Root Cause Analysis Presentation

Root Cause Analysis

Module Outline
Chronic vs. Sporadic Problems
Improvement (Breakthrough) vs. Troubleshooting
Addressing Chronic Problems - Breakthrough
Definitions
Diagnosis
Why “Root Cause”?
Tie to MBF (Management by Fact)
Addressing Sporadic Problems - Troubleshooting
Summary
Resources
?

Module Objectives
You will be able to:
Distinguish between chronic vs. sporadic problems.
Define Problem/Symptoms/Causes/Diagnosis.
Describe approaches to find root causes of chronic problems.
Describe the link between Root Cause Analysis and MBF.
Describe approaches to find root causes of sporadic problems.

Improvement vs. Fire Fighting Sporadic Chronic Gain Time Performance Good Bad

Chronic Problems
Existed for some time
Usually “lived with” or accepted
Cost more $$$$$ than sporadic problems
Don’t sound alarms (allowances for problem have been made in the system)
Competitors may be enduring same losses
Improvement is needed when a chronic problem is occurring
Requires improvement PROJECTS - investment of time and resources
Fire Prevention - attack the chronic level

Sporadic Problems
A “spike” in performance
“ Alarm” usually goes off
Troubleshooting used when a sporadic problem happens (a departure from the normal level)
Aimed at restoring the status quo
May include Interim (temporary) fixes
Corrective Action - eliminate the cause of the problem
Remove the change that produced the deviation or new change to offset deviation
Fire Fighting - focus on control

Improvement vs. Troubleshooting
Improvement: Focused on attaining a new level of performance that is superior to any previous level.
Accomplished through BREAKTHROUGH.
Improves chronic level of performance.
Fire Prevention
Troubleshooting: Focused on solving a sudden change in performance.
Accomplished with CORRECTIVE
ACTION to put out a fire.
Improves sporadic level of performance.
Fire Fighting

Sequence for Breakthrough
Proving the need
Identifying Projects
Organizing project teams
Establishing project
(mission/vision/responsibilities)
Diagnosis - to find the causes
Developing remedies - based on knowledge of the causes
Proving remedies & effectiveness - under operating conditions
Dealing with resistance to change
Controlling at the new level
Focus Here Set-up Carry-out

Definitions
Problem: Any deviation from the standard, expected, or desired which is outside the accepted tolerance, norm, or benchmark.
Project: a problem scheduled for solution!
Symptom: An observable indicator, cue, or event directing attention to a problem. Arising from and accompanying a problem.
Theory: Unproved assertion as to reasons for the problem and symptoms.

Definitions - Continued Cause: “Something” that happened to produce a deviation of the actual from the expected or desired. Proved reason for existence of problem. Often “multiple causes”. Dominant or Root Cause: a major contributor to existence of problem which must be fixed before there is an adequate solution. Remedy: a change that can successfully eliminate or neutralize the cause of a problem.

Definition - Diagnosis
Diagnosis: the process of studying symptoms, theorizing as to causes, testing theories, and discovering causes.
Diagnosis - to find the causes
Diagnostic Journey = “symptom to cause”
Followed by Remedial Journey = “cause to remedy”
“ Symptom to cause” is DIFFICULT!

Diagnosis for Improvement Diagnostic Journey: 1. Study the symptoms surrounding the problem to serve as a basis for theorizing about causes. 2. Theorize the causes of these symptoms. 3. Collect data and do analysis to test the theories and determine the causes. When the problem can be switched on & off at will - the journey is over!

Studying Symptoms
Two forms of “Evidence”:
1. Words/documentation describing problem
2. Physical measurements & analysis of product/process
Agreement on “terms/descriptions” for symptoms
Recording data - established to test specific theories
Quantifying symptoms:
Frequency
Intensity
Use of Pareto Charts/Analysis

Check Sheets
Concentration Diagram
“ Autopsies”
Tools for Symptoms
“ Glossaries” for symptom terms
Pareto Analysis
Check Sheet Example: Scratches IIII II II IIII I 15 Runs IIII IIII IIII IIII IIII I IIII IIII 34 Dirt IIII I IIII 11 Wrong Color IIII I I 7 Paint Peeling I I 2 Total 32 15 22 69 Problem Total Order 1 Order 2 Order 3

Theorizing Causes
Diagnosis is made theory by theory
Need to affirm or deny the validity of theories
This is “IDENTIFYING POTENTIAL CAUSES”
3 Steps
1. Generate Theories
e.g. Brainstorm, Ask Why 5 times
2. Arrangement of Theories
e.g. Matrix, Tables, Cause & Effect Diagrams
3. Choosing Theories to be Tested
e.g. Data Collection, Pareto Analysis
Establish Priorities for testing theories

Ask Why 5+ times
Brainstorming*
Cause & Effect Diagrams*
Force Field Analysis*
Affinity Diagram*
Structure Tree Diagram*
Interrelationship Digraph*
Program Decision Process Chart (PDPC)*
Matrix Diagram*
Check Sheet*
Pareto Analysis*
Designed Experiments
ETC.
Tools for Theorizing Causes * Included in Memory Jogger II Pareto Chart Example:

Tool Example - Ask Why 5 Times Generate Theory: Follow with Remedy! Failures from Supplier A are 2X the industry average. There is excessive damage in transit. Packaging is insufficient. Packaging specifications are incomplete. Why? Why? Why? Why? Real Root Cause There are no technical specifications for packaging available. Why?

Tool Example - Cause & Effect Generate Theory: Follow with Test of Theories based on priorities Out of Date Not Manufacturable Part Problem Cutting oil Bar Stock Capability Scheduling cpk Tolerances Procedures Set-up Maintenance Cost Inaccurate Training Engineering Support Operator Errors Adjustments Materials Machinery Methods Manpower Wrong Material Over Sized Wrong Oil Packaging Print Inaccurate

Tool Example - Structure Tree Elbow Failures Problem Subproblems Theories Most Likely Root Causes Crimp makes inadequate contact Cross Thread Pin not fully seated Cable not fully seated Defective Elbow Operator Material Methods Tools & Equipment Guide Thread Lack of Verification for Alignment # of Revolutions not counted

Testing Theories to Find Cause
Determine which cause is ROOT cause
Identifying most likely cause
DATA COLLECTION & ANALYSIS!
Methods
1. Product/Process “Dissection”
e.g. Flow Map, Process Capability Study, Time to Time
2. Collecting New Data
e.g. Measuring within the process
3. Experiments - create & process trials to test validity
e.g. Designed experiments, pilots, trials
4. Measure for Diagnosis
e.g. Variables vs. attributes, increase precision, new methods

Historical Review
Flow Diagram/Map*
Process Capability Analysis
Time to Time Analysis
Stream to Stream Analysis
Histograms*
Control Charts*
Piece to Piece Analysis
Within Piece to Piece Analysis
Multi-Vari Analysis
Check Sheet*
Pareto Analysis*
Designed Experiments
Correlation Studies
Measurements within process
Study of Work Methods
Measurement Capability Studies
ETC.
Tools for Testing Theories * Included in Memory Jogger II

Tool Example - Histogram & Run Chart Test Theory: Follow with Remedy! Histograms: Run Charts:

Tool Example - Capability Test Theory: - Structured Experimentation Follow with Remedy!
Goal: Collect data on all parts of the process so that:
Capture all contributors to variability
Variability can be partitioned into parts due to each contributor
= Total Machine Cavity Time Sample + + +

Diagnosis of Failures in Systems
Historical Review - objective to improve segment of system used to attain quality
e.g.: Product Development, Supplier Relations
Based on analysis of # of past problems
Interview and Document:
1. Brief description of problem
2. Stage where problem 1st observed
3. Earliest stage at which problem COULD have been discovered
4. Reasons for NOT discovering problem at earlier stage
5. What could have been done to have found the problem earlier or avoided it completely

Diagnosis of Failures in Systems
Examples:
1. Historical review of past product development problems:
Symptoms & Cause: Review revealed use of FMEA/FMECA (Failure Mode, Effect, and Criticality Analysis) would have identified problems upfront.
Remedy: Require FMEA upfront for new products.
2. Historical review of manufacturing defects:
Symptoms & Cause: Review revealed lack of set-up procedure led to high lot to lot variation and defects.
Remedy: Document and implement set-up procedure.

Diagnostic Journey Root Cause Analysis Begins with Collecting Data on Symptoms Ends with agreement on Cause(s)

Why Find the “Root Cause”?

What is MBF Used For?
Address gaps in business performance
Customer Satisfaction
Employee Satisfaction
Business models
Operational processes
Manufacturing processes
Simplify reporting
Link problems and root causes with action and results
Link a reporting format to a problem solving model
Report on projects that address a specific problem

Management by Fact (MBF) Remedies Root Cause Analysis Diagnosis Direction Setting Direction Deployment Management Process Policy Deployment & Management by Fact Policy Deployment Monitor Performance Gap Detected No Yes

2. Root Cause Categorization / Analysis (RCA ) Analyze Problem 2
Separate “beliefs” from “real” problem
Determine, categorize, and analyze Root Causes
Use basic quality tools
Cause and Effect Diagram
Affinity diagram
Ask “WHY” 5 times

MBF Form Root Cause Analysis/Diagnosis Remedies PROBLEM STATEMENT/OBJECTIVES & PERFORMANCE TRENDS: (indicate a brief statement of fact here) Insert graph of performance over time here (e.g., Pareto Chart / Current State vs. Goal) Insert graph of more detailed information here (Supportive Info. as necessary - e.g., Costs associated with the problem statement)

Troubleshooting
Diagnosis & remedial action applied to sporadic problems
Generally receives immediate attention
Result of adverse change
Similar to chronic problem journey, but often simpler
Journey is discovering what the change was and removing or adjusting for it
Journey: Symptom to Cause to Remedy
If troubleshooting is ineffective, the result will not be maintained

Troubleshooting
Ask: What, Where, When, How Much, Who
Compare Good vs. Bad, time to time, ETC.
Ask what “IS & IS NOT”
Reconstruct time sequence
Take corrective action to remedy the problem
Use a structured approach:
1. State deviation.
2. Specify the deviation (is & is not, what, where, etc.).
3. Identify unique characteristics of deviation.
4. Search for changes.
5. Develop possible causes.
6. Test the possible causes against the requirement.
7. Verify the cause (duplicate or eliminate by removing cause).

Summary
Need to distinguish between sporadic & chronic problems
Need to be persistent - get to root cause!
For chronic problems:
Use BREAKTHROUGH
Use Root Cause Analysis (Diagnosis)
For sporadic problems - use Troubleshooting
Improvement requires use of multiple quality tools!
To find true (root) causes you need to be a:
Doctor
Detective
Driver
Gardner
Firefighter

References
Books (+ many others):
“ Quality Planning and Analysis”, J. M. Juran & Frank M. Gryna, Third Edition, McGraw Hill.
“ Juran’s Quality Control Handbook” 4th Edition, McGraw Hill.
The Memory Jogger II , Michael Brassard & Diane Ritter, GOAL/QPC, 1994.
Analytic Trouble Shooting, Kepner Tregoe, 3rd Edition, 1978, Princeton Research Press

Root Cause Analysis Presentation

by E&H Pacheco Consultoria e Assessoria Empresarial Ltda

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