RCA)

Summary (Principals or Root Cause Analysis)

Additional Resources

What is Root Cause Analysis?

What is Root Cause Analysis? Root Cause Analysis (RCA) Definition: Methodology for finding and correcting the

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.

prevent recurrence. • Root Cause: The agent, failure, or fault, from which a chain of effects
prevent recurrence. • Root Cause: The agent, failure, or fault, from which a chain of effects

Why do we perform Root Cause Analysis?

Why do we perform Root Cause Analysis? The goal is to eliminate the defect as far
The goal is to eliminate the defect as far up stream as possible. At the
The goal is to
eliminate the
defect as far up
stream as possible.
At the source!
Design Component Level Assembly During Testing
Design
Component
Level
Assembly
During
Testing

Where a defect is found often has a correlation to the cost of the defect!

By
By

Customer

?

Root Cause Analysis Philosophy

Root Cause Analysis Philosophy • It is critical that everyone take a personal and active role

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

Symptom vs. Root Cause

Symptom vs. Root Cause Symptom Approach • “Errors are often a result of worker carelessness.” •

Symptom Approach

“Errors are often a result of worker carelessness.”

“We need to train and motivate workers to be more careful.”

“We don’t have the time or resources to really get to the bottom of this problem.”

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 won’t happen again.”

“This is critical. We need to fix it for good, or it will come back and burn us.”

Avoid placing band-aids on the symptoms. Seek the real cause(s).
Avoid placing band-aids on the symptoms. Seek the real cause(s).

Root Cause Analysis Process

Root Cause Analysis Process Phase 1: Investigation Phase 2: Analysis Phase 3: Decision 8
Phase 1: Investigation Phase 2: Analysis Phase 3: Decision
Phase 1: Investigation
Phase 2: Analysis
Phase 3: Decision

Root Cause Analysis Process

Root Cause Analysis Process Phase 1: Investigation Purpose: Gather a factual account of the defect/failure –
Phase 1: Investigation
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 first occur? •Verify
What is the problem?
Where is the problem?
When did the problem
first occur?
•Verify non-compliance
•Defect
•Failure
•Factory
•Supplier
•Design
•Day, date
•Location
•Test
•Environment
•Runtime of system
Product History
What is the Impact to
the customer?
To what extent did the
problem occur?
•Failure/Repair History
•Total runtime
•Previous systems, environments,
tests
•Cost
•Schedule
•Retrofit
•Spares
•Life Cycle Cost
•Events leading up to the incident
Collect and review data for trends, process variation, and stability

Root Cause Analysis Process

Root Cause Analysis Process Phase 1: Investigation Document and track the nonconformance and associated root cause
Phase 1: Investigation
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)

Phase 2: Analysis 11
Phase 2: Analysis
Phase 2: Analysis

Root Cause Analysis Process

Root Cause Analysis Process Phase 2: Analysis Purpose: To determine root cause(s), by identifying reasons explaining
Phase 2: Analysis
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
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
Avoid attempts to “fix” the issue during this phase

Problem Solving Tools

Problem Solving Tools Phase 2: Analysis Fault Tree 5 Why’s 13
Phase 2: Analysis Fault Tree 5 Why’s
Phase 2: Analysis
Fault Tree
5 Why’s

5 – Why Analysis

5 – Why Analysis Phase 2: Analysis The 5-Why analysis method is used to move beyond
Phase 2: Analysis
Phase 2: Analysis

The 5-Why analysis method is used to move beyond symptoms and understand the true root cause of a problem.

symptoms and understand the true root cause of a problem. It is said that by asking

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

Example: Jefferson Memorial

Example: Jefferson Memorial Phase 2: Analysis The Jefferson Memorial is deteriorating Why? Too much washing Why?
Phase 2: Analysis
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

Excess bird droppings Why? Lots of spiders to eat Why? Lots of gnats to eat Why?

Why?

We leave the lights on all the time

Problem Solving Tools

Problem Solving Tools Phase 2: Analysis Fault Tree 5 Why’s 16
Phase 2: Analysis Fault Tree 5 Why’s
Phase 2: Analysis
Fault Tree
5 Why’s

Fault Tree Analysis

Fault Tree Analysis Phase 2: Analysis • Fault tree analysis is used to analyze failures in
Phase 2: Analysis
Phase 2: Analysis

Fault tree analysis is used to analyze failures in complex products, processes, or systems.

analyze failures in complex products, processes, or systems. • Fault tree analysis enables teams to effectively

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.

Fault Tree

Fault Tree Phase 2: Analysis Bulb Fails 2.0 Mother 4.0 5.0 Machines/ 1.0 Methods Nature 3.0
Phase 2: Analysis
Phase 2: Analysis
Bulb Fails 2.0 Mother 4.0 5.0 Machines/ 1.0 Methods Nature 3.0 Manpower Measurements/ 6.0 Materials
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
Weather Anomaly
5.1.1 Power Plant
Fails
5.1.2 Power Line
Fails
5.1.3 Connector
6.2.1 Impurities
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

Root Cause Analysis Process

Root Cause Analysis Process Phase 2: Analysis Step 2 Prioritize the potential causes and key contributors
Phase 2: Analysis Step 2 Prioritize the potential causes and key contributors to the causes
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

Root Cause Analysis Process

Root Cause Analysis Process Phase 2: Analysis Step 3 Finalize the analysis by identifying the root
Phase 2: Analysis Step 3 Finalize the analysis by identifying the root cause(s): • Reproduce
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.
Output should be a finite set of root causes showing why the incident was inevitable.
Phase 3: Decision 21
Phase 3: Decision
Phase 3: Decision

Root Cause Analysis Process

Root Cause Analysis Process Phase 3: Decision Purpose: To implement corrective and preventive action • Definition
Phase 3: Decision
Phase 3: Decision

Purpose: To implement corrective and preventive action

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

Step 1 • Brainstorm possible solutions for corrective and preventive action. • Approach corrective and
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

Mistake Proofing

Mistake Proofing Phase 3: Decision When to use Mistake Proofing: • Human error can cause mistakes
Phase 3: Decision
Phase 3: Decision
When to use Mistake Proofing: • Human error can cause mistakes or defects to occur
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
“It follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehand.”
[Shingo]

Root Cause Analysis Process

Root Cause Analysis Process Phase 3: Decision Step 2 • Finalize a solution and determine if
Phase 3: Decision
Phase 3: Decision
Step 2
Step 2
• Finalize a solution and determine if acceptable by considering the following: • Will the
• 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?

Root Cause Analysis Process

Root Cause Analysis Process Phase 3: Decision Step 3 • Objectively Verify: 1. Each action in
Phase 3: Decision
Phase 3: Decision
Step 3 • Objectively Verify: 1. Each action in the implementation plan has been carried
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

Case Study

The "Case" of the Sidelined Spectacles

Case Study The "Case" of the Sidelined Spectacles Situation: It's 3 p.m. and you have a
Case Study The "Case" of the Sidelined Spectacles Situation: It's 3 p.m. and you have a

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.

Case Study

The "Case" of the Sidelined Spectacles

Case Study The "Case" of the Sidelined Spectacles • Finding (Problem): Your glasses have broken several
Case Study The "Case" of the Sidelined Spectacles • Finding (Problem): Your glasses have broken several

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.

Summary – Principles of RCA

1. Define the problem

2. Gather data and evidence

3. Ask "why" and identify the root causes

evidence 3. Ask "why" and identify the root causes 4. Implement corrective/preventive action(s) that

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
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.

Additional Resources

Root Cause Analysis Training and Tools

Additional Resources Root Cause Analysis Training and Tools • Think Reliability http://www.thinkreliability.com/ •

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

Credits

Credits 12 October 2011. Air University. 8 March 2012.

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>.

Please send all questions to: mfc.training.supplier@lmco.com 31

Please send all questions to:

mfc.training.supplier@lmco.com