Root cause analysis apr 2010

Root Cause Analysis Workshop Michael Sahota

Overview
Stop the line  quality, speed
Root cause thinking
Tool #1: ask “Why?” 5 times
Tool #2: fishbone diagram
Additional considerations make this work

Stop the Line to improve quality, reduce waste and go faster
When there is a problem
No problem is a problem!
Image by http://www.exchange3d.com

Find the root cause and invent countermeasures to mitigate it
Surface problems are only symptoms
“ Putting out the fire” will only mask the problem
Every problem has one or more root causes
Find countermeasures for these so that they do not recur

Caution: countermeasures obey the law of unintended consequences
Not helpful to think about “fixing problems”
Not permanent; a step in working towards perfection
Think of countermeasures that mitigate problems
Be open to multiple possibilities
Everything we do has consequences, so we may be introducing our next problem
Examples: rabbits in Australia, Streisand effect

Goal is to identify the problem and find countermeasures - not to blame people
“ No blame” policy
“ Everyone is doing the best they can with the resources they have”
Systems thinking is a good model
How has the system functioned to bring about this result?
For this to work, people need to feel safe and trust one another

Tool #1: ask “Why?” 5 times to uncover details
Start with the problem and ask “Why” 5 times
Sounds simple and takes practice
Requires creative thinking
Use beginners mind to avoid the expert trap

Example of Jeff Bezos – CEO at Amazon.com asking “Why?” to find the root cause
Why did the associate damage his thumb?
Because his thumb got caught in the conveyor.
Why did his thumb get caught in the conveyor?
Because he was chasing his bag, which was on a running conveyor.
Why did he chase his bag?
Because he placed his bag on the conveyor, but it then turned-on by surprise
Why was his bag on the conveyor?
Because he used the conveyor as a table
http://www.shmula.com/987/jeff-bezos-5-why-exercise-root-cause-analysis-cause-and-effect-ishikawa-lean-thinking-six-sigma

Countermeasures identified at Amazon
Provide portable, light tables
Greater focus on safety training
Look into accident prevention as standard work
http://www.shmula.com/987/jeff-bezos-5-why-exercise-root-cause-analysis-cause-and-effect-ishikawa-lean-thinking-six-sigma

Exercise: Find a partner, pick a problem and ask why 5 times

Tool #2: fishbone (Ishikawa) diagram facilitates looking at the big picture

Demo: Fishbone with Amazon Example

Exercise: Draw, Pardner!

Additional considerations to make this work…

Go and see (Genchi Genbutsu) – Go to the source to see the facts for yourself
Often when performing root cause analysis you will not know the answer
Beware of data someone else has prepared
Get the Facts! – Go and see for yourself
Look, See, Understand
Think for yourself

Kaizen – continuous improvement in the pursuit of perfection
"A journey of a thousand miles must begin with the first step.“ - Lao Tzu
Ask small questions
Take small actions
Solve small problems
Constraints:
Spend no Money
Add no People
Add no Steps
http://www.shmula.com/1112/the-atomic-rules-of-kaizen

Everyone needs to work towards shared goals of quality for this to be successful
1 person @ 100% will not have sustained success
Toyota has proven 100 people @ 1% works
Successful companies build people
Culture of empowerment
Ownership of problems and countermeasures

What questions do you have?

http://agilitrix.com	2974
http://agile.dzone.com	416
http://www.agilitrix.com	93
http://www.brijj.com	6
http://translate.googleusercontent.com	2
http://www.slideshare.net	1
http://translate.yandex.net	1

Root cause analysis apr 2010

by Michael Sahota on Jun 28, 2010

Accessibility

Categories

Tags

Upload Details

Usage Rights

7 Embeds 3,493

Statistics

Root cause analysis apr 2010 — Presentation Transcript