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1Determining Root Cause 1
Determining the Root
Cause of a Problem
Approved for Public Release
2Determining Root Cause 2
Why Determine Root Cause?
• Prevent problems from recurring
• Reduce possible injury to personne...
3Determining Root Cause 3
Look Beyond the Obvious
• Invariably, the root cause of a
problem is not the initial reaction
or...
4Determining Root Cause 4
Often the Stated Root Cause
is the Quick, but Incorrect Answer
For example, a normal response is...
5Determining Root Cause 5
Most Times Root Cause
Turns Out to be Much More
Such as:
• Process or program failure
• System o...
6Determining Root Cause 6
What is Root Cause Analysis?
Root Cause Analysis is an in-depth
process or technique for identif...
7Determining Root Cause 7
When Should Root Cause
Analysis be Performed?
• Significant or consequential events
• Repetitive...
8Determining Root Cause 8
How to Determine the Real
Root Cause?
• Assign the task to a person (team if necessary)
knowledg...
9Determining Root Cause 9
How to Determine the Real
Root Cause? (continued)
• Develop possible solutions
• Define and impl...
10Determining Root Cause 10
Useful Tools For
Determining Root Cause are:
• The “5 Whys”
• Pareto Analysis (Vital Few, Triv...
11Determining Root Cause 11
Example of Five Whys for Root
Cause Analysis
Problem - Flat Tire
• Why? Nails on garage floor
...
12Determining Root Cause 12
Pareto Analysis
Count 14 14 11 9 7 7 3 3 3 3162 2 2 1 513934 20 19 19 15 15
Percent 3 3 2 2 1 ...
13Determining Root Cause 13
Cause and Effect Diagram
(Fishbone/Ishikawa Diagrams)
EFFECT
CAUSES (METHODS) EFFECT (RESULTS)...
14Determining Root Cause 14
Cause and Effect Diagram
Loading My Computer
MAN/WOMAN METHODS
MATERIALS MACHINERY
OTHER
Canno...
15Determining Root Cause 15
Tree Diagram
Result Cause/Result Cause/Result Cause
Result Primary
Causes
Secondary
Causes
Ter...
16Determining Root Cause 16
Tree Diagram
Poor Safety
Performance
Stale/Tired
Approaches
Inappropriate
Behaviors
Lack of
Em...
17Determining Root Cause 17
Bench Marking
Benchmarking: What is it?
• "... benchmarking ...[is] ...'the process of identif...
18Determining Root Cause 18
Bench Marking
All process improvement efforts require a sound
methodology and implementation, ...
19Determining Root Cause 19
Common Errors of Root Cause
• Looking for a single cause- often 2 or 3
which contribute and ma...
20Determining Root Cause 20
Successful application of the
analysis and determination of
the Root Cause should result
in el...
21Determining Root Cause 21
Summary:
• Why determine Root Cause?
• What Is Root Cause Analysis?
• When Should Root Cause A...
22Determining Root Cause 22
Where Can I Learn More?
• “Solving a Problem & Getting Along: Toward the Effective Root Cause
...
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root cause analyse

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root cause analyse

  1. 1. 1Determining Root Cause 1 Determining the Root Cause of a Problem Approved for Public Release
  2. 2. 2Determining Root Cause 2 Why Determine Root Cause? • Prevent problems from recurring • Reduce possible injury to personnel • Reduce rework and scrap • Increase competitiveness • Promote happy customers and stockholders • Ultimately, reduce cost and save money Approved for Public Release
  3. 3. 3Determining Root Cause 3 Look Beyond the Obvious • Invariably, the root cause of a problem is not the initial reaction or response. • It is not just restating the Finding Approved for Public Release
  4. 4. 4Determining Root Cause 4 Often the Stated Root Cause is the Quick, but Incorrect Answer For example, a normal response is: •Equipment Failure •Human Error Initial response is usually the symptom, not the root cause of the problem. This is why Root Cause Analysis is a very useful and productive tool. Approved for Public Release
  5. 5. 5Determining Root Cause 5 Most Times Root Cause Turns Out to be Much More Such as: • Process or program failure • System or organization failure • Poorly written work instructions • Lack of training Approved for Public Release
  6. 6. 6Determining Root Cause 6 What is Root Cause Analysis? 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 individuals Approved for Public Release
  7. 7. 7Determining Root Cause 7 When Should Root Cause Analysis be Performed? • Significant or consequential events • Repetitive human errors are occurring during a specific process • Repetitive equipment failures associated with a specific process • Performance is generally below desired standard • May be SCAR or CPAR (NGNN) driven • Repetitive VIRs Approved for Public Release
  8. 8. 8Determining Root Cause 8 How to Determine the Real Root Cause? • Assign the task to a person (team if necessary) knowledgeable of the systems and processes involved • Define the problem • Collect and analyze facts and data • Develop theories and possible causes - there may be multiple causes that are interrelated • Systematically reduce the possible theories and possible causes using the facts Approved for Public Release
  9. 9. 9Determining Root Cause 9 How to Determine the Real Root Cause? (continued) • Develop possible solutions • Define and implement an action plan (e.g., improve communication, revise processes or procedures or work instructions, perform additional training, etc.) • Monitor and assess results of the action plan for appropriateness and effectiveness • Repeat analysis if problem persists- if it persists, did we get to the root cause? Approved for Public Release
  10. 10. 10Determining Root Cause 10 Useful Tools For Determining Root Cause are: • The “5 Whys” • Pareto Analysis (Vital Few, Trivial Many) • Brainstorming • Flow Charts / Process Mapping • Cause and Effect Diagram • Tree Diagram • Benchmarking (after Root Cause is found) Some tools are more complex than others Approved for Public Release
  11. 11. 11Determining Root Cause 11 Example of Five Whys for Root Cause 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 missing Approved for Public Release
  12. 12. 12Determining Root Cause 12 Pareto Analysis Count 14 14 11 9 7 7 3 3 3 3162 2 2 1 513934 20 19 19 15 15 Percent 3 3 2 2 1 1 1 1 1 132 0 0 0 127 7 4 4 4 3 3 Cum % 86 89 91 93 94 96 96 97 97 9832 98 99 991005966 70 74 78 80 83 Count Defect O ther EB D am aged Supplier Cleanliness EB M arking Supplier Rusted, Corroded EB Incorrect M aterial EB Docum entation EB D im ension Supplier M issing Parts ESD Packaging Supplier Lab Test Failure Supplier Shelf Life Exceeded Supplier W rong Configuration Supplier O ther W orkm anship Supplier Incorrect M aterial Supplier D am aged Packaging Supplier D im ensions EB O ther Supplier Docum entation Supplier M arking 180 160 140 120 100 80 60 40 20 0 Supplier Material Rejections May 06 to May 07 Vital Few Trivial Many 60 % of Material Rejections Approved for Public Release
  13. 13. 13Determining Root Cause 13 Cause and Effect Diagram (Fishbone/Ishikawa Diagrams) EFFECT CAUSES (METHODS) EFFECT (RESULTS) “Four M’s” Model MAN/WOMAN METHODS MATERIALS MACHINERY OTHER Approved for Public Release
  14. 14. 14Determining Root Cause 14 Cause and Effect Diagram Loading My Computer MAN/WOMAN METHODS MATERIALS MACHINERY OTHER Cannot Load Softwar e on PC Inserted CD Wrong Instructions are Wrong Upside Down Backward Not Enough Free Memory Inadequate System Graphics Card Incompatible Hard Disk Crashed Not Following Instructions Cannot Answer Prompt Question Brain Fade CD Missing Wrong Type CDBad CD Power Interruption Approved for Public Release
  15. 15. 15Determining Root Cause 15 Tree Diagram Result Cause/Result Cause/Result Cause Result Primary Causes Secondary Causes Tertiary Causes Approved for Public Release
  16. 16. 16Determining Root Cause 16 Tree Diagram Poor Safety Performance Stale/Tired Approaches Inappropriate Behaviors Lack of Employee Attention Lack of Models/ Benchmarks No Outside Input Research Not Funded No Money for Reference Materials No Funds for Classes No Consequences Infrequent Inspections Inadequate Training No Publicity Lack of Sr. Management Attention No Performance Reviews No Special Subject Classes Lack of Regular Safety Meetings Zero Written Safety Messages No Injury Cost Tracking Result Cause/Result Cause/Result Cause Approved for Public Release
  17. 17. 17Determining Root Cause 17 Bench Marking Benchmarking: What is it? • "... benchmarking ...[is] ...'the process of identifying, understanding, and adapting outstanding practices and processes from organizations anywhere in the world to help your organization improve its performance.'" —American Productivity & Quality Center • "... benchmarking ...[is]... an on-going outreach activity; the goal of the outreach is identification of best operating practices that, when implemented, produce superior performance." —Bogan and English, Benchmarking for Best Practices • Benchmark refers to a measure of best practice performance. Benchmarking refers to the search for the best practices that yields the benchmark performance, with emphasis on how you can apply the process to achieve superior results. Approved for Public Release
  18. 18. 18Determining Root Cause 18 Bench Marking All process improvement efforts require a sound methodology and implementation, and benchmarking is no different. You need to: • Identify benchmarking partners • Select a benchmarking approach • Gather information (research, surveys, benchmarking visits) • Distill the learning • Select ideas to implement • Pilot • Implement Approved for Public Release
  19. 19. 19Determining Root Cause 19 Common Errors of Root Cause • Looking for a single cause- often 2 or 3 which contribute and may be interacting • Ending analysis at a symptomatic cause • Assigning as the cause of the problem the “why” event that preceded the real cause Approved for Public Release
  20. 20. 20Determining Root Cause 20 Successful application of the analysis and determination of the Root Cause should result in elimination of the problem and create Happy Campers! Approved for Public Release
  21. 21. 21Determining Root Cause 21 Summary: • Why determine Root Cause? • What Is Root Cause Analysis? • When Should Root Cause Analysis be performed? • How to determine Root Cause • Useful Tools to Determine Root Cause 1. Five Whys 2. Pareto Analysis 3. Cause and Effect Diagram 4. Tree Diagram 5. Brainstorming • Common Errors of Root Cause • Where can I learn more? Approved for Public Release
  22. 22. 22Determining Root Cause 22 Where Can I Learn More? • “Solving a Problem & Getting Along: Toward the Effective Root Cause Analysis”, Khaimovich,1998. • “The Quality Freeway”, Goodman, 1990 • “Potential Failure Modes & Effects Analysis: A Business Perspective”, Hatty & Owens, 1994 • “In Search of Root Cause”, Dew, 1991 • “Solving Chronic Quality Problems”, Meyer, 1990 • “The Tools of Quality, Part II: Cause and Effect Diagrams”, Sarazen, 1990 • “Root Cause Analysis: A Tool for Total Quality Management”, Wilson, Dell & Anderson, 1993 Approved for Public Release

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