Root Cause Analysis                   An IntroductionDr Rovel Shackleford           1                                     ...
Course Content• Objectives• What is Root Cause?• Benefits & the Hurdles• Problem Solving Process• Examples• Root Cause “Ti...
Course ObjectivesUpon completion of this (abridged) course, participants should be able to:• Understand the importance of ...
What is root cause?ROOT CAUSE =• The causal or contributing factors that, if corrected,  would prevent recurrence of the i...
What is root cause analysis?• A standard process of:    identifying a problem    containing and analyzing the problem    d...
BenefitsBy eliminating the root cause…         You save time and money!• Problems are not repeated  – Reduce rework, retes...
When should root cause                       analysis be performed?              When PROBLEMS occur !!Dr Rovel Shacklefor...
How does it differ from what we do                                         now?                           USUAL APPROACH  ...
Money Talks     State the problem in terms of                dollars!• Determine how much each occurrence of theproblem co...
How does it work?Defect found at “Customer”…PROCESS           PROCESS       PROCESS        PROCESS   A                 B  ...
How does it work?Contain the problem…PROCESS           PROCESS    PROCESS        PROCESS   A                 B          C ...
How does it work?Contain the root process…PROCESS           PROCESS    PROCESS        PROCESS   A                 B       ...
How does it work?Prevent the problem…PROCESS           PROCESS    PROCESS        PROCESS   A                 B          C ...
Corrective Actions3 types of Corrective Action:Immediate action   – The action taken to quickly fix the impact of the prob...
ApproachesI have been conducting investigations of power station (andother industry) incidents for many years and, through...
Examples of Corrective ActionsImmediate                (step #3) All current batch of paperwork re-inspected by another wo...
Examples of Corrective ActionsImmediate                (step #3) Part removed and replaced in product, retested Permanent ...
The Difference between                                     Permanent vs. Preventive Corrective                            ...
Problem Solving Process                                      1                                   Identify                 ...
1                      8                                                            Step #1                               ...
1                      8                                                                 Step #1                          ...
1                      8                                                     Step #2                               2      ...
1                           8                                                           Step #2                           ...
1                      8                                                  Step #2                               2         ...
1                         8                                                      Step #3                                  ...
1                      8                                                   Step #3                               2        ...
1                      8                                                           Step #4                               2...
1                       8                                                      Step #5                                2   ...
1                      8                                                      Step #5                               2     ...
1                       8                                                   Step #6                                2      ...
1                      8                                                      Step #7                               2     ...
1                      8                                                  Step #8                               2         ...
Manufacturing          Root Cause Analysis              Example #1Dr Rovel Shackleford   33                              R...
1                  8                                          Example #1                           2              7       ...
Determine TeamTeam members:Team Leader – TerryInspector – JaneWorker – TammyWorker - JoeQuality Eng – RobEngineer – Sally ...
Immediate Action• Additional inspection added after this  assembly process step to check for  reversed part defects• Last ...
Root Cause                          Part reversed                   Why?Dr Rovel Shackleford                      37      ...
Root Cause                          Part reversed            Worker not sure of correct part orientation                  ...
Root Cause                              Part reversed            Worker not sure of correct part orientation              ...
Root Cause                             Part reversed            Worker not sure of correct part orientation               ...
Root Cause                             Part reversed            Worker not sure of correct part orientation               ...
Corrective ActionPermanent       – Changed part to one that can only be placed in correct direction (Mistake proofed). Fou...
Transactional          Root Cause Analysis              Example #2Dr Rovel Shackleford   43                             Ro...
1                     8                                            Example #2                              2              ...
1                     8                                           Determine Team                              2           ...
Immediate Action• Additional resources applied to help  get the project team back on schedule• No new projects started unt...
Root Cause                   Didn’t complete project on time                   Why?Dr Rovel Shackleford                   ...
Cause and Effect      Procedures                            Personnel                                                     ...
Cause and Effect      Procedures                            Personnel                                                     ...
Root Cause                   Didn’t complete project on time               Resources unavailable when needed              ...
Root Cause                   Didn’t complete project on time               Resources unavailable when needed              ...
Root Cause                   Didn’t complete project on time               Resources unavailable when needed              ...
Root Cause                   Didn’t complete project on time               Resources unavailable when needed              ...
Corrective ActionPermanent – Hired another worker to meet needs of next project teamPreventive - Developed checklist form ...
Hints about root causes• One problem may have more than one  root cause• One root cause may be contributing to  many probl...
ReviewYou learned:• How to identify the root cause• Why it is important• The process for proper root cause  analysis• How ...
Additional Resources                Power Industry Solutions                       http://www.optec.com.au                ...
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Root cause-analysis-course by Dr Rovel Shackleford of Arrina Global

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Root cause-analysis-course by Dr Rovel Shackleford of Arrina Global

  1. 1. Root Cause Analysis An IntroductionDr Rovel Shackleford 1 Root Cause Analysis
  2. 2. Course Content• Objectives• What is Root Cause?• Benefits & the Hurdles• Problem Solving Process• Examples• Root Cause “Tips & Traps”• Review• Additional Resources Dr Rovel Shackleford 2 Root Cause Analysis
  3. 3. Course ObjectivesUpon completion of this (abridged) course, participants should be able to:• Understand the importance of performing root cause analysis• Identify the root cause of a problem using the problem solving process• Understand the application of basic RCA tools in the problem solving process Dr Rovel Shackleford 3 Root Cause Analysis
  4. 4. What is root cause?ROOT CAUSE =• The causal or contributing factors that, if corrected, would prevent recurrence of the identified problem• The “factor” that caused a a problem or defect and should be permanently eliminated through process improvement• The factor that sets in motion the cause and effect chain that creates a problem• The “true” reason that contributed to the creation of a problem, defect, failure or nonconformance Dr Rovel Shackleford 4 Root Cause Analysis
  5. 5. What is root cause analysis?• A standard process of: 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 problem Dr Rovel Shackleford 5 Root Cause Analysis
  6. 6. BenefitsBy 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 profits $$ Less rework = Increased profits! $$ Dr Rovel Shackleford 6 Root Cause Analysis
  7. 7. When should root cause analysis be performed? When PROBLEMS occur !!Dr Rovel Shackleford 7 Root Cause Analysis
  8. 8. How does it differ from what we do now? USUAL APPROACH Firefighting! Problem Problem Immediate Containment reoccurs Identified Action Implemented elsewhere! PREFERRED APPROACH Immediate Defined Solutions are Solutions Problem Containment Root Cause applied across validatedIdentified Action Analysis company and with data Implemented Process never return! Dr Rovel Shackleford 8 Root Cause Analysis
  9. 9. Money Talks State the problem in terms of dollars!• Determine how much each occurrence of theproblem costs the company• $$$ speaks the language of management• Justifies any spending on root cause analysisand corrective actions• Prioritizes financial impact of problems Dr Rovel Shackleford 9 Root Cause Analysis
  10. 10. How does it work?Defect found at “Customer”…PROCESS PROCESS PROCESS PROCESS A B C D CUSTOMER “Customer” can be Internal or External Dr Rovel Shackleford 10 Root Cause Analysis
  11. 11. How does it work?Contain the problem…PROCESS PROCESS PROCESS PROCESS A B C D CUSTOMER Nothing is allowed to further escape to the customer Dr Rovel Shackleford 11 Root Cause Analysis
  12. 12. How does it work?Contain the root process…PROCESS PROCESS PROCESS PROCESS A B C D CUSTOMER Nothing is allowed to further escape to the next process Dr Rovel Shackleford 12 Root Cause Analysis
  13. 13. How does it work?Prevent the problem…PROCESS PROCESS PROCESS PROCESS A B C D CUSTOMER Corrective action implemented so root cause of problem does not occur again! Dr Rovel Shackleford 13 Root Cause Analysis
  14. 14. Corrective Actions3 types of Corrective Action:Immediate action – The action taken to quickly fix the impact of the problem so the “customer” is not further impactedPermanent root cause corrective action – The action taken to eliminate the error on the affected processPreventive (Systemic) root cause corrective action – The action taken to Prevent the error from recurring on any process Dr Rovel Shackleford 14 Root Cause Analysis
  15. 15. ApproachesI have been conducting investigations of power station (andother industry) incidents for many years and, through trialand error, developed my own system of investigation thatinvolved RCA (though I never realized that this was a formalprocedure when I was originally using it). I have found that itdoesn’t always matter whether a problem has beencorrectly identified or not, provided that you start with aknown factual situation. This can then be built upon, bothupstream and downstream. In this instance the startingpoint was #1 boiler trip. I have not shown how theinvestigation was conducted as that is not part of thisexercise. It took some time to complete and even longer totake corrective action. This is an important point toemphasize. (Bob Ellis Feb 2008) Dr Rovel Shackleford 15 Root Cause Analysis
  16. 16. Examples of Corrective ActionsImmediate (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” If preventive not addressed, problem will return!! Dr Rovel Shackleford 16 Root Cause Analysis
  17. 17. Examples of Corrective ActionsImmediate (step #3) Part removed and replaced in product, retested Permanent (step #5) Product redesigned to account for part variability Preventive (step #5) Design process changed to require variation analysis testing on similar supplier parts If preventive not addressed, problem will return!! Dr Rovel Shackleford 17 Root Cause Analysis
  18. 18. The Difference between Permanent vs. Preventive Corrective ActionsPermanent Preventive• Trained employee on proper machine use • Made training a requirement to new employees working in that area• Changed product design to make parts • Changed design guidelines to not allow easier to assemble manually for use of part in full scale production • All documents that are critical to project• Specific customer document critical to are identified with red folders project is identified with red folder• Update all customers with latest software • Check for those software bugs added to revision to fix problem checklist and performed prior to release of software• Fallen patient given full-time assistant to • Process developed to identify “at risk” provide help moving around hospital patients for falls who require assistant • Ethics training developed and provided• Employee fired for ethical violation to all employees Dr Rovel Shackleford 18 Root Cause Analysis
  19. 19. Problem Solving Process 1 Identify 8 Problem 2 Validate Identify Team 7 3 Problem Follow Up Immediate Plan Solving Action Process Complete Root Plan Cause Action 6 Plan 4 5Dr Rovel Shackleford 19 Root Cause Analysis
  20. 20. 1 8 Step #1 2 7 3 6 4 5 Identify the Problem Very important!•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? Dr Rovel Shackleford 20 Root Cause Analysis
  21. 21. 1 8 Step #1 2 7 3 6 4 5 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) andhow will the problem be corrected (corrective action)?How Many? Size and frequency of problem Dr Rovel Shackleford 21 Root Cause Analysis
  22. 22. 1 8 Step #2 2 7 3 6 4 5 Identify TeamWhen a problem cannot be solved quickly by anindividual, use a team!• Should consist of domain knowledge experts• Small group of people (4-10) with process andproduct knowledge, available time and authority tocorrect the problem• Must be empowered to “change the rules”• Should have a designated Champion• Membership in team is always changing! Dr Rovel Shackleford 22 Root Cause Analysis
  23. 23. 1 8 Step #2 2 7 3 6 4 5 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 info – quiet for concentration and avoiding distractions Dr Rovel Shackleford 23 Root Cause Analysis
  24. 24. 1 8 Step #2 2 7 3 6 4 5 Roles and Responsibilities• Champion: Mentor, guide and direct teams,advocate to upper management• Leader: day-to-day authority, calls meetings,facilitation of team, reports to Champion• Record Keeper: Writes and publishes minutes• Participants: Respect all ideas, keep an open mind,know their role within team Dr Rovel Shackleford 24 Root Cause Analysis
  25. 25. 1 8 Step #3 2 7 3 6 4 5 Immediate Action• Must isolate effects of problem from customer• Usually “Band-aid” fixes – 100% sorting of parts – Re-inspection before shipping – Rework – Recall parts/documents from customer or from storage• Only temporary until corrective action isimplemented (very costly, but necessary)• Must also verify that immediate action is effective Dr Rovel Shackleford 25 Root Cause Analysis
  26. 26. 1 8 Step #3 2 7 3 6 4 5 Verify Immediate ActionImmediate 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 placeto prevent further impact to customer until permanentsolution is implemented. Dr Rovel Shackleford 26 Root Cause Analysis
  27. 27. 1 8 Step #4 2 7 3 6 4 5 Root Cause• Brainstorm possible causes of problem with team• Organize causes with Cause and Effect Diagram• “Pareto” the causes to identify those most likely oroccurring most often• Use 5 Why? method to further define the root causeof 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 address Dr Rovel Shackleford 27 Root Cause Analysis
  28. 28. 1 8 Step #5 2 7 3 6 4 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 actionwill be measured. – (Pareto charts, Paynter charts, check sheets, etc…) Dr Rovel Shackleford 28 Root Cause Analysis
  29. 29. 1 8 Step #5 2 7 3 6 4 5 Verification vs. Validation (Before) (After)• Verification – Assures that at a point in time, the action taken will actually do what is intended without causing another problem• Validation – Provides measurable evidence over time that the action taken worked properly, and problem has not recurred Dr Rovel Shackleford 29 Root Cause Analysis
  30. 30. 1 8 Step #6 2 7 3 6 4 5 Complete Action Plan• Make certain all actions that are defined arecompleted as planned• If one task is still open, verification and validation ispushed back• If the plan is compromised, most likely the solutionwill not be as effective Dr Rovel Shackleford 30 Root Cause Analysis
  31. 31. 1 8 Step #7 2 7 3 6 4 5 Follow Up Plan• What actions will be completed in the future toensure that the root cause has been eliminated bythis 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 determinethat the problem has not recurred? Dr Rovel Shackleford 31 Root Cause Analysis
  32. 32. 1 8 Step #8 2 7 3 6 4 5 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 correctiveaction in Step #5• If problem did not reoccur, celebrate team success!• Document savings to publicize team effort, obtaincustomer satisfaction and continued managementsupport of teams Dr Rovel Shackleford 32 Root Cause Analysis
  33. 33. Manufacturing Root Cause Analysis Example #1Dr Rovel Shackleford 33 Root Cause Analysis
  34. 34. 1 8 Example #1 2 7 3 6 4 5 Identify ProblemPart polarity reversed on circuit boardDr Rovel Shackleford 34 Root Cause Analysis
  35. 35. Determine TeamTeam members:Team Leader – TerryInspector – JaneWorker – TammyWorker - JoeQuality Eng – RobEngineer – Sally Dr Rovel Shackleford 35 Root Cause Analysis
  36. 36. Immediate 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 Dr Rovel Shackleford 36 Root Cause Analysis
  37. 37. Root Cause Part reversed Why?Dr Rovel Shackleford 37 Root Cause Analysis
  38. 38. Root Cause Part reversed Worker not sure of correct part orientation Why?Dr Rovel Shackleford 38 Root Cause Analysis
  39. 39. Root Cause Part reversed Worker not sure of correct part orientation Part is not marked properly Why?Dr Rovel Shackleford 39 Root Cause Analysis
  40. 40. Root Cause Part reversed Worker not sure of correct part orientation Part is not marked properly Engineering ordered it that way from vendor Why?Dr Rovel Shackleford 40 Root Cause Analysis
  41. 41. Root Cause Part reversed Worker not sure of correct part orientation Part is not marked properly Engineering ordered it that way from vendor Process didn’t account for possible manufacturing issuesDr Rovel Shackleford 41 Root Cause Analysis
  42. 42. Corrective ActionPermanent – 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. Dr Rovel Shackleford 42 Root Cause Analysis
  43. 43. Transactional Root Cause Analysis Example #2Dr Rovel Shackleford 43 Root Cause Analysis
  44. 44. 1 8 Example #2 2 7 3 6 4 5 Identify ProblemDepartment didn’t complete their project on time Dr Rovel Shackleford 44 Root Cause Analysis
  45. 45. 1 8 Determine Team 2 7 3 6 4 5Team members:Boss – JimWorker – TomWorker - KarenProject Mgr – BobAdmin – Sally Dr Rovel Shackleford 45 Root Cause Analysis
  46. 46. Immediate Action• Additional resources applied to help get the project team back on schedule• No new projects started until Root Cause Analysis completed Dr Rovel Shackleford 46 Root Cause Analysis
  47. 47. Root Cause Didn’t complete project on time Why?Dr Rovel Shackleford 47 Root Cause Analysis
  48. 48. Cause and Effect Procedures Personnel Lack of worker knowledgePoor project plan Poor project mgmt skills Lack of resources Didn’t complete project on time Inadequate Poor Inadequate computer documentation computer system programs Materials Equipment Dr Rovel Shackleford 48 Root Cause Analysis
  49. 49. Cause and Effect Procedures Personnel Lack of worker knowledgePoor project plan Poor project mgmt skills Lack of resources Didn’t complete project on time Inadequate Poor Inadequate computer documentation computer system programs Materials Equipment Dr Rovel Shackleford 49 Root Cause Analysis
  50. 50. Root Cause Didn’t complete project on time Resources unavailable when needed Why?Dr Rovel Shackleford 50 Root Cause Analysis
  51. 51. Root Cause Didn’t complete project on time Resources unavailable when needed Took too long to hire Project Manager Why?Dr Rovel Shackleford 51 Root Cause Analysis
  52. 52. Root Cause Didn’t complete project on time Resources unavailable when needed Took too long to hire Project Manager Lack of specifics given to Human Resources Dept Why?Dr Rovel Shackleford 52 Root Cause Analysis
  53. 53. Root Cause Didn’t complete project on time Resources unavailable when needed Took too long to hire Project Manager Lack of specifics given to Human Resources Dept No formal process for submitting job openingDr Rovel Shackleford 53 Root Cause Analysis
  54. 54. Corrective ActionPermanent – Hired another worker to meet needs of next project teamPreventive - Developed checklist form with HR for submitting job openings in the future Dr Rovel Shackleford 54 Root Cause Analysis
  55. 55. Hints about root causes• One problem may have more than one root cause• One root cause may be contributing to many problems• When the root cause is not addressed, expect the problem to reoccur• Prevention is the key! Dr Rovel Shackleford 55 Root Cause Analysis
  56. 56. ReviewYou learned:• How to identify the root cause• Why it is important• The process for proper root cause analysis• How basic quality tools can be applied to examples Dr Rovel Shackleford 56 Root Cause Analysis
  57. 57. Additional Resources Power Industry Solutions http://www.optec.com.au Arrina Global www.arrinaglobal.comDr Rovel Shackleford 57 Root Cause Analysis

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