Root Cause Analysis | RCA | Gaurav Singh Rajput

1. Root Cause Analysis (RCA)
A TPM Tool for a Learning Organization

2. Course Topics:
This course will cover the following topics:
Why-Why RCA Process
Role of Why-Why Analysis in TPM
Application of Why Why

3. Section 1
Why-Why Process

4. Causes of :Losses
Complex
combination
of causes
Problem
Multiple Causes -
Need
countermeasures
for each cause
Single Cause -
Easy to discover
& Address
cause
cause
cause cause
cause
cause
cause

5. Causes of Losses are Often Complicated :
Common Failure scenario:
1. Management system breakdown
2. Failure to implement counter-measures
3. Premature equipment failure
4. Employees fails to follow procedure
5. Failure to ID & Respond
6. Large Loss Results
Mgmt
breakdown
Equipment failure
Failure to Follow
procedure
Loss

6. The Loss Pyramid
AT RISK BEHAVIOR
Near Misses
First Aid
MT
R
LTA
PROCESS DEVIATIONS, SUB STD
CONDITIONS
On Hold / med. defect
Out of Spec / minor defect
Rework
Retrieval
Recall/ major
defect
Traditional
Programs
Measures
Reactions

7. TPM RCA is Proactive
Addresses the Underling Causes of Losses
• Why- Why identifies the Root Causes of Losses
• Supports Implementation of Countermeasures
• Promotes Transfer of Learning

8. Steps in Why - Why RCA
1. Identify the Problem
– observe, gather facts
2. Understand Ideal Situation
3. Identify & Understand the Phenomenon
- answer 5 W’s & 1 H of incident (what, when, where, who,
which, how severe)
4. Ask Why loss occurred...
– Consider both equipment & behavioral branches
– Ask successive Why for each branch
– ID Root Causes
5. Implement Countermeasures
6. Standardize (One Point Lesson)

9. Step 1 - Identify Problem
Exercise
Quantify
Loss

10. Step - 2 Understanding the Ideal Situation
Where analysis
involves equipment
and manufacturing
related matters
One needs to
understand equipment
functions, structures
and operational
principals
• Draw a equip sketch
of all parts and
locations of the related
subjects.
• Learn operational
principals
Where analysis
involves operational
matters
One needs to
understand flow of
work and what is
involved in each
situation
• Draw a work flow chart.
• Gather together and know
what forms and papers
there are to fill out
How does it Work?

11. Step - 3 Identifying the Phenomenon
Phenomenon Means:
• Observing the facts with
your own eyes & all senses
• The facts without
presumption
Complex
combination of
causes
Problem Phenomenon

12. Utilize 5W’s 1H When Identifying the Phenomenon
% / Piece
Status
How
How (many)
Direction (+) (-)
Trend
Which
Shift / Experience
Skill Level
Who
Part /Range
Location
Line/ Equipment
Process
Where
Start-up On Processing
Time / Period
Continuous Rate
Trend
When
Lots/Types
Material/ Prod No’s
What

13. Step 4 - Ask Why...? (Ask Successive Whys)
(Follow Phenomenon - Factor Relationship)
Phenomenon Factor (Why)
Phenomenon Factor (Why)
Phenomenon Factor (Why)
Phenomenon Factor (Why)
Phenomenon
CAUSE

14. Phenomenon
(1)
(2)
What triggered 1?
(1.1)
(1.2)
(1.1.1)
(1.1.2)
(1.2.1)
(1.2.2)
What triggered 1.1?
What triggered 1.2?
What triggered this phenomenon?
(2.1)
(2.2)
What triggered 2?
: Last “why’s”
(original sources of factors
that had led to phenomenon)
Why
Why
Why
Develop a Cause Tree to Order your Thinking

15. #1 Why?
#2 Why? #2 Why?
#3 Why?
#3 Why?
#4 Why?
1 2 5
4
3 6
Recommendations:
Root Cause Analysis - 5 Why
5 W 1 H
Plant (where):
Date (when):
Case / Injury (What):
Who:
Which:
How severe:
Behavioral Branch
Equipment Branch
#4 Why?
#5 Why?
Loss / Problem

16. Causes to Consider
• Improper Equipment Ordered
• Poorly Designed Equipment
• Inadequate Maintenance
• Wear & Tear
• Abuse or Misuse
Equipment Branch

17. • Lack of Procedures
• Inadequate Procedures
• Misunderstood Procedures
• Failure to Warn or Respond
Note: Large losses often occur because of failure to
take timely action
Procedural Branch
Causes to Consider

18. • Lack of Knowledge
• Lack of Skill
• Physically Incapable
• Lack of Motivation
Behavioral Branch
Causes to Consider

19. Why - Why Steps 1- 4 –
1. Identify Problem 2. Identify & Draw
Ideal Situation
3. Identify Phenomenon
What:
When:
Where:
Who:
Which:
How Many:
Phenomenon:
4. Follow Phenomenon-Factor
Relationship – Draw Cause
Tree (Ask Why?)
WHY 1?
WHY 2?
WHY 3?
WHY 4?
WHY 5?

20. Step 5 - Countermeasures
Last “Why’s” Countermeasures
Lack of lubrication
standards
Material strength is not
enough
Installation positions are
not clear
Prepare lubrication
standards
Strengthen
materials
Mark all positions where
things are to be installed

21. Step 6 - Standardize
After improving work methods or equipment, it is
important to standardize them to prevent people from
slipping back into old habits.
Typical standards include the following:
•Cleaning, Inspection and Lubrication Standards
•Maintenance Standards
•Education Standards (i.e. One Point Lessons)
•Engineering Standards