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Root Cause Analysis


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  • Remind participants to have a printed copy of the corrective/preventive action form to each participant for referencing to throughout the training session. Introduction: Different solutions are required for different problems. Even similar problems may require different ways of finding solutions. This training event is designed as an aid to help you standardize your problem solving efforts in an effective and efficient way. It also will better structure your approach to problem solving by helping you select and use the appropriate tools, ensure your efforts are successful and help prevent the same or similar problems from occurring in the future
  • Read slide
  • Beginning Comments In order to understand the corrective action process, you need to see the big picture. It is important to understand the language or the “buzz” words of the process. Problem solving efforts needed to correct a non conformance should follow a logical systematic process. The process is a five step approach to solving the problem. Click 1 – Step 1 - Describe the problem Click 2 - Step 2 – Determine the root cause Click 3 - Step 3 – Develop C/PA steps Click 4 – Step 4 – Verification of implementation Click 5 – Step 5 – Conclusion of effectiveness
  • Beginning Comment The first step to solving a problem is to correctly define the problem. Read Slide Ending Comment If specifics are not included in the problem description, you will attempt to take actions on vague, incomplete, or inaccurate information that might only identify the symptoms of the problem
  • Read slide Comment: Only when the root cause is found, can actions be taken to FIX THE PROBLEM FOR GOOD.
  • Beginning comment The primary objective of the first step is to be sure that you have identified the true problem Read slide. Ending Comment: Clarification of the Description prevents confusion and jumping to conclusions.
  • Beginning Comment: Here is a quick guide to help you more clearly work through defining a problem. It is known as the 4W-2H-1C FORMULA Read slide Ending Comment: By including the consequences, the situation becomes real in terms of the impact the problem caused to an area in the site or the customer. It also helps to understand the benefit of solving the problem.
  • Beginning Comment: Common mistakes made when defining a problem are: Read Bullet #1 and example The “short term fix” (solution) should not be in the problem statement, but more appropriately in an area where you document what immediate action was taken . Read Bullet #2 and example This is not an actionable description. You would want to state WHY the operator was confused on how to place the label on the pallet. Such as: The new pallet design confused the operator to where the label should be placed. Read Bullet #3 and example How slow is “slowly” – what is the standard for that area. (cases per hour, packages per minute) Ending Comments: WATCHOUT: Training should rarely be considered an acceptable root cause and will be covered in more detail in the next section.
  • Read Bullet #1 Read Bullet #2 Read bullet #3 Comment after bullet #3 Currently this is rarely done, but the value is that it keeps the group focused on what they are working on. INTRODUCE JIM: Jim Philpott, our CI/Root Cause Analysis expert is with us today to walk us through some techniques that you can take back to your plants (This is part of the ISO C/PA KNAM 2008005 audit response). Jim will introduce us to tools that are available to facilitate work at the plants to get to root cause so that time, energy and resources can be focused on solving problems PERMANENTLY.
  • Read slide Go to easel board and direct the following question to the participants. “ WHAT ARE SOME TECHNIQUES TO SOLVE PROBLEMS?” LIMIT THIS EXERCISE TO A 5 MINUTE ACTIVITY Some ideas that might be written on the easel board. brainstorming cause and effect diagram (fishbone analysis) 5 whys check sheets pareto diagrams run charts interviews process mapping
  • Beginning Comment Our first tool for discussion is what we just did – Brainstorming. Read Slide Ending Comments One idea stimulates another spontaneously! Brainstorming works best when you have a larger group of varied people. Try to get as varied a group as possible to participate - this will result in the widest and most creative range of ideas. This is a valuable activity since each group member contributes a unique view of a situation
  • Opening Comment Here is how you facilitate the brainstorming activity To get started – first ensure that the group is clear on the problem description or the problem being explored. Read slide
  • Beginning Comment The 2 nd problem solving tool we’ll discuss today is the 5-whys. It is simple and easy to use without statistical analysis. It is most useful in day to day business life when problems involve human factors or interactions Read Slide Here’s how it works: Click 1 Write down the specific problem. Writing the issue helps you formalize the problem and describe it completely. It also helps a team focus on the same problem. Click 2 Ask Why the problem happens and write the answer next to the problem. If the answer you just provided doesn't identify the root cause of the problem that you wrote down in step 1, ask Why again and write that answer down. Click 3 Loop back to previous step until the team is in agreement that the problem's root cause is identified. Again, this may take fewer or more times than five Whys.
  • Comment: For reference, here are the details on how to facilitate the 5-why technique. DO NOT READ THIS SLIDE
  • Beginning Comment: The 3 rd tool is considered to be more of a “support tool”. It’s often used for gathering factual supporting evidence about an incident or failure. Read Slide Ending Comment One point to caution you on: When needing to collect data to further identify a problem, you should evaluate what information is already being collected in the process. It may be just pulling information from various operator check sheets, instead of having to create another form. Also, make sure you consider controlling any temporary document created for tracking information within your processes. As we go along through this presentation – you will see how check sheets will provide the details to support other problem solving tools.
  • Beginning Comment: This is an example of a check sheet created to collect more detailed information regarding an increase of down time for a packaging area. Summarize information on slide Note to speaker  Ignore the read button in the lower right hand corner – proceed with the presentation.
  • Beginning Comment: As you can see, the strength of a pareto chart is the ability to see where to focus Click In this example, if we would work on only ½ of the causes, we would clear up 2/3rds of our problems – which is a pretty decent pay back! Ending comment: It’s beneficial to have “methods to your madness” in our world of limited resources. Pareto analysis is valuable to use when communicating issues and request for resources with your management team.
  • Beginning Comment: The 5 th tool - the Time Line – is another “support-type of tool” Read Slide Ending Comment Knowing the nature of a change and when it occurred in time, allows you to determine if it affected anything else.
  • Beginning Comment: In this example – Packaging defects have risen from 3% to 10% in the last 2 months. Your start/end points of your time line is based on the time period to analyze. Using post-it notes, you record all known changes to the process during that time period and place them in chronological order on the line. Click on View Check Sheet Box – in upper left corner When looking at the data we collected on packaging issues for the week of January 21, the 2 largest hitters were Loose wrap and No seal (point them out) Click on red return button in lower right corner **Click again When plugging this into our time line – we see that these may be symptoms as a result of the PM activity performed on January 20 th . - we would want to evaluate how and what is being done on this PM Ending comment: As you can see by combining the right tools, (timeline, check sheets, 5-whys) you can more accurately “drill down to the root causes” of a problem.
  • Beginning Comment: The last, but most powerful tool that we’ll discuss is the Cause and Effect Diagram. Read Slide Bullet #1 The design of the diagram looks much like the skeleton of a fish. Bullet #2 Use when you have a fairly large-scale problem that involves a number of activities such as a process, which would have a number of causes. Bullet #3 (read)
  • Read slide
  • Opening comment: Here is an example of how this works. Read Slide
  • Beginning Comment The next step is to brainstorm potential causes to the problem. As possible causes are identified – decide as a group under which category to place them under. These are considered as the 2 nd bones Click 1 - Under People - we have identified a temporary position as the potential cause Click 2 – Under Equipment - excessive downtime and scale errors Click 3 - Under Methods - Poor inspections, overloading hopper and tote size Click 4 – Under materials - excessive waste, temperature and tote size Click 5 – Under environment – room temperature Click 6 It is acceptable to list a possible cause under more than one major cause category For example you will see “tote size” listed under materials and Methods For materials the group identified the tote size being too large – causing product to mold into blocks at the bottom – causing chunks on the line. For Methods – “tote size” was also identified as being too large causing operator to dump the tote unevenly into the hopper. Click 7 For simplicity – we will now look at only one of the categories – Methods, to demonstrate the next steps
  • When applying root cause analysis tools you may identify a multitude of things to work on. This is an easy tool to use to prioritize what to go after. As a team effort, you categorize the activities into the appropriate box, based on the following: Click 1 On the left side (Y axis) you consider the impact - the probability of this being the permanent correction Click 2 On the bottom (X axis) you evaluate how difficult the action would be to implement. Other labels for the X and Y axis could be cost or resource needs The numbers inside the box represent the order you would prioritize what to work on based on #1 - Being activities that would have the greatest impact and easiest to implement #2 - Being low impact but easy to implement – reducing a variable, even though it’s small and still making an improvement. #3 - Being high impact, hard to implement – “the sky’s the limit” to get it done where you get the “biggest bang for your buck” This is usually the target for a high performance work team #4 - Being low impact, hard to implement - any actions in this box may not justify working on. NOTE: Ask participant’s to identify examples for each quadrant based on the C&E Diagram (replicated in next slide).
  • Read slide. Comment Currently, some sites are finding the Corrective Action Process a challenge to manage: Failure to identify the true root cause Ineffective communication of activities, information and closure Failure to categorize or include the appropriate issues into the process Bogging down the system with the Day to Day non-conformances.
  • Read Slide
  • Read slide. Ending Comment After the C/PA steps are in place and has been implemented, an auditor or designee shall verify the implementation & effectiveness of the corrective action.
  • Read slide The key here is that there must be objective evidence that the established C/PA action steps were implemented.
  • Read slide To be effective the action taken must achieve the desired result and the process capable and efficient. Very likely that ongoing monitoring may be necessary
  • Comment The question you need to ask is—has it gotten better? You have done all this work-you at least want to have fixed the problem. If the problem has been fixed it means that the changes you have made through your Action Plan were effective (i.e. that it is working). If you would like more help, here are some additional resources.
  • Transcript

    • 1. Successful Corrective Action Through Effective Problem Solving IT470a Six Sigma Green Belt-I Summer 2009 Reference Material #2 Ken White
    • 2. Course Objectives
      • Understand the basic structure of the C/PA Process
      • Understand how to define a problem to allow a solution
      • Review of basic root cause analysis tools
      • Understand the importance of tracking and completing C/PA Steps
      K White 2/12/2009
    • 3. K White 2/12/2009 #1 - Describe the Problem #2 - Determine the Root Cause #3 – Determine C/PA Steps #4 - Verification #5 - Conclusion
    • 4. Problem Description
      • If we do not define the problem correctly, we will never be able to solve the problem --- PERMANENTLY
      K White 2/12/2009
    • 5. Symptoms
      • Any circumstance, event or condition that accompanies something and indicates its evidence or occurrence; a sign
      • Examples of symptoms:
        • Procedures are not followed
        • Operator error
        • Incomplete information
      • Ensure you break through symptoms by asking “WHYS”
      K White 2/12/2009
    • 6. Problem Description
      • Must be clearly defined
      • Define in terms of WHAT, WHERE, WHEN, WHO, HOW MUCH, and the CONSEQUENCES
      K White 2/12/2009 Example: At 9:07 p.m., mixer operator found 2”x 4” metal piece in mix tank #5. The cook process was stopped immediately – batch #1-8 were put on hold.
    • 7. K White 2/12/2009
    • 8. Problem Description
      • Common mistakes
      • Defining the problem and the solution at the same time
        • The lot tags were not found on the pallet and the supervisor has shown the operator the correct location for placement.
      • Defining a symptom as the problem
        • The operator was confused on how to place the label on the pallet.
      • Defining the problem without data to support definition.
        • The case operator works slowly.
      K White 2/12/2009
    • 9. Problem Description
      • Avoid mistakes
      • State WHAT is wrong, not WHY it’s wrong
      • Define the “gap” between what is expected and what is actually happening
      • As new information/data becomes available review and update the problem description as necessary.
      K White 2/12/2009
    • 10. Step #2 Determining the Root Cause
      • What is a root cause?
        • The single, verifiable reason for the problem, which if corrected – prevents its recurrence.
      K White 2/12/2009
    • 11. Problem Solving Tools
      • Brainstorming
      • The act of defining a problem or idea and coming up with anything related to the topic – no matter how remote a suggestion may sound.
      K White 2/12/2009
    • 12. Brainstorming
      • How to Facilitate
      • Assign a scribe – set a time limit
      • Ask each member to contribute an idea or suggestion
      • Allow no positive or negative comments about the suggestions, at this point
      • Record all possible causes or sources of a problem
      • Evaluate the responses as a group discussion
        • Look for answers that are repeated or similar
        • Group like-concepts together
        • Eliminate responses that definitely do not fit
      • Decide which cause to attack first, by voting
      K White 2/12/2009
    • 13. Problem Solving Tools
      • 5 Whys
      • Helps to identify the relationship between causes
      • Forces you to “drill down” the symptoms
      K White 2/12/2009
    • 14. 5-Whys
      • How to facilitate
      • Write down the specific problem
      • Ask “ Why the problem happens” and write the answer down below the problem
      • If the answer you just provided doesn't identify the root cause of the problem that you wrote down in step 1, ask Why again and write that answer down
      • Loop back to previous step until the team is in agreement that the problem's root cause is identified.
        • May take fewer or more times than five Whys.
      • Please note that the 5 WHYs make take the group down multiple paths – and that’s OK.
      K White 2/12/2009
    • 15. Problem Solving Tools
      • 5 Why’s
      • Check Sheet
      • Pareto Chart
      • Time Line
      • Fishbone
      K White 2/12/2009
    • 16. Problem Solving Tools
      • Check Sheets
      • For Collecting data and is Useful when data is needed to determine frequency, patterns, defects by type or location
      K White 2/12/2009
    • 17. Check Sheet K White 2/12/2009
    • 18. Pareto Chart K White 2/12/2009 Working on top ½ of your causes may help 2/3 of the problems go away! 65%
    • 19. Problem Solving Tools
      • Develop a Time Line
      • Provides a clear picture for understanding the incident and how it evolved
      • Record known changes
        • Must be specific with verifiable facts
      K White 2/12/2009
    • 20. Time Line Example K White 2/12/2009 View Check Sheet
    • 21. Problem Solving Tools
      • Cause and Effect Diagram
      • Also referred to as “fishbone” diagram
      • Useful for organizing large amounts of information about a problem
      • Most effective when done as a team with individuals who are knowledgeable of the overall process
      K White 2/12/2009
    • 22. C & E Diagram
      • As a group, identify what the major categories of causes are to the process.
        • Most common:
          • - People
          • - Materials
          • - Equipment
          • - Environment
          • - Methods
          • - Measurement
      K White 2/12/2009
    • 23. C & E Diagram
      • Problem
      • Product placed on hold due to uneven distribution of fruit topping. This caused uncontrollable weights and below standard appearance of finished product
      K White 2/12/2009
    • 24. C & E Diagram K White 2/12/2009 UNEVEN FRUIT APPLICATION ON PRODUCT ENVIRONMENT METHODS PEOPLE MATERIALS EQUIPMENT Temporary Position Excessive downtime Scale errors Room Temperature Temperature Tote size Excessive waste Poor Inspections Overloading hopper Tote size
    • 25. Prioritizing Activities K White 2/12/2009
    • 26. Step #3 C/PA Steps
      • Well defined steps…
        • Can be the difference between a successful resolution or one that falls short of preventing recurrence
      K White 2/12/2009
    • 27. C/PA Steps
      • The process:
      • Formalize and capture the activities that need to take place
      • Clearly identify:
        • WHO is going to do WHAT by WHEN
      • Use an Action Register to track activities
      K White 2/12/2009
    • 28. C/PA Steps
      • Monitor the status of the activities
        • Continually update action register (adding new tasks, completion dates)
        • Add as a standard agenda item in department meetings, management review
      • Maintain action register as part of the C/PA Program
      K White 2/12/2009
    • 29. Step #4 Verification
      • Verification needs to be supported by evidence :
        • Type of data
          • What was reviewed (charts, observation, records)
        • Observations
        • Titles and data range
        • Records reviewed
        • Who was interviewed
        • Summary of overall findings
      K White 2/12/2009
    • 30. Step #5 Conclusion
      • Confirms the solution - has fixed the problem so it doesn’t come back
      • Confirms that the system change is effective
          • Process
          • People
      • May need additional long-term monitoring
        • Incorporate as an internal audit check point
      K White 2/12/2009
    • 31. Questions
    • 32. Additional Resources
      • References
      • Correct! Prevent! Improve! – ASQ (American Society of Quality) publication
      • The Root Cause Handbook – Max Ammerman
      • The Basics of FMEA (Failure Mode and Effect Analysis) – McDermott, Mikulak, Beauregard. Focus is on machinery and safety
      • Courses
      • Problem Solving and Decision Making
      • Problem Solving and Decision-Making: A Course in Critical Thinking Skills
      K White 2/12/2009