Introduction to Root Cause Corrective Action and the 5 Why Process Dataplate Training Konrad Burgoyne

Introduction to Root Cause Corrective Action and the 5 Why Process

Dataplate Training

Konrad Burgoyne

www.dataplate.co.uk

© 2014 Dataplate 2

Introduction

Aim - To understand the concepts of cause analysis and to be able to apply those concepts to prevent or eliminate errors and defects

Reason - This is a requirement of the aerospace industry

Incentive – RCCA is a fundamental and valued skill used within many areas of business.

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What is Root Cause Corrective Action?

An effective process for finding the causes of an event and facilitating

effective corrective actions to prevent recurrence.

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RCCA for Non Conformances

A requirement of the aerospace industry for many years.

A process of determining the causes that led to a nonconformance or event.

An effective method for implementing corrective actions to prevent recurrence.

Requirements are not new, but they may not have been aggressively enforced in the past.

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Event

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An all inclusive term for any of the following:

Product FailureNon ConformanceAudit findingSpecial Cause (SPC)AccidentCustomer complaintFailure Mode (FMEA)

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The Traditional Approach to an Event

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Event (Problem)

Fix it

• Containment• Establish Team• Identify Problem• Gather & Analyze Data• Find the Root Cause• Determine Corrective Action• Implement Corrective Action• Review Corrective Action

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Traditional Problem Solving

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DoesIt Work?

You CouldBe In

Trouble!

Uh - Oh !

PROBLEM!NO

PROBLEM !

DidYou MessWith It?

DoesAnyone KnowYou Messed

With It?

WillYou Be

Blamed For ItAnyway?

CanIt Be Fixed

Before YourBoss Finds

Out?

Can YouTransfer Blame

To SomeoneElse?

Hide It OrThrow

Away TheEvidence!

Yes

YesYes

Yes

Yes

Yes

No No

No

No

No

No

J

L

Don't Mess With It!

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The Requirement - AS9100

8.5.2 Corrective Action: The organization shall take action to eliminate the cause of nonconformities in order to prevent recurrence. Corrective actions shall be appropriate to the effects of the nonconformities encountered.

A documented procedure shall be established to define requirements for:

a) reviewing nonconformities (including customer complaints),b) determining the causes of nonconformities,c) evaluating the need for action to ensure that nonconformities do not occur,d) determining and implementing action needed,e) records of the results of action taken,f) reviewing corrective action taken,g) flow down of the corrective action requirement to a supplier, when it is determined that the supplier is responsible for root cause, andh) specific actions where timely and/or effective corrective actions are not achieved.

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The RCCA Approach to an Event

Event (Problem)

• Containment• Establish Team• Identify Problem• Gather & Analyze Data• Find Root Cause• Determine Corrective Action• Implement Corrective Action• Review Corrective Action

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Containment

Immediate Corrective Action

Put out the fireSTOP producing bad productEvaluate product impactInform customer if shipped product impact is

suspected – A legal requirement.

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Establish Teams

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Natural Team

Assignment of wrong personnel a common problem.Common to assign to Quality – did quality make the error?

Who owns the problem?Who has a stake in the outcome and the solution to the problem?Who are the vested owners of both the problem and the solution?Who knows the process – have data and experience?Who will have to implement and live with the corrective action?

Without the full buy-in and support of the stakeholders, long-term solutions are not likely.


Establish Teams

Qualified Team

The Natural team plus other individuals who can provide necessary resources to understand the problem further.

Those who can provide additional informationThose who have technical expertise – Subject Matter Experts (SME)Those who may need to act as advisorsThose providing management support


Remember

Take action:

To a degree appropriate to the magnitude of the problem.

Proportionate with the risks encountered.


Identify Problem

• You must understand the problem.

• Is there more than one problem?

• You must know what you don’t know, to be able to find out.

• Keep it simple


The Problem

Must be clearly and appropriately defined. The nonconformance identified may not be the real

problem – only a symptom of the problem.

Asking questions is helpful. What is the scope of the problem? How many problems are there? What is affected by the problem? What is the impact on the company? How often does the problem occur?

Addressing appropriate questions will assist in clarifying and defining the problem(s).


Caution

If you cannot say it simply, you do not

understand the problem!


Gather & Analyse Data

Location.Names of Personnel.Date and Time.Operational Conditions.Environmental Conditions.Communications.

Sequence of Events. Equipment. Physical Evidence. Recent Changes. Training. Other Events.

Look for:Performed by Team Members


Gather & Analyse Data

Problem identified – begin data collection.May need to be collected several times.The preliminary collection phase occurs now and

will guide the analysis process.Initial data gathering starts at the scene.

Data has a shelf life. Waiting makes it difficult to obtain good information. Go to the scene. Note those present, what is in place, when the event

occurred, and where the event happened.


Remember

Take action:




Find The Root Cause

The Cause Chain

Direct>Contributing>Root

• The direct cause is the cause that immediately caused the problem

• Causes in-between are contributing causes • A root cause is the last cause in the cause chain


Find The Root Cause

An Important Thing to Remember About “Root Cause.”

It’s not always the most significant cause in the chain ...

Just focus on the fact that it is the LAST cause in the chain ...


The 5-Why Process

The ‘5 why’ is one method that can be used to find: - the cause chain. A natural logical progression for thinking

through a problem. The direct cause. The root cause. The contributing causes.


Why?

State the Problem as an Event Question starting with:

• An event question is short, concise, and focused on ONE problem.

• It is a question starting with Why . . . ?

• It is the first “Why” in the process.

Why . . . ?


Common Initial Considerations

Operator error (most common).Honest mistake.Second shift did it.We didn’t include the requirement in our

internal procedure.We didn’t know it was a requirement.Not familiar with the specification.


Caution : Operator Error

Yes, it does happen, but . . .Used as “root cause” much too often.Used as an easy way out.

Ask: If the operator was replaced, could the next person make the same mistake? If so, then you have not determined the Root Cause!


Is it really Operator Error?

You must ask these five questions:

• Proper Instructions?

• Proper Tools?

• Proper Training?

• Clear Expectations / Goals?

• Is the process Complex or Unusual?


How many whys?

Do not believe that the 5 Why process restricts you to asking why 5 times

A root cause may be found with 3 Whys or it may take 7 Whys


How many whys?

Times asked why


Remember

Take action:




No Big Secret

Simple Answer Simple Answer Simple Answer

Simple Question Simple Question

Simple Answer

Simple Question


Don’t fall into the trap

CAUTIONCause chain under

construction.No corrective

actions allowed!


The cause chain

DirectCause

Contr.Cause

RootCause

How many root causes are you allowed?

Event


The cause chain

CC

CC

Problem#1

DirectCause

RootCause

Two or more, if you have multiple branches.

Problem#2

DirectCause

RootCause

CC

CC

Event


Fishbone Diagram

A fishbone diagram is a graphic methodology to identify “Whys.” To make a Fishbone Diagram, start with your problem or event and brainstorm ideas about why that problem/event is happening. Each one of these ideas (or causes) becomes a “bone” that shoots off the main one. Then, brainstorm ideas that might have caused those “bones.” Eventually, it will look like a skeleton of a fish.


5 Why Example

For job 6 (OEM Prime, job no. B140898), drawing DX667-039 required "stress relieve at 525 +/-5°C for 30min to KPS425”

It was found that the data card, DC2488, required 538 +/-13.9°C for 20 - 25min. Although this is in line with the requirement of KPS425, there was no customer or delegated approval on the data card to show that this deviation from the drawing was acceptable.

Nadcap Audit 54345 NCR5

The Problem

It was determined by OEM Prime that a Drawing Clarification Form should have been raised in the first instance. Drawing Clarification Forms were not formalised or understood throughout the company


5 Why Example

The “Drawing Clarification Form” was known as a “query form” and came into use in September 2013. There is no identified formal process or procedure in place in obtaining clarification from the OEM Prime.

Why is there no formal process for implementing the Drawing Clarification Form (Query form)?This form was a new form that was sent to a specific engineer in January 2014 for project G053XX016-103, G053XX038-103 and G053XX048-101 queries.

Why was this form not put in general use for OEM Prime queries?There was no other information or instruction flowed down from OEM Prime in relation to this form

Why was there no other information requested?It was understood that this form was an informal document specific to project G053XX

Why was this form understood to be an informal document?It was created with no process or instruction document and showed no document ID number and it is not referenced in the OEM Prime Q700 Requirements for Suppliers document?

Root cause: Inadequate control of documentation

Containment:The Drawing Clarification Form has now been completed for drawing DX667-039 and sent to OEM Prime (See attached)

Corrective ActionQuality Alert OEM11 has been raised and distributed throughout. (See attached)


5 Why Example

Quality Alert – OEM11– Control of Documents

Aim – The aim of this quality alert is to put in place corrective action and initiate preventative action for similar situations. Reason – Control of Documents is a requirement of AS9100 Incentive – A well understood standardised quality system will improve efficiency, productivity and profitability throughout the business.

Issue A recent Nadcap audit NCR response led to a discovery of a document (issued by a customer) used without a formal process or written procedure.

Action With immediate effect, all users of documents both internally generated and externally provided shall ensure there is a formal process to follow that is referenced in the Quality Management System (QMS). In the event a document is identified having no formal process please refer to P-Q-2-11 Document Control & Control of Records Procedure for the process to follow.


Caution

Complex problems, especially those where an entire process has been brought into question require a

more thorough analysis.

Process Planning& Materials

Requirements& Design

Equipment& Maintenance

Production Operations& Quality Assurance

Root Cause Analysis (RCA) is a systematic approach to determining all the contributors to a problem before attempting to implement a corrective action plan.


Corrective Action

A set of planned activities (actions) implemented for the sole purpose of permanently

resolving the problem.


Types of Corrective Action

Specific corrective action changes only the direct cause or the effect. Action(s) taken to correct the direct cause and/or the effect.

Sustaining corrective action changes contributing and root causes. Actions taken to prevent recurrence of the event


Sustaining Corrective Action

Sustaining corrective actions focus on changing root cause(s) and contributing cause(s).

If you have only identified one cause, you probably won’t get a 100% effective fix.

Remember – today’s contributing cause is tomorrow's root cause.


Corrective Action – What, Who & When

The three W’s

What, Who, When.What is the corrective action?Who is responsible for doing it?When is it going to be done?


Corrective Action

Establish the most effective corrective action to put in place.

Must correct the root causeMust correct contributing causesMust be workableMust have a effectivity dateMust be sustainableMust not be the cause of other unforeseen non-

conformancesMust be reviewed


Remember

Take action:




Corrective Action - Review

The corrective action can have a working review to ensure it is effective

Adjustments to the corrective action can be made and documented

A formal review is required to document effectivity


Summary

EVENT Form Team

Contributing

Gather & Verify Data

Mistake ProofingDetermine Corrective Actions

(Specific & Preventive)

Determine Causes

Implement & Follow up

Identify Problem

SolutionAcceptable?No Yes!

RootDirect

Containment

Done


Documentation

EVENT Form Team

Contributing

Gather & Verify Data

Mistake ProofingDetermine Corrective Actions

(Specific & Preventive)

Determine Causes

Implement & Follow up

Identify Problem

SolutionAcceptable?No Yes!

RootDirect

Containment

Done

Document Causes

Document Corrective Action

Document Follow-up

Write Final Report

Minutes Team Meetings


Remember

Take action:




Questions?