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Root Cause Analysis By Deepak
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Root Cause Analysis By Deepak

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ABOUT THE TRAINING PROGRAM :- …

ABOUT THE TRAINING PROGRAM :-
Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to address, correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is more probable that problem recurrence will be prevented.

DESIGNED FOR :-
Managers, Engineers, Supervisor and officers engaged in maintenance operation and engineering activities.

OBJECTIVE :-
At the end of the training program, participants will be able
- To gain a basic understanding of the problem solving and decision-making process and the applicable quality tools that support this process.
- To develop specific competencies to use the structured approach to problem solving and decision making and the supporting quality tools.

TRAINING PROGRAM COVERAGE :-
- Basic knowledge about RCA program.
- What are the RCA tools ?
- More about Why- Why analysis ?
- Videos and case studies on RCA

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  • 1. RCA Root Cause Analysis Excellence in Problem Solving Prepared and Presented by :- Mr. Deepak Kumar SahooPrepared By – Mr. Deepak Kumar Sahoo
  • 2. What is RCA ? Root Cause Analysis is an in-depth process or technique for identifying the most basic factor(s) underlying a variation in performance (problem).  Focus is on systems and processes  Focus is not on individualsPrepared By – Mr. Deepak Kumar Sahoo
  • 3. Types of RCA• Safety-based RCA  Investigating accident , occupational safety and health.  Root causes:- unidentified risks, or inadequate safety engineering, missing safety barriers.• Production-based RCA  Quality control for industrial manufacturing.  Root causes:- non-conformance like, malfunctioning steps in production line.• Process-based RCA  Extension of Production-based RCA.  Includes business processes also.  Root causes:- Individual process failures• Systems-based RCA  Hybrid of the previous types  New concepts includes:- change management, systems thinking, and risk management.  Root causes:- organizational culture and strategic managementPrepared By – Mr. Deepak Kumar Sahoo
  • 4. Whether we know the Cause? Solution Not Known Brain Storm / Seek Root Cause Analysis Expert Help Solution Known Task Force Trial & Error Root Cause Analysis Cause Known Cause Not KnownPrepared By – Mr. Deepak Kumar Sahoo
  • 5. RCA Benefits :-By eliminating the root cause… You save time and money!• Problems are not repeated• Reduce rework, retest, re-inspect, poor quality costs, etc…• Problems are prevented in other areas• Communication improves between groups and Process cycle times improve (no rework loops)• Secure long term company performance and profitsPrepared By – Mr. Deepak Kumar Sahoo
  • 6. When we need RCA IMPACT 5 WHY’s Cause Mapping OBSERVATION MINOR MAJOR FREQUENCYPrepared By – Mr. Deepak Kumar Sahoo
  • 7. RCA ProcessA standard process of RCA is as follows:  Identifying a problem  Containing and analyzing the problem  Defining the root cause  Defining and implementing the actions required to eliminate the root cause  Validating that the corrective action prevented recurrence of problemPrepared By – Mr. Deepak Kumar Sahoo
  • 8. RCA Process 1 Identify 8 Problem 2 Validate Identify Team Problem Follow Immediate Up Plan Solving Action 7 Process 3 Complete Root Plan Cause Action 6 Plan 4 5Prepared By – Mr. Deepak Kumar Sahoo
  • 9. RCA Process : Step - 1 Identify the Problem• Clearly state the problem the team is to solve – Teams should refer back to problem statement to avoid getting off track• Use 5W2H approach – Who? What? Why? When? Where? How? How Many? 5W2HWho? Individuals/customers associated with problemWhat? The problem statement or definitionWhen? Date and time problem was identifiedWhere? Location of complaints (area, facilities, customers)Why? Any previously known explanationsHow? How did the problem happen (root cause) and how will the problem be corrected (corrective action)?How Many? Size and frequency of problem It’s the most important step.Prepared By – Mr. Deepak Kumar Sahoo
  • 10. RCA Process : Step - 2 Identify Team When a problem cannot be solved quickly by an individual, use a team! Should consist of domain knowledge experts Small group of people (4-10) with process and product knowledge, available time and authority to correct the problem Must be empowered to “change the rules” Should have a designated Team leader. Membership in team is always changing!Prepared By – Mr. Deepak Kumar Sahoo
  • 11. RCA Process : Step – 2 (Continue..)Key Ideas for Team Success Define roles and responsibilities Identify external customer needs Identify internal customer needs Appropriate levels of organization present Clearly defined objectives and outputs Solicit input from everyone! Good meeting location - Near work area for easy access to information. Roles and Responsibilities  Team Leader: Mentor, guide and direct teams, advocate to upper management  Leader: day-to-day authority, calls meetings, facilitation of team, reports to TL.  Record Keeper: Writes and publishes minutes  Participants: Respect all ideas, keep an open mind, know their role within teamPrepared By – Mr. Deepak Kumar Sahoo
  • 12. RCA Process : Step – 3 Immediate Action Must isolate effects of problem from customer Only temporary until corrective action is implemented Must also verify that immediate action is effective Verify Immediate Action Immediate action = activity implemented to screen, detect and/or contain the problem. Must verify that immediate action was effective  Run Pilot Tests  Make sure another problem does not arise from the temporary solutions Ensure effective screens and detections are in place to prevent further impact to customer until permanent solution is implemented.Prepared By – Mr. Deepak Kumar Sahoo
  • 13. RCA Process : Step – 4 Finding Root Cause• Brainstorm possible causes of problem with team• Organize causes with Cause and Effect Diagram• Use 5 Why? method to further define the root cause of symptoms – May involve additional research/analysis/investigation to get to each “Why?”• Must identify the process that caused the problem – if root cause is company-wide, elevate these process issues (outside of team control) to upper management to addressPrepared By – Mr. Deepak Kumar Sahoo
  • 14. RCA Process : Step – 4 RCA Tools.Most commonly use :- – The “5 Whys” – Brainstorming – Fish bone Analysis or Ishikawa Diagram – Cause Mapping or Cause and Effect Analysis – FMEA or FMECAOther RCA tools :-  Process Maps  Run Chart  Risk Tree Diagrams  Barrier Analysis  Change Analysis  Histograms  Pareto Charts  Affinity Diagrams  Interrelationship  pie chat  Control Plans Diagram  Tree Diagrams  Scatter Diagram  Force Field Analysis  Benchmarking  Event and Causal  Flowcharts Factor Analysis  MORT AnalysisPrepared By – Mr. Deepak Kumar Sahoo
  • 15. Why-Why Analysis.Problem - Flat Tire Why? Nails on garage floor Why? Box of nails on shelf split open Why? Box got wet Why? Rain thru hole in garage roof Why? Roof shingles are missingPrepared By – Mr. Deepak Kumar Sahoo
  • 16. TIPS for Why-Why Analysis. It should be done within 24 hours of problem occurrence Person who was present when the problem occurred should be part of why-why analysis Why-Why analysis should be done at the location where the problem has occurred Stop when the answers become less important. Stop when the root cause condition is isolated. Ask “Why?” 5 times can extend maximum 7 times. If you will not find the possible solution then use Other RCA tools.Prepared By – Mr. Deepak Kumar Sahoo
  • 17. Why-Why Analysis ExamplesWhy • RAVANA KILLEDWhy • He Kidnapped SITAWhy • She was in the Forest • Her Father in law King Dhasaratha Promised to oneWhy of his wife Kaikeyee • One day King Dhasaratha Roaming with his chariot Vehicle it wheel lock pin was damaged and Kaikeyee was put her finger inWhy to the Pin hole and saved King DhasarathaWhy • The chariot vehicle wheel lock pin was damaged.Prepared By – Mr. Deepak Kumar Sahoo
  • 18. Why-Why Analysis ExamplesWhy • The chariot vehicle wheel lock pin was damagedWhy • Poor maintenanceRoot Why • No PPM & no FMEA carried out. Cause • Think ….. • Because EMCO was not there on that time If EMCO was at that time and King Dhasaratha gave maintenance contracts to EMCO History might Change. Ravana life also might be saved. Prepared By – Mr. Deepak Kumar Sahoo
  • 19. More about Cause-Effect Diagram : Materials MethodsEnvironment Effect Machine ManNOTE: Causes are not limited to the 5 listed categories, but serve as a starting point Steps used to create a Cause-Effect Diagram:  Define the issue or problem clearly  Decide on the root causes of the observed issue or problem  Brainstorm each of the cause categories  Write ideas on the cause-effect diagram.Prepared By – Mr. Deepak Kumar Sahoo
  • 20. Fish Bone Analysis Materials Methods Incorrect Quantity Late Dispatch Spillage Incorrect BOL Shipping Delay Wrong Destination Traffic Delays ShippingEnvironment Wrong Equipment Problems Weather Driver Dispatcher Breakdown Dirty Equipment Wrong Directions Attitude Machine ManPrepared By – Mr. Deepak Kumar Sahoo
  • 21. RCA Process : Step – 5 Corrective Action Plan• Must verify the solution will eliminate the problem – Verification before implementation whenever possible• Define exactly… – What actions will be taken to eliminate the problem? – Who is responsible? – When will it be completed?• Make certain customer is happy with actions• Define how the effectiveness of the corrective action will be measured. Verification vs. ValidationVerification – Assures that at a point in time, the action taken will actually do what is intended without causing another problemValidation – Provides measurable evidence over time that the action taken worked properly, and problem has not recurredPrepared By – Mr. Deepak Kumar Sahoo
  • 22. Types of Corrective action.3 types of Corrective Action:• Immediate action – The action taken to quickly fix the impact of the problem so the “customer” is not further impacted• Permanent root cause corrective action – The action taken to eliminate the error on the affected process or product• Preventive (Systemic) root cause corrective action – The action taken to Prevent the error from recurring on any process or productPrepared By – Mr. Deepak Kumar Sahoo
  • 23. Corrective Action Examples Immediate (step #3) All current batch of paperwork re-inspected by another worker for same type of problem Permanent (step #5) Form changed to mandate completion of certain fields Preventive (step #5) Similar forms with same fields used all over in company are changed to “mandatory”Prepared By – Mr. Deepak Kumar Sahoo
  • 24. RCA Process : Step – 6 Complete Action Plan Make certain all actions that are defined are completed as planned If one task is still open, verification and validation is pushed back If the plan is compromised, most likely the solution will not be as effectivePrepared By – Mr. Deepak Kumar Sahoo
  • 25. RCA Process : Step – 7 Follow Up Plan What actions will be completed in the future to ensure that the root cause has been eliminated by this corrective action? Who will look at what data? How long after the action plan will this be done? What criteria in the data results will determine that the problem has not recurred?Prepared By – Mr. Deepak Kumar Sahoo
  • 26. RCA Process : Step – 8 Validate and Celebrate• What were the results of the follow up?• If problem did reoccur, go back to Step #4 and re-evaluate root cause, then re-evaluate corrective action in Step #5• If problem did not reoccur, celebrate team success!• Document savings to publicize team effort, obtain customer satisfaction and continued management support of teamsPrepared By – Mr. Deepak Kumar Sahoo
  • 27. RCA Example - 1 Identify Problem A manager walks past the assembly line and notices a puddle of water on the floor. Knowing that the water is a safety hazard, she asks the supervisor to have someone get a mop and clean up the puddle. The manager is proud of herself for “fixing” a potential safety problem. Immediate Action Knowing that the water is a safety hazard, the manager asks the supervisor to have someone get a mop and clean up the puddle. But What is the Root Cause? The supervisor looks for a root cause by asking why?’Prepared By – Mr. Deepak Kumar Sahoo
  • 28. RCA Example – 1 WHY Puddle of water on the floor WHY Leak in overhead pipe WHY Water pressure is set too high WHY Water pressure valve is faulty Root Cause Valve not in PPM programPrepared By – Mr. Deepak Kumar Sahoo
  • 29. RCA Example – 1 Corrective Action Permanent – Water pressure valves placed in preventative maintenance program. Preventive - Developed checklist form to ensure new equipment is reviewed for possible inclusion in preventative maintenance program.Prepared By – Mr. Deepak Kumar Sahoo
  • 30. RCA Example – 2 Identify Problem Customers are unhappy because they are being shipped products that dont meet their specifications. Immediate Action Inspect all finished and in-process product to ensure it meets customer specifications. Find out the root causePrepared By – Mr. Deepak Kumar Sahoo
  • 31. RCA Example – 2 WHY Product doesn’t meet specifications Manufacturing specification is different from what customer and sales WHY person agreed. Sales person tries to expedite work by calling head of manufacturing WHY directly. Manufacturing schedule is not available for sales person to provide WHY realistic delivery date. Confidence in manufacturing schedule is not high enough to WHY release/link with order system WHY Parts sometimes not available thereby creating schedule changes WHY Expediting and priority changes consume parts not planned for Manufacturing schedule does not reflect realistic assembly and test WHY time. Root Cause No ongoing review of manufacturing standards.Prepared By – Mr. Deepak Kumar Sahoo
  • 32. RCA Example – 2Corrective Action• Permanent – Manufacturing standards reviewed and updated.• Preventive - Regular ongoing review of actuals vs standards is implemented.Prepared By – Mr. Deepak Kumar Sahoo
  • 33. RCA Example – 3Identify ProblemPart polarity reversed on circuit boardImmediate Action Additional inspection added after this assembly process step to check for reversed part defects. Last 10 lots of printed circuit boards were re-inspected to check for similar errors.Prepared By – Mr. Deepak Kumar Sahoo
  • 34. RCA Example – 3 WHY Part reversed. WHY Worker not sure of correct part orientation. WHY Part is not marked properly. WHY Engineering ordered it that way from vendor Process didn’t account for possible Root Cause manufacturing issuesPrepared By – Mr. Deepak Kumar Sahoo
  • 35. RCA Example – 3Corrective Action:-• Permanent – Changed part to one that can only be placed in correct direction (Mistake proofed). Found other products with similar problem and made same changes.• Preventive - Required that any new parts selected must have orientation marks on them.Prepared By – Mr. Deepak Kumar Sahoo
  • 36. RCA Example – 4 Identify Problem Department didn’t complete their project on time. Immediate Action Additional resources applied to help get the project team back on schedule No new projects started until Root Cause Analysis completed Now we will find the root causePrepared By – Mr. Deepak Kumar Sahoo
  • 37. RCA Example – 4 WHY Didn’t complete project on time Method Man Lack of worker knowledge Poor project Lack of resources management skills Didn’t complete project on time Inadequate computer programs Inadequate computer system Materials MachinePrepared By – Mr. Deepak Kumar Sahoo
  • 38. RCA Example – 4 WHY Didn’t complete project on time WHY Resources unavailable when needed. WHY Took too long to hire Project Manager Lack of specifics given to WHY Human Resources Department. Root Cause No formal process for submitting job openingPrepared By – Mr. Deepak Kumar Sahoo
  • 39. RCA Example – 4Corrective Action Permanent – Hired another worker to meet needs of next project team Preventive - Developed checklist form with HR for submitting job openings in the future.Prepared By – Mr. Deepak Kumar Sahoo
  • 40. More on Why-Why analysis ? Why People turnover is high in EMCO? Why work load is more in QF? Why PPM in QF is not so effective ? Why Rajnikant is to too famous? Why CM has reduced in QF from EMCO side ?Prepared By – Mr. Deepak Kumar Sahoo
  • 41. Why-Why Analysis (multiple cause Examples) Employee turnover rate has been increasing Why? Why? Why? Why? Why? Employees Employees Employees Other Demand for are leaving are not feel that they employers such for other jobs satisfied are are paying employees underpaid higher has increased salaries in the marketPrepared By – Mr. Deepak Kumar Sahoo
  • 42. Thank you !!!Connect With Me @Mobile :- +974 – 3370 8982Email :- dksahoo2@gmail.comLinkedIn :- www.linkedin.com/in/dksahooFacebook :- www.facebook.com/dksahoo2Twitter :- www.twitter.com/defydeepakSlideshare :- www.slideshare.net/dksahoo2 Prepared By – Mr. Deepak Kumar Sahoo