Root Cause Analysis By Deepak

Prepared By – Mr. Deepak Kumar Sahoo

Root Cause Analysis

Prepared and Presented by :-

Mr. Deepak Kumar Sahoo

RCA

Excellence in Problem Solving


Root Cause Analysis is an in-depth process or technique for identifying the most basic factor(s) underlying a variation in performance (problem).

Focus is on systems and processes

Focus is not on individuals

What is RCA ?


• Safety-based RCA

Investigating accident , occupational safety and health.

Root causes:- unidentified risks, or inadequate safety engineering, missing safety

barriers.

• Production-based RCA

Quality control for industrial manufacturing.

Root causes:- non-conformance like, malfunctioning steps in production line.

• Process-based RCA

Extension of Production-based RCA.

Includes business processes also.

Root causes:- Individual process failures

• Systems-based RCA

Hybrid of the previous types

New concepts includes:- change management, systems thinking, and risk

management.

Root causes:- organizational culture and strategic management

Types of RCA


Whether we know the Cause?

Cause Known Cause Not Known

Solu

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n K

no

wn

Solu

tio

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No

t K

no

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Task Force

Brain Storm / Seek Expert Help

Root Cause Analysis

Trial & ErrorRoot Cause Analysis


By eliminating the root cause…

You save time and money!

• Problems are not repeated

• Reduce rework, retest, re-inspect, poor quality costs, etc…

• Problems are prevented in other areas

• Communication improves between groups and Process

cycle times improve (no rework loops)

• Secure long term company performance and profits

RCA Benefits :-


When we need RCA

FREQUENCY

IMPA

CT

OBSERVATION MINOR MAJOR

5 WHY’s Cause Mapping


A standard process of RCA is as follows:

Identifying a problem

Containing and analyzing the problem

Defining the root cause

Defining and implementing the actions required to eliminate

the root cause

Validating that the corrective action prevented recurrence of

problem

RCA Process


RCA Process

Validate

Follow

Up Plan

Complete

PlanAction

Plan

Root

Cause

Immediate

Action

Identify

Team

Identify

Problem

Problem

Solving

Process

1

2

3

45

6

7

8


Identify the Problem • Clearly state the problem the team is to solve

– Teams should refer back to problem statement to avoid getting off track

• Use 5W2H approach

– Who? What? Why? When? Where? How? How Many?

5W2H

Who? Individuals/customers associated with problem

What? The problem statement or definition

When? Date and time problem was identified

Where? Location of complaints (area, facilities, customers)

Why? Any previously known explanations

How? How did the problem happen (root cause) and how will the problem be

corrected (corrective action)?

How Many? Size and frequency of problem

RCA Process : Step - 1

It’s the most

important step.


Identify TeamWhen a problem cannot be solved quickly by an individual,

use a team!

Should consist of domain knowledge experts

Small group of people (4-10) with process and product

knowledge, available time and authority to correct the

problem

Must be empowered to “change the rules”

Should have a designated Team leader.

Membership in team is always changing!

RCA Process : Step - 2


Key Ideas for Team Success

Define roles and responsibilities

Identify external customer needs

Identify internal customer needs

Appropriate levels of organization present

Clearly defined objectives and outputs

Solicit input from everyone!

Good meeting location - Near work area for easy access to information.

Roles and Responsibilities

Team Leader: Mentor, guide and direct teams, advocate to upper management

Leader: day-to-day authority, calls meetings, facilitation of team, reports to TL.

Record Keeper: Writes and publishes minutes

Participants: Respect all ideas, keep an open mind, know their role within team

RCA Process : Step – 2 (Continue..)


Immediate Action Must isolate effects of problem from customer

Only temporary until corrective action is implemented

Must also verify that immediate action is effective

Verify Immediate Action Immediate action = activity implemented to screen, detect and/or contain

the problem.

Must verify that immediate action was effective

Run Pilot Tests

Make sure another problem does not arise from the temporary solutions

Ensure effective screens and detections are in place to prevent further impact to customer until permanent solution is implemented.

RCA Process : Step – 3


Finding Root Cause

• Brainstorm possible causes of problem with team

• Organize causes with Cause and Effect Diagram

• Use 5 Why? method to further define the root cause of symptoms

– May involve additional research/analysis/investigation to get to each “Why?”

• Must identify the process that caused the problem

– if root cause is company-wide, elevate these process issues (outside of team control) to upper management to address



Most commonly use :-

– The “5 Whys”

– Brainstorming

– Fish bone Analysis or Ishikawa Diagram

– Cause Mapping or Cause and Effect Analysis

– FMEA or FMECA

Other RCA tools :-

RCA Process : Step – 4 RCA Tools.

Process Maps Barrier Analysis Pareto Charts pie chat Tree Diagrams Benchmarking

Run Chart Change Analysis Affinity Diagrams Control Plans Scatter Diagram Event and Causal

Factor Analysis

Risk Tree Diagrams Histograms Interrelationship

Diagram Force Field Analysis Flowcharts MORT Analysis


Problem - Flat Tire

Why? Nails on garage floor

Why? Box of nails on shelf split open

Why? Box got wet

Why? Rain thru hole in garage roof

Why? Roof shingles are missing

Why-Why Analysis.


It should be done within 24 hours of problem

occurrence

Person who was present when the problem occurred

should be part of why-why analysis

Why-Why analysis should be done at the location

where the problem has occurred

Stop when the answers become less important.

Stop when the root cause condition is isolated.

Ask “Why?” 5 times can extend maximum 7 times. If you will not find the possible solution then use Other RCA tools.

TIPS for Why-Why Analysis.


Why-Why Analysis Examples

Why• RAVANA KILLED

Why• He Kidnapped SITA

Why• She was in the Forest

Why

• Her Father in law King Dhasaratha Promised to one of his wife Kaikeyee

Why

• One day King Dhasaratha Roaming with his chariot Vehicle it wheel lock pin was damaged and Kaikeyee was put her finger in to the Pin hole and saved King Dhasaratha

Why• The chariot vehicle wheel lock pin was damaged.


Why-Why Analysis Examples

Why• The chariot vehicle wheel lock pin was damaged

Why• Poor maintenance

• No PPM & no FMEA carried out.

• Think …..

• Because EMCO was not there on that time

If EMCO was at that time and King Dhasaratha gave maintenance contracts to EMCO History might Change.

Ravana life also might be saved.

WhyRoot

Cause


More about Cause-Effect Diagram :

Environment Effect

ManMachine

MethodsMaterials

NOTE: Causes are not limited to the 5 listed categories, but serve as a starting point

Steps used to create a Cause-Effect Diagram:

Define the issue or problem clearly Decide on the root causes of the observed issue or problem Brainstorm each of the cause categories Write ideas on the cause-effect diagram.


Fish Bone Analysis

Materials

Incorrect Quantity

Incorrect BOL

Wrong Destination

Methods

Late Dispatch

Shipping DelaySpillage

EnvironmentShipping

Problems

Traffic Delays

Weather

Machine

Wrong Equipment

Dirty EquipmentBreakdown

Man

Driver

Attitude

Dispatcher

Wrong Directions


Corrective Action Plan

• Must verify the solution will eliminate the problem

– Verification before implementation whenever possible

• Define exactly…

– What actions will be taken to eliminate the problem?

– Who is responsible?

– When will it be completed?

• Make certain customer is happy with actions

• Define how the effectiveness of the corrective action will be measured.

Verification vs. Validation

Verification

– Assures that at a point in time, the action taken will actually do what is intended without

causing another problem

Validation

– Provides measurable evidence over time that the action taken worked properly, and

problem has not recurred



3 types of Corrective Action:

• Immediate action

– The action taken to quickly fix the impact of the problem so the “customer” is not further impacted

• Permanent root cause corrective action

– The action taken to eliminate the error on the affected process or product

• Preventive (Systemic) root cause corrective action

– The action taken to Prevent the error from recurring on any process or product

Types of Corrective action.


Corrective Action Examples

Immediate (step #3)

Permanent (step #5)

Preventive (step #5)

All current batch of paperwork re-inspected by another worker for same type of problem

Form changed to mandate completion of certain fields

Similar forms with same fields used all over in company are changed to “mandatory”


Complete Action Plan

Make certain all actions that are defined are completed as

planned

If one task is still open, verification and validation is pushed

back

If the plan is compromised, most likely the solution will not be

as effective



Follow Up Plan

What actions will be completed in the future to ensure that the

root cause has been eliminated by this corrective action?

Who will look at what data?

How long after the action plan will this be done?

What criteria in the data results will determine that the problem

has not recurred?



Validate and Celebrate

• What were the results of the follow up?

• If problem did reoccur, go back to Step #4 and re-evaluate root cause, then re-evaluate corrective action in Step #5

• If problem did not reoccur, celebrate team success!

• Document savings to publicize team effort, obtain customer satisfaction and continued management support of teams



Identify Problem

A manager walks past the assembly line and notices a puddle of

water on the floor. Knowing that the water is a safety hazard,

she asks the supervisor to have someone get a mop and clean up

the puddle. The manager is proud of herself for “fixing” a

potential safety problem.

Immediate Action

Knowing that the water is a safety hazard, the manager asks the

supervisor to have someone get a mop and clean up the puddle.

But What is the Root Cause?

The supervisor looks for a root cause by asking 'why?’

RCA Example - 1


Leak in overhead pipe

RCA Example – 1

Puddle of water on the floorWHY

WHY

Water pressure is set too highWHY

Water pressure valve is faultyWHY

Valve not in PPM programRoot Cause


Corrective Action

Permanent – Water pressure valves placed in preventative maintenance program.

Preventive - Developed checklist form to ensure new equipment is reviewed for possible inclusion in preventative maintenance program.

RCA Example – 1


Identify Problem

Customers are unhappy because they are being shipped

products that don't meet their specifications.

Immediate Action

Inspect all finished and in-process product to ensure it

meets customer specifications.

Find out the root cause

RCA Example – 2


Manufacturing schedule is not available for sales person to provide realistic delivery date.

RCA Example – 2

Product doesn’t meet specifications WHY

Manufacturing specification is different from what customer and sales person agreed.WHY

Sales person tries to expedite work by calling head of manufacturing directly.WHY

WHY

Confidence in manufacturing schedule is not high enough to release/link with order system

Parts sometimes not available thereby creating schedule changes

Expediting and priority changes consume parts not planned for

Manufacturing schedule does not reflect realistic assembly and test time.

No ongoing review of manufacturing standards.

WHY

WHY

WHY

WHY

Root Cause


Corrective Action

• Permanent – Manufacturing standards reviewed and

updated.

• Preventive - Regular ongoing review of actuals vs

standards is implemented.

RCA Example – 2


Identify Problem

Part polarity reversed on circuit board

Immediate Action

Additional inspection added after this assembly

process step to check for reversed part defects.

Last 10 lots of printed circuit boards were re-inspected

to check for similar errors.

RCA Example – 3


Worker not sure of correct part orientation.

RCA Example – 3

Part reversed.WHY

WHY

Part is not marked properly.WHY

Engineering ordered it that way from vendorWHY

Process didn’t account for possible

manufacturing issuesRoot Cause


Corrective Action:-

• Permanent – Changed part to one that can only be

placed in correct direction (Mistake proofed). Found

other products with similar problem and made same

changes.

• Preventive - Required that any new parts selected

must have orientation marks on them.

RCA Example – 3


Identify Problem

Department didn’t complete their project on time.

Immediate Action

Additional resources applied to help get the project

team back on schedule

No new projects started until Root Cause Analysis

completed

Now we will find the root cause

RCA Example – 4


RCA Example – 4

Didn’t complete project on timeWHY

Didn’t complete

project on time

MachineMaterials

ManMethodLack of worker

knowledge

Poor project

management

skills

Inadequate

computer

programs Inadequate

computer system

Lack of resources


Didn’t complete project on timeWHY

Resources unavailable when needed.WHY

Took too long to hire Project Manager

Lack of specifics given to

Human Resources Department.

No formal process for submitting job opening

WHY

WHY

Root Cause

RCA Example – 4


Corrective Action

Permanent – Hired another worker to meet needs of

next project team

Preventive - Developed checklist form with HR for

submitting job openings in the future.

RCA Example – 4


Why People turnover is high in EMCO?

Why work load is more in QF?

Why PPM in QF is not so effective ?

Why Rajnikant is to too famous?

Why CM has reduced in QF from EMCO side ?

More on Why-Why analysis ?


Why-Why Analysis (multiple cause Examples)

Why? Why? Why? Why? Why?

Employees are leaving

for other jobs

Employees are not

satisfied

Employees feel that they

are underpaid

Other employers are paying

higher salaries

Demand for such

employees has increased in the market

Employee turnover rate has been increasing


Thank you !!!

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Root Cause Analysis By Deepak