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Hi, my name is Root Cause Analysis. Have we met?

CMMI® Technology Conference November 2009

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Don’t Repeat the Same Mistakes

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Understand the Problem

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Create a Good Problem Description

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Example: Late to Work

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Problem Description» Joe usually arrives to work between 7:45 and

8:05. Joe showed up at 8:20 on Wednesday November 18, 2009.

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Gather the Data

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Recommendation: Ishikawa

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The Five Ms

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Ishikawa: Jack late for workCause Effect

Equipment Process People

Materials Environment Management

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Don’t Make Assumptions

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Enough Information?

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Late to Work: Research the Issue

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ID Root Cause & Resolve

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Five WhysProblem

Root Cause

Why?

Yes

No

Create Action Plan

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Ishikawa/Fishbone

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Causal Tree DiagramLate to Work

Issue at home Delayed on the road

Rely on other transportation

Got up late

Child was sick

Traffic Gas AccidentRoad work Got lost

Alarm didn’t go off

No alarm Went to bed too late

Hung over

Train Walk

Car trouble

Other

Car late

Bus Car pool

Stopped for foodTraffic

Branch applies to each box on this

branch

Why?

Why? Why? Why? Why?

Why?

Why?

Bike

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Watch Out for Pitfalls

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Symptoms Can Be Misleading

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Fix It!

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Measure Results: Is Problem Resolved?

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Repeating the same problems?

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Identify & Solve the REAL Problem

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It is Time for Root Cause Analysis

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Questions?

Contact Info:Craig Hale

Senior Software Engineer/Engineering Process Group Lead

Esterline Control Systems - AVISTA Phone (608) 348-8815

Fax (608) 348-8819Email Craig.Hale@avistainc.com

www.avistainc.com