7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 131

1

Continuous Improvement

Through EffectiveRoot Cause amp Corrective Action

Cedric Baker

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 231

2

Goals

bull Create an understanding of the concept of Root Causeanalysis

bull To impart a familiarity with analytical tools utilized inthe determination of Root Causes

bull To teach the members of this class how to effectivelyanalyze problems determine their Root Causes anddefine appropriate Corrective Actions

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 331

3

Agenda

bull What is Root Cause Analysis

bull Why Do We Perform Root Cause Analysis

bull Root Cause Analysis Philosophy

bull Symptom vs Root Causebull Root Cause Analysis Process

ndash Phase 1 Investigation

ndash Phase 2 Analysis

bull Problem Solving Tools

ndash Phase 3 Decision

bull Mistake Proofing

bull Case Study (Good RCA versus Bad RCA)bull Summary (Principals or Root Cause Analysis)

bull Additional Resources

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 431

4

What is Root Cause Analysis

Root Cause Analysis (RCA) DefinitionMethodology for finding and correcting the trueroot cause(s) of a problem while implementingcorrective action to prevent recurrence

bullRoot Cause The agent failure or fault fromwhich a chain of effects or failures originates

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 531

5

Why do we perform

Root Cause Analysis

ComponentLevel

Assembly

DuringTesting

ByCustomer

Design

Where a defect is found

often has a correlationto the cost of the

defect

The goal is to

eliminate thedefect as far up

stream as possible At the source

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 631

6

Root Cause Analysis Philosophy

bull It is critical that everyone take a personal and activerole in improving quality

bull Each problem is an opportunity because it can tell astory about why and how it occurred

bull To do this well we must

ndash Understand true problem before taking action ndash Remain open-minded and avoid jumping to conclusions

ndash Take action using sound judgment based on facts and data

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 731

7

Symptom vs Root Cause

bull ldquoErrors are often a result of

worker carelessnessrdquo

bull ldquoWe need to train andmotivate workers to be more

carefulrdquo

bull ldquoWe donrsquot have the time orresources to really get to thebottom of this problemrdquo

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

Symptom Approachbull ldquoErrors are the result of

defects in the systemPeople are only part of theprocessrdquo

bull ldquoWe need to find out whythis is happening andimplement mistake-proofs soit wonrsquot happen againrdquo

bull ldquoThis is critical We need tofix it for good or it will come

back and burn usrdquo

Root Cause Approach

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 831

8

Root Cause Analysis Process

Phase 3 Decision

Phase 2 Analysis

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 931

9

Root Cause Analysis Process

Purpose Gather a factual account of the defectfailure

ndash Be as neutral as possible

Phase 1 Investigation

What is the problem

bullVerify non-compliance

bullDefect

bullFailure

Where is the problem

bullFactory

bullSupplier

bullDesign

When did the problemfirst occur

bullDay date

bullLocationbullTest

bullEnvironment

bullRuntime of system

To what extent did theproblem occur

bullEvents leading up to the incident

What is the Impact tothe customer

bullCost

bullSchedulebullRetrofit

bullSpares

bullLife Cycle Cost

Product History

bullFailureRepair HistorybullTotal runtime

bullPrevious systems environmentstests

Collect and review data for trends process variation and stability

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1031

10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1131

11

Phase 2 Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1231

12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

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23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

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27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

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30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 231

2

Goals

bull Create an understanding of the concept of Root Causeanalysis

bull To impart a familiarity with analytical tools utilized inthe determination of Root Causes

bull To teach the members of this class how to effectivelyanalyze problems determine their Root Causes anddefine appropriate Corrective Actions

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 331

3

Agenda

bull What is Root Cause Analysis

bull Why Do We Perform Root Cause Analysis

bull Root Cause Analysis Philosophy

bull Symptom vs Root Causebull Root Cause Analysis Process

ndash Phase 1 Investigation

ndash Phase 2 Analysis

bull Problem Solving Tools

ndash Phase 3 Decision

bull Mistake Proofing

bull Case Study (Good RCA versus Bad RCA)bull Summary (Principals or Root Cause Analysis)

bull Additional Resources

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 431

4

What is Root Cause Analysis

Root Cause Analysis (RCA) DefinitionMethodology for finding and correcting the trueroot cause(s) of a problem while implementingcorrective action to prevent recurrence

bullRoot Cause The agent failure or fault fromwhich a chain of effects or failures originates

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 531

5

Why do we perform

Root Cause Analysis

ComponentLevel

Assembly

DuringTesting

ByCustomer

Design

Where a defect is found

often has a correlationto the cost of the

defect

The goal is to

eliminate thedefect as far up

stream as possible At the source

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 631

6

Root Cause Analysis Philosophy

bull It is critical that everyone take a personal and activerole in improving quality

bull Each problem is an opportunity because it can tell astory about why and how it occurred

bull To do this well we must

ndash Understand true problem before taking action ndash Remain open-minded and avoid jumping to conclusions

ndash Take action using sound judgment based on facts and data

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 731

7

Symptom vs Root Cause

bull ldquoErrors are often a result of

worker carelessnessrdquo

bull ldquoWe need to train andmotivate workers to be more

carefulrdquo

bull ldquoWe donrsquot have the time orresources to really get to thebottom of this problemrdquo

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

Symptom Approachbull ldquoErrors are the result of

defects in the systemPeople are only part of theprocessrdquo

bull ldquoWe need to find out whythis is happening andimplement mistake-proofs soit wonrsquot happen againrdquo

bull ldquoThis is critical We need tofix it for good or it will come

back and burn usrdquo

Root Cause Approach

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 831

8

Root Cause Analysis Process

Phase 3 Decision

Phase 2 Analysis

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 931

9

Root Cause Analysis Process

Purpose Gather a factual account of the defectfailure

ndash Be as neutral as possible

Phase 1 Investigation

What is the problem

bullVerify non-compliance

bullDefect

bullFailure

Where is the problem

bullFactory

bullSupplier

bullDesign

When did the problemfirst occur

bullDay date

bullLocationbullTest

bullEnvironment

bullRuntime of system

To what extent did theproblem occur

bullEvents leading up to the incident

What is the Impact tothe customer

bullCost

bullSchedulebullRetrofit

bullSpares

bullLife Cycle Cost

Product History

bullFailureRepair HistorybullTotal runtime

bullPrevious systems environmentstests

Collect and review data for trends process variation and stability

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1031

10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1131

11

Phase 2 Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1231

12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

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16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

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17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

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18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

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19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

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20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

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21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

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24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

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25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

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26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

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28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

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29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

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30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

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31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

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3

Agenda

bull What is Root Cause Analysis

bull Why Do We Perform Root Cause Analysis

bull Root Cause Analysis Philosophy

bull Symptom vs Root Causebull Root Cause Analysis Process

ndash Phase 1 Investigation

ndash Phase 2 Analysis

bull Problem Solving Tools

ndash Phase 3 Decision

bull Mistake Proofing

bull Case Study (Good RCA versus Bad RCA)bull Summary (Principals or Root Cause Analysis)

bull Additional Resources

7172019 Root Cause Corrective Action

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4

What is Root Cause Analysis

Root Cause Analysis (RCA) DefinitionMethodology for finding and correcting the trueroot cause(s) of a problem while implementingcorrective action to prevent recurrence

bullRoot Cause The agent failure or fault fromwhich a chain of effects or failures originates

7172019 Root Cause Corrective Action

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5

Why do we perform

Root Cause Analysis

ComponentLevel

Assembly

DuringTesting

ByCustomer

Design

Where a defect is found

often has a correlationto the cost of the

defect

The goal is to

eliminate thedefect as far up

stream as possible At the source

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6

Root Cause Analysis Philosophy

bull It is critical that everyone take a personal and activerole in improving quality

bull Each problem is an opportunity because it can tell astory about why and how it occurred

bull To do this well we must

ndash Understand true problem before taking action ndash Remain open-minded and avoid jumping to conclusions

ndash Take action using sound judgment based on facts and data

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

7172019 Root Cause Corrective Action

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7

Symptom vs Root Cause

bull ldquoErrors are often a result of

worker carelessnessrdquo

bull ldquoWe need to train andmotivate workers to be more

carefulrdquo

bull ldquoWe donrsquot have the time orresources to really get to thebottom of this problemrdquo

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

Symptom Approachbull ldquoErrors are the result of

defects in the systemPeople are only part of theprocessrdquo

bull ldquoWe need to find out whythis is happening andimplement mistake-proofs soit wonrsquot happen againrdquo

bull ldquoThis is critical We need tofix it for good or it will come

back and burn usrdquo

Root Cause Approach

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8

Root Cause Analysis Process

Phase 3 Decision

Phase 2 Analysis

Phase 1 Investigation

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9

Root Cause Analysis Process

Purpose Gather a factual account of the defectfailure

ndash Be as neutral as possible

Phase 1 Investigation

What is the problem

bullVerify non-compliance

bullDefect

bullFailure

Where is the problem

bullFactory

bullSupplier

bullDesign

When did the problemfirst occur

bullDay date

bullLocationbullTest

bullEnvironment

bullRuntime of system

To what extent did theproblem occur

bullEvents leading up to the incident

What is the Impact tothe customer

bullCost

bullSchedulebullRetrofit

bullSpares

bullLife Cycle Cost

Product History

bullFailureRepair HistorybullTotal runtime

bullPrevious systems environmentstests

Collect and review data for trends process variation and stability

7172019 Root Cause Corrective Action

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10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

7172019 Root Cause Corrective Action

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11

Phase 2 Analysis

7172019 Root Cause Corrective Action

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12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

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16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

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19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

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21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

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24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

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25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

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28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

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31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

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4

What is Root Cause Analysis

Root Cause Analysis (RCA) DefinitionMethodology for finding and correcting the trueroot cause(s) of a problem while implementingcorrective action to prevent recurrence

bullRoot Cause The agent failure or fault fromwhich a chain of effects or failures originates

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5

Why do we perform

Root Cause Analysis

ComponentLevel

Assembly

DuringTesting

ByCustomer

Design

Where a defect is found

often has a correlationto the cost of the

defect

The goal is to

eliminate thedefect as far up

stream as possible At the source

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6

Root Cause Analysis Philosophy

bull It is critical that everyone take a personal and activerole in improving quality

bull Each problem is an opportunity because it can tell astory about why and how it occurred

bull To do this well we must

ndash Understand true problem before taking action ndash Remain open-minded and avoid jumping to conclusions

ndash 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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7

Symptom vs Root Cause

bull ldquoErrors are often a result of

worker carelessnessrdquo

bull ldquoWe need to train andmotivate workers to be more

carefulrdquo

bull ldquoWe donrsquot have the time orresources to really get to thebottom of this problemrdquo

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

Symptom Approachbull ldquoErrors are the result of

defects in the systemPeople are only part of theprocessrdquo

bull ldquoWe need to find out whythis is happening andimplement mistake-proofs soit wonrsquot happen againrdquo

bull ldquoThis is critical We need tofix it for good or it will come

back and burn usrdquo

Root Cause Approach

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8

Root Cause Analysis Process

Phase 3 Decision

Phase 2 Analysis

Phase 1 Investigation

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9

Root Cause Analysis Process

Purpose Gather a factual account of the defectfailure

ndash Be as neutral as possible

Phase 1 Investigation

What is the problem

bullVerify non-compliance

bullDefect

bullFailure

Where is the problem

bullFactory

bullSupplier

bullDesign

When did the problemfirst occur

bullDay date

bullLocationbullTest

bullEnvironment

bullRuntime of system

To what extent did theproblem occur

bullEvents leading up to the incident

What is the Impact tothe customer

bullCost

bullSchedulebullRetrofit

bullSpares

bullLife Cycle Cost

Product History

bullFailureRepair HistorybullTotal runtime

bullPrevious systems environmentstests

Collect and review data for trends process variation and stability

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10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

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11

Phase 2 Analysis

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12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

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13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

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14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

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15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

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16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

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17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

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18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

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19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

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20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

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21

Phase 3 Decision

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22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

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23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

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24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

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25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

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26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

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27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 531

5

Why do we perform

Root Cause Analysis

ComponentLevel

Assembly

DuringTesting

ByCustomer

Design

Where a defect is found

often has a correlationto the cost of the

defect

The goal is to

eliminate thedefect as far up

stream as possible At the source

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 631

6

Root Cause Analysis Philosophy

bull It is critical that everyone take a personal and activerole in improving quality

bull Each problem is an opportunity because it can tell astory about why and how it occurred

bull To do this well we must

ndash Understand true problem before taking action ndash Remain open-minded and avoid jumping to conclusions

ndash Take action using sound judgment based on facts and data

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 731

7

Symptom vs Root Cause

bull ldquoErrors are often a result of

worker carelessnessrdquo

bull ldquoWe need to train andmotivate workers to be more

carefulrdquo

bull ldquoWe donrsquot have the time orresources to really get to thebottom of this problemrdquo

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

Symptom Approachbull ldquoErrors are the result of

defects in the systemPeople are only part of theprocessrdquo

bull ldquoWe need to find out whythis is happening andimplement mistake-proofs soit wonrsquot happen againrdquo

bull ldquoThis is critical We need tofix it for good or it will come

back and burn usrdquo

Root Cause Approach

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 831

8

Root Cause Analysis Process

Phase 3 Decision

Phase 2 Analysis

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 931

9

Root Cause Analysis Process

Purpose Gather a factual account of the defectfailure

ndash Be as neutral as possible

Phase 1 Investigation

What is the problem

bullVerify non-compliance

bullDefect

bullFailure

Where is the problem

bullFactory

bullSupplier

bullDesign

When did the problemfirst occur

bullDay date

bullLocationbullTest

bullEnvironment

bullRuntime of system

To what extent did theproblem occur

bullEvents leading up to the incident

What is the Impact tothe customer

bullCost

bullSchedulebullRetrofit

bullSpares

bullLife Cycle Cost

Product History

bullFailureRepair HistorybullTotal runtime

bullPrevious systems environmentstests

Collect and review data for trends process variation and stability

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1031

10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1131

11

Phase 2 Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1231

12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 631

6

Root Cause Analysis Philosophy

bull It is critical that everyone take a personal and activerole in improving quality

bull Each problem is an opportunity because it can tell astory about why and how it occurred

bull To do this well we must

ndash Understand true problem before taking action ndash Remain open-minded and avoid jumping to conclusions

ndash Take action using sound judgment based on facts and data

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 731

7

Symptom vs Root Cause

bull ldquoErrors are often a result of

worker carelessnessrdquo

bull ldquoWe need to train andmotivate workers to be more

carefulrdquo

bull ldquoWe donrsquot have the time orresources to really get to thebottom of this problemrdquo

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

Symptom Approachbull ldquoErrors are the result of

defects in the systemPeople are only part of theprocessrdquo

bull ldquoWe need to find out whythis is happening andimplement mistake-proofs soit wonrsquot happen againrdquo

bull ldquoThis is critical We need tofix it for good or it will come

back and burn usrdquo

Root Cause Approach

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 831

8

Root Cause Analysis Process

Phase 3 Decision

Phase 2 Analysis

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 931

9

Root Cause Analysis Process

Purpose Gather a factual account of the defectfailure

ndash Be as neutral as possible

Phase 1 Investigation

What is the problem

bullVerify non-compliance

bullDefect

bullFailure

Where is the problem

bullFactory

bullSupplier

bullDesign

When did the problemfirst occur

bullDay date

bullLocationbullTest

bullEnvironment

bullRuntime of system

To what extent did theproblem occur

bullEvents leading up to the incident

What is the Impact tothe customer

bullCost

bullSchedulebullRetrofit

bullSpares

bullLife Cycle Cost

Product History

bullFailureRepair HistorybullTotal runtime

bullPrevious systems environmentstests

Collect and review data for trends process variation and stability

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1031

10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1131

11

Phase 2 Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1231

12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

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17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

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31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 731

7

Symptom vs Root Cause

bull ldquoErrors are often a result of

worker carelessnessrdquo

bull ldquoWe need to train andmotivate workers to be more

carefulrdquo

bull ldquoWe donrsquot have the time orresources to really get to thebottom of this problemrdquo

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

Symptom Approachbull ldquoErrors are the result of

defects in the systemPeople are only part of theprocessrdquo

bull ldquoWe need to find out whythis is happening andimplement mistake-proofs soit wonrsquot happen againrdquo

bull ldquoThis is critical We need tofix it for good or it will come

back and burn usrdquo

Root Cause Approach

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 831

8

Root Cause Analysis Process

Phase 3 Decision

Phase 2 Analysis

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 931

9

Root Cause Analysis Process

Purpose Gather a factual account of the defectfailure

ndash Be as neutral as possible

Phase 1 Investigation

What is the problem

bullVerify non-compliance

bullDefect

bullFailure

Where is the problem

bullFactory

bullSupplier

bullDesign

When did the problemfirst occur

bullDay date

bullLocationbullTest

bullEnvironment

bullRuntime of system

To what extent did theproblem occur

bullEvents leading up to the incident

What is the Impact tothe customer

bullCost

bullSchedulebullRetrofit

bullSpares

bullLife Cycle Cost

Product History

bullFailureRepair HistorybullTotal runtime

bullPrevious systems environmentstests

Collect and review data for trends process variation and stability

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1031

10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1131

11

Phase 2 Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1231

12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

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8

Root Cause Analysis Process

Phase 3 Decision

Phase 2 Analysis

Phase 1 Investigation

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9

Root Cause Analysis Process

Purpose Gather a factual account of the defectfailure

ndash Be as neutral as possible

Phase 1 Investigation

What is the problem

bullVerify non-compliance

bullDefect

bullFailure

Where is the problem

bullFactory

bullSupplier

bullDesign

When did the problemfirst occur

bullDay date

bullLocationbullTest

bullEnvironment

bullRuntime of system

To what extent did theproblem occur

bullEvents leading up to the incident

What is the Impact tothe customer

bullCost

bullSchedulebullRetrofit

bullSpares

bullLife Cycle Cost

Product History

bullFailureRepair HistorybullTotal runtime

bullPrevious systems environmentstests

Collect and review data for trends process variation and stability

7172019 Root Cause Corrective Action

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10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

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11

Phase 2 Analysis

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12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

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13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

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14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

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15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

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16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

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17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

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18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

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19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

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20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

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21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

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23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

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25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

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26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 931

9

Root Cause Analysis Process

Purpose Gather a factual account of the defectfailure

ndash Be as neutral as possible

Phase 1 Investigation

What is the problem

bullVerify non-compliance

bullDefect

bullFailure

Where is the problem

bullFactory

bullSupplier

bullDesign

When did the problemfirst occur

bullDay date

bullLocationbullTest

bullEnvironment

bullRuntime of system

To what extent did theproblem occur

bullEvents leading up to the incident

What is the Impact tothe customer

bullCost

bullSchedulebullRetrofit

bullSpares

bullLife Cycle Cost

Product History

bullFailureRepair HistorybullTotal runtime

bullPrevious systems environmentstests

Collect and review data for trends process variation and stability

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1031

10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1131

11

Phase 2 Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1231

12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1031

10

Document and track the nonconformance and associatedroot cause analysis

Examples of media used for documentation are

bull Non-conformance Documents (DMR)

bull Corrective Action Request Form (CAR)

bull Supplier Corrective Action Request Form (SCAR)

bull Corrective Action Plan (CAP)

Root Cause Analysis Process

Phase 1 Investigation

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1131

11

Phase 2 Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1231

12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

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11

Phase 2 Analysis

7172019 Root Cause Corrective Action

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12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

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20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1231

12

Phase 2 Analysis

Purpose To determine root cause(s) by identifyingreasons explaining WHY an incident occurred

Root Cause Analysis Process

Step 1

bull Using the factual information gathered in the investigationphase determine the root cause(s) by identifying potentialcauses of the problem using one or more structured problemsolving tools

bull Utilize all stakeholders and subject matter experts

Avoid attempts to ldquofixrdquo the issue during this phase

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1331

13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

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31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

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13

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1431

14

Phase 2 Analysis

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

It is said that by asking ldquoWhyrdquo 5 times successively causes one tounderstand the ultimate root cause

This tool is often used to complement the analysis necessary tocomplete a Cause amp Effect (Fishbone) Diagram

5 ndash Why Analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1531

15

Phase 2 Analysis

Example Jefferson Memorial

Why

The Jefferson Memorial is deteriorating

Too much washing

Excess bird droppings

Lots of spiders to eat

Lots of gnats to eat

We leave the lights on all the time

Why

Why

Why

Why

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1631

16

Problem Solving Tools

Phase 2 Analysis

Fault Tree

5 Whyrsquos

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1731

17

Phase 2 Analysis

bullFault tree analysis is used to analyze failures in complex productsprocesses or systems

bullFault tree analysis enables teams to effectively evaluate the designand operational performance of their process As a result the teamis able to objectively view a process and identify areas whereproblems may arise

bullA basic fault tree starts with the undesirable condition or failure

bullThe contributing causes are branched out until the root cause(s) isreached

Fault Tree Analysis

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1831

18

Phase 2 Analysis

Fault Tree

Bulb Fails

10 Methods20 Mother

Nature(environment)

21 Power

Outage

211 ExtremeWeather Anomaly

30 Manpower40

MeasurementsMetrics

50 MachinesSystems

51 No electricity

511 Power PlantFails

512 Power LineFails

5122 TreeBreaks Line

5121 WindBreaks Line

513 ConnectorCorroded

60 Materials

61 Glass Broken62 Filament

Broken

621 Impurities

622 Vibrations

623 ExceededLife Expectancy

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 1931

19

Phase 2 Analysis

Root Cause Analysis Process

Prioritize the potential causes and keycontributors to the causes of the problem

Search Lessons Learned for similar failure modes

Review defect and failure data and determine theneed for formal ldquolaboratoryrdquo failure analysis

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2031

20

Phase 2 Analysis

Root Cause Analysis Process

Finalize the analysis by identifying the root cause(s)

bullReproduce the failure or demonstrate it by appropriatesimulation for verification purposes if practical

bullRe-evaluate problem containment steps to assure thedefect failure mechanism has been effectively contained

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

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2131

21

Phase 3 Decision

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2231

22

Purpose To implement corrective and preventive actionbull Definition of CorrectivePreventive Action Improvements to an organizationrsquosprocesses taken to eliminate and prevent causes or other undesirable situations

Phase 3 Decision

Root Cause Analysis Process

Step 1

bull Brainstorm possible solutions for corrective and preventive action

bull Approach corrective and preventive action with the use of mistake

proofing

bull Other examples of corrective actions include visible or audiblealarms process redesign product redesign training or workinstruction improvements improvement to material handling orstorage

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2331

23

When to use Mistake Proofing

bull Human error can cause mistakes or defects to occurbull The customer can make an error which affects the output

bull At a hand-off step in a process

bull Minor error early in the process causes major problems later in process

bull Consequences are expensive or dangerous

Phase 3 Decision

Mistake Proofing

ldquoIt follows that mistakes will not turn into defects if worker errors are discovered and eliminated beforehandrdquo[Shingo]

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2431

24

Phase 3 Decision

Root Cause Analysis Process

bull Finalize a solution and determine if acceptable by consideringthe following

bull Will the solution cause new problems

bull The level of difficulty of implementing the solution

bull How much time will it take to implement

bull What is the cost of implementation

bull Is the solution transferable to other processes or areas

Step 2

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2531

25

Phase 3 Decision

Root Cause Analysis Process

bull Objectively Verify

1 Each action in the implementation plan has beencarried out and completed

2 Each solution effectively resolves root cause(s) andeliminates 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 furtherensure effectiveness of correctivepreventative actions

Step 3

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2631

26

Case Study

The Case of the Sidelined Spectacles

Situation Its 3 pm and you have a 5 pm deadline You are hurriedly reviewing a lengthy procedure

that needs to be amended and on the boss desk by 5 pm when disaster strikes- the lens of your

glasses falls out again What do you do

bull Finding (Problem) Your glasses have broken several times within the last few weeks which isslowing your productivity

bull Understanding the need to solve the problem immediately so that you can get on with your day aswell as to prevent it from happening again by implementing corrective action you decide to take a rootcause analysis approach to problem solving

bull Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause The glasses keep breaking causing me to miss deadlines

bull Corrective Action Use clear adhesive tape to secure the lens in the frame each time they breakask boss for deadline extension

bull REFLECTION Why is this a poor example of root cause analysis

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

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

983107983151983151983147 983111983154983141983143983151983154983161 983137983150983140 983129983141983139983144983145983141983148 983122983151983155983141983150983142983151983148983140 983122983151983141983145983150983143 983122983107983107983105 983113983150983156983154983151983140983157983139983156983145983151983150 983156983151 983122983151983151983156 983107983137983157983155983141 983137983150983140 983107983151983154983154983141983139983156983145983158983141

983105983139983156983145983151983150 983150983140

983115983145983154983157983152983137983147983137983154 983106 983122 983121983157983137983148983145983156983161 983122983145983155983147 983117983137983150983137983143983149983141983150983156 983142983151983154 983120983144983137983154983149983137983139983141983157983156983145983139983137983148 983113983150983140983157983155983156983154983161 983110983141983138983154983157983137983154983161 2007 983117983137983154983139983144

2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

983145983150983140983157983155983156983154983161983102

983120983137983143983141 983114983151983140983161 983107983137983157983155983137983148 983105983150983137983148983161983155983145983155 983127983151983154983147983155983144983151983152 983120983154983141983155983141983150983156983137983156983145983151983150 983116983117983117983110983107 983122983107 983122983107983105 983127983151983154983155983144983151983152 983119983154983148983137983150983140983151 2012

983122983151983151983156 983107983137983157983155983141 2012 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983157983155983145983150983141983155983155983140983145983139983156983145983151983150983137983154983161983139983151983149983140983141983142983145983150983145983156983145983151983150983154983151983151983156983085

983139983137983157983155983141983144983156983149983148983102

983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155 8 983117983137983154983139983144 2012 8 983117983137983154983139983144 2012

983100983144983156983156983152983141983150983159983145983147983145983152983141983140983145983137983151983154983143983159983145983147983145983122983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983102

983124983137983143983157983141 983118983137983150983139983161 983122 983117983145983155983156983137983147983141 983120983154983151983151983142983145983150983143 2004 5 983117983137983154983139983144 2012 983100983144983156983156983152983137983155983153983151983154983143983148983141983137983154983150983085983137983138983151983157983156983085

983153983157983137983148983145983156983161983152983154983151983139983141983155983155983085983137983150983137983148983161983155983145983155983085983156983151983151983148983155983151983158983141983154983158983145983141983159983149983145983155983156983137983147983141983085983152983154983151983151983142983145983150983143983144983156983149983148983102

983127983145983148983155983151983150 983106983145983148983148 2010 983122983151983151983156 983107983137983157983155983141 983105983150983137983148983161983155983145983155983086 8 983117983137983154983139983144 2012 983100983144983156983156983152983159983159983159983138983145983148983148983085983159983145983148983155983151983150983150983141983156983154983151983151983156983085983139983137983157983155983141983085

983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2731

27

Case StudyThe Case of the Sidelined Spectacles

bull Finding (Problem) Your glasses have broken several times within the last few weeks which is slowing your

productivity

bull Short-Term Containment Use clear adhesive tape to secure the lens in the frame

bull Root Cause Analysis Methodology 5-Whybull Restate the finding The lens keeps falling out of my eyeglasses

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

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

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

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

bull 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 dont need towear them

bull REFLECTION Why is this a good example of root cause analysisThe example illustrates good root cause analysis that will allow clients to identify the true root cause and determinethe proper systemic corrective action The root cause listed above addresses the true problem in the system Alsothe corrective action provided is not simply an act of containment instead it provides systemic corrective action Inthis example the client used the 5 Why Methodology which is a helpful tool when analyzing your root cause

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

983100983144983156983156983152983159983159983159983137983157983137983142983149983145983148983137983157983137983159983139983137983159983139983143983137983156983141983150983137983155983137983154983151983151983156983135983139983137983157983155983141983135983137983150983137983148983161983155983145983155983152983140983142983102

2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

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983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2831

28

Summary ndash Principles of RCA

1 Define the problem

2 Gather data and evidence

3 Ask why and identify the root causes

4 Implement correctivepreventive action(s) that mistake-proofs root cause

5 Ensure effectiveness by observing the implemented correctivepreventive

actions

6 Incorporate corrective action into other business areas where applicable

Root cause analysis can transform a reactive culture into a forward-lookingculture that solves problems before they occur or escalate More

importantly it reduces the frequency of problems occurring over time bycreating an environment of continuous improvement

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

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2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

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2012 983100983144983156983156983152983159983159983159983152983144983137983154983149983137983145983150983142983151983150983141983156983154983141983158983145983141983159983155983153983157983137983148983145983156983161983085983154983145983155983147983085983149983137983150983137983143983141983149983141983150983156983085983152983144983137983154983149983137983139983141983157983156983145983139983137983148983085

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983137983150983137983148983161983155983145983155983102

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 2931

29

Additional ResourcesRoot Cause Analysis Training and Tools

bull Think Reliability

httpwwwthinkreliabilitycombull ASQ Learning Institute

httpasqorgtrainingroot-cause-analysis_RCAhtml

bull Sologic(Formerly Apollo Associated Services)

httpwwwsologiccom

bull Lockheed Martin Supplier Corrective Action Process

httpsembastionexternallmcocomqissupplier_ca

bull Washington Memorial Root Cause Examplehttpwwwyoutubecomwatchv=IETtnK7gzlEampnoredirect=1

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

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2012 8 983117983137983154983139983144 2012 9831009831449831569831569831529831599831599831599831529831469831549831399831519831499831549831519831519831569831359831399831379831579831559831419831549831519831519831569831359831399831379831579831559831419831359831559831399831419831509831379831549831459831519831351983106983144983156983149983102

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7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3131

31

Please send all questions to

mfctrainingsupplierlmcocom

7172019 Root Cause Corrective Action

httpslidepdfcomreaderfullroot-cause-corrective-action-568ce3a21e9dd 3031

30

Credits12 983119983139983156983151983138983141983154 2011 983105983145983154 983125983150983145983158983141983154983155983145983156983161983086 8 983117983137983154983139983144 2012

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