Corrective Action And Root Cause Analysis


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Here is a simple presentation on the basics of a corrective action system

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  • You’ve been there. The contractor calls, screaming “You’re vault is leaking!” What went wrong? Who’s at fault? There’s a lot of questions to answer, and people to point a finger to. But right now, you just have to get this leak fixed, no matter what it takes.
  • So you fix it; you fix the problem that is. You but a bans-aid on the symptoms to satisfy the customer. And now that the leak has been plugged, you forget about the problem all together.
  • Nonconformances occur frequently in our lives. You order a sandwich at McDonnalds and ask for no Ketchup, only to discover that the request was not fulfilled. The new cell phone you just purchased doesn’t have good reception. Your new car makes a noise when you turn corners. Our lives are filled with nonconformances in products we use all the time. Mistakes happen; we are all human. It is how we respond to our mistakes that sets World Class companies apart from the rest. If we learn from our experience and make the necessary adjustments to our process, we will provide better service, or a better product the next time.How good is 99.9%?- 12 newborns will be given to the wrong parents daily.- 18,322 pieces of mail will be mishandled every hour. Three planes will miss their landing at the Atlanta airport every day. 20,000 incorrect drug prescriptions will be written each year. 291 pacemaker operations will be performed incorrectly.
  • The traditional way of solving problems is to just fix it. There is no time to find out what caused the problem.
  • Corrective Action And Root Cause Analysis

    1. 1. Corrective Action and Root Cause Analysis By Sam Lines, Concrete Sealants
    2. 2. Agenda Overview • Nonconformances • Corrective Action Process • Root Cause Analysis • Cost of quality
    3. 3. Opener LEAKING JOINT
    4. 4. Opener PROBLEM SOLVED! RIGHT?
    6. 6. Nonconformances • What are non-conformances? – Product does not match specification • Discovered by inspection – Pre-pour – Post pour – Final • Discovered by an external source – NPCA Plant Certification Audit – DOT Inspector • Discovered by the customer – Product’s form, fit, or function has been altered
    7. 7. Bad Forms = Bad Product
    8. 8. Enough Steel?
    9. 9. Leaking at Honeycomb
    10. 10. Poor Consolidation?
    11. 11. Insufficient Cover Reba r
    12. 12. Where’s My Hammer?
    13. 13. Nonconformances • Formwork • Concrete • Blockouts and cast in items • Drawings • Sales Order • Other?
    14. 14. Nonconformances • Material from supplier – Incoming inspection – Setup and installation – Mill Certificates • Traceability Question: What products might contain material from nonconforming lot? Do you know?
    15. 15. Nonconformances • Where is the product? • Is the product quarantined? • Are any other products affected? • Are bad products still being produced? • Were nonconforming products shipped? Don’t spend your time determining who was at fault.
    16. 16. Now, let’s solve the problem.
    17. 17. Traditional Problem Solving YES NO Is It Working? Don’t Mess With It! YES Did You Mess YOU IDIOT! With It? NO YES You’re SCREWED! Anyone Else Knows? NO Look The Other Way NO Can You Blame Hide It Someone Else? Yes NO PROBLEM!
    18. 18. The Traditional Way Event (Problem) Form Team Identify Problem Gather Data Analyze Data Determine Causes Determine Corrective Action Implement (fix It)
    19. 19. A Better Way: The Corrective Action Process
    20. 20. Corrective Action Process • What is it? • Why is it needed? • When is it used? • Who performs it? • How is it performed? • What documentation is needed? • Correction vs. Corrective Action
    21. 21. Corrective Action Process THE STEPS WITHIN THE PROCESS
    22. 22. Corrective Action Process • Problem Identification – Who, what, where, when, why, and how – Is the problem isolated? • Problems with significant risk need corrective action – Has this happened before? Recently? STEP 1 • Reoccurring problems need corrective action – Use statistics to evaluate trends • Trends will show a process which is out of control where corrective action is needed • Document the corrective action on a form. • Assign responsibility for the activity. • Track corrective actions using a master list.
    23. 23. Document the Problem
    24. 24. Corrective Action Process • Short term remedy (immediate fix) – Repair product – Quarantine bad product(s) STEP 2 – Stop producing bad product – Evaluate extent of problem – Has any bad product been shipped? – Notify customers as necessary
    25. 25. Corrective Action Process • Root Cause Analysis – A process of determining what underlying cause or causes are responsible STEP 3 – Tools: We will learn more about how to perform a root cause analysis in • Fishbone Diagram later slides. • 5 Whys • Flowchart • Pareto Diagram – Document the Analysis
    26. 26. Corrective Action Process • Implementation of the action – Eliminate root cause • Training • STEP 4 Procedures • Work instructions • Visual indicators • Mistake proof – Document actions taken – Evaluate the effectiveness of the actions
    27. 27. Corrective Action Process ROOT CAUSE ANALYSIS
    28. 28. Definition • What is root cause analysis? “Root cause analysis is the process of defining all of the major and minor causation factors, and then determining the one or ones that, if eliminated, would prevent a future nonconformance.”
    29. 29. The Problem Solving Funnel
    30. 30. Tools • Cause and Effect Diagram, Ishikawa Diagram, Fishbone Diagram
    31. 31. Why is my toast burnt? • Effect: Burnt Toast • Main Cause Categories: – People – Equipment – Methods – Materials
    32. 32. People • I don’t usually make the toast – My wife is out of town – I was not trained on this toaster • My wife assumed I was smarter than the toaster – Assumptions are bad!
    33. 33. Equipment • The toaster is old – The toaster is full of bread crumbs • The toaster is not maintained – I didn’t know it mattered – My wife wasn’t complaining about it » She knows what she’s doing • The settings were changed – A different material was used last time – There are no instructions
    34. 34. Methods • There are no work instructions – I thought it seemed easy • I am smarter than a toaster – Re-evaluate my self worth • I didn’t adjust the settings – Don’t know what setting it should be • Lack of instructions
    35. 35. Materials • The bread is stale. – Didn’t use it fast enough • Not home for breakfast – Leave early for work » Working on a special project • The bread is thinner than usual – We change brands • Save money
    36. 36. Cause and Effect: Burnt Toast Equipment People I don’t usually Material is The toaster is old make the toast different Bad I didn’t know assumption it mattered My wife assumed I The settings She knows what was smarter than were changed she’s doing the toaster The toaster is full I was not No instructions of bread crumbs trained on this My wife hadn’t toaster complained Burnt Toast No instructions Thinner bread Didn’t Lack of change the Save Stale bread knowledge settings money Not home for Need No instructions breakfast training Leave early Don’t know what Changed Thought it was easy for work setting to use brand Special project Didn’t use it fast Methods Materials enough
    37. 37. 5 Why’s • Ask “Why” 5 times • Best used when people are involved • Great for auditing a process to gain understanding • Can be 4 or 6 why’s Why?
    38. 38. 5 Why’s Problem Statement: You are on your way home from work and your engine dies. 1. Why did your engine die? - Because your car ran out of gas. 2. Why did your car run out of gas? - Because I didn't buy any gas on my way to work. 3. Why didn't you buy any gas this morning? - Because I didn't have any money. 4. Why didn't you have any money? - Because I lost it all last night in a poker game. 5. Why did you lose your money in last night's poker game? - Because I'm not very good at "bluffing“.
    39. 39. Solution • Good solution: Stop bluffing • Better solution: Set a dollar limit • Best solution: Stop playing poker for money
    40. 40. Other Problem Solving Tools • 8D Method – Developed by Ford in the 80’s • A3 Format – Uses A3 Size paper (11” x 17”) – Used extensively by Toyota • Process Cause and Effect – Follows the process to find out where mistakes can happen.
    41. 41. Example of an A3
    42. 42. Example of Process Cause and Effect What can What can What can go wrong go wrong go wrong Inputs Process Outputs What can What can What can go wrong go wrong go wrong
    43. 43. Eliminate the Root Cause • Implement action based on root cause analysis – Creation of instruction – Training of operator(s) • Verify effectiveness – Increase inspection (temporary or long term) – Create a metric for evaluation – Audit the process in 1, 3, and 6 months
    44. 44. Mistake Proofing – Poka yoke: the Japanese work for mistake proofing • Go / no-go gauge • Warning lights • Color coding – Proportionate to the risk and/or cost of a future failure
    45. 45. Examples of Poka-Yoke Lights and gauges Tethers and holders
    46. 46. Posted Signs and Instructions
    47. 47. • Stop lights • Spell Cheker • “Lights on” warning buzzer • “Auto-off” on coffee maker • Pictures and signs • Color coded bins and instructions
    48. 48. Poka Yoke Rules
    49. 49. Corrective Action Process THE VALUE OF QUALITY
    50. 50. “Quality is free. It’s not a gift, but it is free. What costs money are the unquality things – all the actions that involve not doing the job right the first time.” Phillip Crosby
    51. 51. Defect Escalation Cost COSTS $6,000 $5,000 $4,000 $3,000 COSTS $2,000 $1,000 $1,000 $1 $10 $100 $- Order Design Pre-pour Post-pour Delivery Entry Inspection Inspection
    52. 52. Cost of Quality Prevention Costs Appraisal Costs + Failure Costs Total Quality Costs
    53. 53. Cost of Quality Prevention Costs: The costs of all activities specifically designed to prevent poor quality in products or services. Examples: – New product review – Quality planning – Supplier capability surveys – Process capability evaluations – Quality improvement team activities – Quality improvement projects – Quality education and training
    54. 54. Cost of Quality Appraisal Costs: The costs associated with measuring, evaluating or auditing products or services to assure conformance to quality standards and performance requirements. Examples: – Incoming and source inspection/test of purchased material – In-process and final inspection/test – Product, process or service audits – Calibration of measuring and test equipment – Associated supplies and materials
    55. 55. Cost of Quality Failure Costs: The costs resulting from products or services not conforming to requirements or customer/user needs. • Internal Failure Costs: Failure costs occurring prior to delivery or shipment of the product, or the furnishing of a service, to the customer. Examples: – Scrap – Rework – Re-inspection – Re-testing – Material review – Downgrading
    56. 56. Cost of Quality • External Failure Costs: Failure costs occurring after delivery or shipment of the product; and during or after furnishing of a service to the customer. Examples: – Processing customer complaints – Customer returns – Warranty claims – Product recalls
    57. 57. Cost of Quality - Optimized High Total Cost of Quality Where you want to be Cost Minimum Cost of Quality Cost of Cost of Quality Service Defects Management Optimum Level of Service Quality Low Low High Quality
    58. 58. Cost of Quality – Trifecta Investment in a quality strategy will yield: – Lower defects – Reduce cycle time to delivery – Improve customer satisfaction – Higher employee morale
    59. 59. Value of Quality • Save 10% (or more) from: – Reduction of waste, scrap, and repairs – Less variability in processes – Less time fixing, more time producing – Reduced incoming material problems – Reduced overtime – Reduced warranty and service calls
    60. 60. Conclusion • A corrective action program is simple to implement and easy to use. • Eliminating the root cause is essential in preventing future nonconformances. • Preventing problems saves money.
    61. 61. Questions