1. Continuous Improvement
Learning Organization
ROOT CAUSE
SYSTEMS
PROCESSES
SYSTEMS
PROCESSES
ANALYSIS
and
Continuous
Improvement
1
2. Topics to be discussed
• What is Root Cause
Analysis?
• Tools and
Techniques
• Step-by-Step Root
Cause Analysis
• Corrective Action
Planning
2
3. Process Improvement Control System
Forecast
Forecast Monthly
Monthly
Action
Action Action
Action
Review
Review
Log
Log Log
Log
Meeting
Meeting
Process
Process
Master
Master
Schedule
Schedule
Daily
Daily Weekly
Weekly Weekly
Weekly Review
Review
Operating
Operating Meeting
Weekly Report Meeting
Report
Planning
Meeting
ACTION
1 2 3
Action
Daily
Daily Action
Weekly Short
Short Review Log
Weekly Interval Log
Process
Process Interval Meeting
Plan Control
Control
Plan
3
4. Action Log
Review at the beginning and end of every meeting Copy and distribute
to all attendees
before they leave
GKN Sinter Metals ACTION LOG
Meeting: Date: Sheet 1 of ___
Action Log completed by: Meeting attendees: Distribution: Attendees +:
Listed below are the issues discussed and actions agreed at the above meeting. The actions
assigned were committed to by the responsible parties. Relevant material presented or
reviewed is attached or referenced in the text.
# Issue Action Required / Status Responsible Date due Completed?
NEVER ASSIGN RESPONSIBILITY
TO SOMEONE WHO IS NOT AT THE
MEETING
4
6. Interruptions in Process Flow
Emergency
Unforeseen and unplanned or
uncontrolled quality defect or
stoppage of the process that will
adversely impact the delivery of
value to the customer. Requires
immediate, unscheduled response.
Waste and Improvement
Deterioration in process performance.
Responses can be planned and scheduled.
6
7. Achieving Breakthrough Results
SPORADIC
departure from
historic level
HISTORIC LEVEL
L
o The difference between the HISTORIC
s and OPTIMUM level represents a
tremendous cost savings
s
OPTIMUM LEVEL
time
7
8. What is “Failure”?
It no longer achieves a desired standard of
performance.
We fail to achieve our plan.
We fail to deliver value to
our customer.
8
9. If it’s not adding value it is...
is anything other than the minimum amount of
equipment, materials, parts, space and employee’s time which are
absolutely essential to add value to the product or service.
9
10. What is RCA?
Root Cause Analysis is a process of analyzing the
cause-effect relationships between events.
DATA
ACTION ANALYSIS
DECISION
It aims to identify and separate symptoms from the true cause of a
problem, and to identify the actions necessary
to ELIMINATE it.
10
11. Step-by-Step Root Cause Analysis
1. FORM / CONVENE THE TEAM
2. GATHER EXPERTS
3. INVESTIGATE AND GATHER DATA
4. DETERMINE SEQUENCE OF EVENTS
5. AGREE ON THE EFFECTS
6. SEVERITY-OCCURRENCE-DETECTION RANKING
7. CAUSE AND EFFECT DIAGRAM (Fishbone, Mind map)
8. DEVELOP CORRECTIVE ACTION PLAN AND TIMETABLE.
ASSIGN RESPONSIBILITY
9. FOLLOW UP FOR COMPLETION OF ACTIONS
10. EVALUATE EFFECTIVENESS OF ACTIONS
11
12. 1. Form the Team
• Appoint an RCA facilitator and Team
Leader. Facilitator has been trained on
leading an RCA. Team leader has the
content expertise pertaining to the event.
• Team Leader and Facilitator meet and
identify data to be gathered and who
should be on the team for this particular
analysis.
• Select meeting date, time and place and
inform members.
• Ask team members to bring data and a
draft of the sequence of events.
12
13. 2. Gather Experts
• Decide who should help determine the root
cause in addition to the standing team.
• Operators, supervisors, anyone who has
knowledge of the specific event.
• Experts who may not have “been there” but
who have relevant experience are valuable
resources, including manufacturers reps and
contractors.
13
14. 3. Investigate and Gather Data
•As soon as possible after the event, collect
information, including control charts,
operator notes, gage readings, data forms.
Try to get data before, during and after the
event.
• Interview operators, supervisors and
anyone who may have information about
what happened. Ask questions about what
they saw and heard.
• WHO, WHAT, WHERE, AND WHEN
14
15. THE SEVEN QC
TOOLS
RUN CHART HISTOGRAM CONTROL
CHARTS SCATTER DIAGRAM
10 10 UCL •
• • •
5 X VARIABLE •
5 2 •
• •
LCL • • •
0 0
TIME X VARIABLE
•
1
CAUSE AND
EFFECT FLOWCHART PARETO CHART
DIAGRAM
MACHINE MEASUREMENT 10
METHOD 5
MATERIALS MAN 0
TYPE
16. Pareto Chart
3.1 Line, 331 Work order data
Source: PMC work order data 10/09/00
Machine parts/subsystems with more than 1 work order Cumm %
10.9%
Machine part/subsystem No. WO's Machine part/subsystem No. WO's % of Ttl 21.2%
Load nest 3 Probe 17 10.9% 28.2%
Prox 16 Prox 16 10.3% 34.0%
Infeed gear box 1 Hydraulic 11 7.1% 39.7%
Elec 3 Bushing 9 5.8% 44.9%
Pivot stop 1 Clamps 9 5.8% 49.4%
Sealtite connector 1 Swing clamp 8 5.1% 53.2%
Program 3 Sideclamp 7 4.5% 57.1%
Cylinders 1 Switch 6 3.8% 60.3%
Hydraulic 11 Hardstop 6 3.8% 62.8%
Valve 3 Split nuts 5 3.2% 64.7%
66.7%
68.6%
3.1 Line-Work Order Pareto 70.5%
% of total Work
12.0%
72.4%
74.4%
10.0% 76.3%
Orders
8.0% 78.2%
80.1%
6.0%
4.0%
2.0%
0.0%
m
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or
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ey
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ot
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ob
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El
K
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be
M
Pr
la
ec
V
yd
pr
ar
C
Lu
id
H
H
o
S
N
Subsystem/Machine Part
16
17. 4. Determine The Sequence of Events
1. • Develop a clear picture of what happened first,
second, third, etc.
2. • Don’t try to determine root cause at this stage,
just get the sequence of events right.
3. • Don’t “Rush to Judgement”. The obvious may
not be the right answer.
17
18. 5. Agree On The Effects
Use the results of the investigation and
sequence of events
• Brainstorm any other possibilities
• Rank the effects using
• Severity
• Occurrence
• Detection
18
19. 7. Cause and Effect Diagram
AKA: Ishikawa or Fishbone Diagrams
CAUSES EFFECT
Manpower
Method
Last Minute
rush to build
Material Machinery
19
20. WHAT IS A CAUSE & EFFECT DIAGRAM ?
• Also known as a “Fishbone” (Ishikawa diagram) or Mind Map
• Shows the relationship between the Effect / Problem & possible
causes.
• Helps to differentiate between symptoms and primary causes
• A problem / effect can have several causes. These can be
identified and categorized.
• Often emerges out of a Brainstorming session
• A primary tool for Root Cause Determination
20
21. FISHBONE DIAGRAM
THE EFFECT
• Represented by the HEAD of the skeleton
• The Effect should be stated in simple terms.
• General Effects should be broken down into more specific Effects.
THE CAUSES
• Represented by the RIBS of the skeleton.
• Use the “4M’s” / “4P’s” or others to
categorize the causes.
• Add the causes to the rib.
• Add further riblets to show relationships between causes.
21
22. CAUSE & EFFECT DIAGRAM reminders
The 4 ‘s The 4 ‘s
anpower ersonnel
achinery lant
aterials olicies
ethods rocedures
22
23. Cause & Effect Diagrams
HOW TO CONSTRUCT A CAUSE & EFFECT DIAGRAM
• STEP 1: Agree on one statement that
describes the selected problem
• STEP 2: Generate the causes needed to build
up the problem
• STEP 3: Construct the diagram
• STEP 4: Interpretation
23
24. Cause & Effect Diagrams
FISHBONE DIAGRAM
CAUSES EFFECT
Manpower
Method
Build on
Rush To
Complete
Material Machinery
24
25. FISHBONE DIAGRAM - DAILY EXAMPLE
METHODS MACHINERY
No record
Use wrong gears tire pressure
Drive Fuel mix too
too rich Under-inflated tires
fast Poor hearing
Mech. doesn’t
Radio too loud have specs Poor design
Always
late
POOR
Can’t hear engine Carburetor Difficult air valve GAS
Impatience adjustment stems MILEAGE
Poor training Wrong gas No oil change
Poor type
maintenance
$
No owner’s
$ “When in Rome” manual
Improper
No awareness lubrication
Don’t know Don’t know right oil
recommended
Poor driving petrol type Wrong oil
No owner’s manual
habits
MANPOWER MATERIALS
25
26. Mind-mapping
What is it?
What value does it
have?
Where can it be used?
26
27. Mind Mapping
An unstructured / creative tool
Is an advanced form of Cause and Effect
METHOD MANPOWER
Rules of Mind Mapping
No Operator
Wrong start
g
procedure
nin
al
u
lan
an
Lost
rm
p
Use a brainstorming base
or
Mowe
•
Op
Po
No es
r
fil
No
Lazy
won’t
start
• Centralize the theme Pull rope broken
Gas tank empty
Di
Fouled spark plugs
pe
dn
g
ro
’t
nin
ive
Don’t question or judge
ch
•
lea
ec
ct
fe
k
rc
De
la
gu
MATERIAL MACHINERY
re
• Revisit the tool
No
• As many input sources as possible
27
28. 6. Ranking the Causes
MIND MAP
Process Name_______________________________
Severity
Cause
• Occurrence
Ca
us • Detection
e
Risk Priority No. =
Effect
(Severity) X
(Occurrence) X
(Detection)
Subsystem / Part Severity Occurrence Detection RPN
28
29. SEVERITY EVALUATION CRITERIA
5 Very High Process Problem affects Quality of the Output
4 High Process Problem will likely impact the Quality of
the Output
3 Moderate Process Problem may impact the Quality of the Output
2 Low Subsystem partially fails with a slight impact on quality
performance
1 Minor Potential failure mode has no real affect on quality
performance
29
30. OCCURRENCE EVALUATION CRITERIA
Probability Frequency
5 Very High Failure is certain 1 Daily or every
unit
4 High Failure is highly likely 1 Weekly
3 Moderate Occasional failure 1 Monthly
2 Low Failure not likely 1 Quarterly
1 Remote No failures recorded 1 Annual
30
31. Process Control Detection Criteria
5 Can not detect will not detect that the failure is occurring or will occur
4 Low have a poor chance of detecting the failure
3 Moderate may detect the failure
2 High have a good chance of detecting the failure
1 Very High will almost certainly detect the failure
Risk Priority Number = Severity X Occurrence X Detection
31
32. GUIDELINES-Fish bones and Mind Maps
1. Make sure that everyone agrees completely on the problem
statement
2. Construct carefully to achieve the best result
3. Do not be afraid to spread the diagram out.
4. Avoid using too many ideas under one main cause
5. If the problem is too complex, draw more than one diagram
6. Keep it simple
7. Ranking using Severity-Occurrence-Detection
8. Keep asking....WHY ?…5 times!!!!!
?
32
34. CAUSE AND EFFECT DIAGRAM
METHOD MANPOWER
CAUSES EFFECT
No Operator
Wrong start procedure
Manpower
ng
l
Method
ua
ni
Lost
an
an
pl
rm
or
PO5 STOPS
No
Op
Po
Solenoid valve Mower
file
Lazy
No
gone won’t
s
start
Gas tank empty
Material Pull rope broken
Machinery
Di
Fouled spark plugs
dn
pe
’t
ro
ch
g
nin
ive
ec
k
ct
lea
fe
rc
De
la
gu
MATERIAL MACHINERY
re
No
KEEPING RECORDS
Keep copies of the Cause & Effect diagrams.
They can be used if a similar problem arises in the future.
34
35. 8. DEVELOP CORRECTIVE ACTION PLAN
Recommended Corrective Action-Operations Who? When?
Root Cause Analysis (RCA) Log
Prepared By Date
Maint Supv
RCA No.
ANALYSIS Recommended Corrective Action-Maintenance Who? When?
Problem Description:
What events lead to the above stated problem?
Recommended Corrective Action-Engineering Who? When?
Long term Analysis Assignment Who? When?
Ask Why 5 Times!
Why:
Why:
SIGNOFF:
Why:
Why:
Maintenance Supv. Production Engineer Production Superintendent
Why:
35
36. 9. Follow up on Completion
CORRECTIVE ACTION LOG
RCA No. Date:
Corrective Action Date
No. Date Location Equip/ Resp Due Detailed Description Compltd?
36
37. Human Error
“Errors must be accepted as System
flaws,not character flaws.” L. Leape
The Root Cause of many failures may involve
human error:
• Poor training
• Fatigue
Don’t be afraid to identify Human error as a root cause.
Errors can be addressed positively.
Enter corrective actions involving Human Error in the Corrective
Action Log and complete them with the same urgency as other
“mechanical” corrective actions.
37
38. Evaluate Effectiveness Of Corrective Actions
•After corrective actions
are in place, evaluate
failure history again. Look
at the data!
• Recalculate S.O.D. and
compare with original
number
• Implement additional
corrective actions as
necessary
38
39. WHIDTMSIWNHA
What It
Will
Have
Never
I Happen
Done Again
To
Make
Sure
39
40. Processes, Systems and the Tools Will Empower
the Organization to Make It All Happen
Corrective Action Log CORRECTIVE ACTION LOG
RCA No. Date:
Corrective Action Date
No. Date Location Equip/ Resp Due Detailed Description Compltd?
DATA
Control
the
S
ACTION
whole...
E MANALYSIS
S T
S Y ...by
controlling
the parts
DECISION
40
Editor's Notes
SYSTEMS and PROCESS are the pillars of continuous improvement. SYSTEMS drive all improvement. PROCESS everything can be mapped as a process flow (HR, Customer Service) To be effective a process flow must reflect the “real life flow” of what happens. By identifying what actually is being done improvement can be made. Only those who are involved know what actually happens on a day to day basis. Can’t really problem solve until the process flow is defined. In a LEARNING ORGANIZATION there is degree of empowerment - so that people doing the work - the experts - are the ones from whom information is sought.. The old Boss/subordinate system is replaced with with a new system that solicits everyone's input.
AGENDA Recommended reading: Systems Thinking Peter Synge SPC for the Rest of Us - Root Cause Analysis - Quality Planning and Analysis - Juran & Gryna
Based on Demings’ PDCA 1. The Daily Plan Establish standards for process without waste. Determine how long before the process can run to this standard before it is out of control Determine what the process is suppose to be and compare this to what it actually is. Use examples from your own experiences When you talk about the process real time it is CONTROL - afterward it is an EXCUSE. 2. REVIEW MEETING - What do we do to make sure this never happens again? 3. ACTION LOG - What action has been taken? What still needs to be done. Who is going to do it?
Record both ACTION and ISSUES. Issues may not be resolved by the action taken.
This is a good opportunity to discuss the LEAN philosophy to control waste.
This is another good opportunity to draw on your personal experiences and relate EMERGENCY back to your audience. Use product or processes that they are familiar with.
This is a good chart to help people visualize the difference - the way they usually do things and how they could be doing them. Describe that determining the ROOT CAUSE of why is the catalyst to improvement. This chart can be use to create a dialogue between you and your audience about their particular functions. This can be a hunt to identify the frustrated and angry. They can lead you to more problems to solve.
The above definition of waste has become widely accepted as a main driver of the change process and LEAN Manufacturing. It states that the MINIMUM amount of resources should be used for each and every task throughout the company. Waste is everywhere and its elimination brings massive cost benefits. To create a dialogue with your audience ask for some examples of waste in their areas.
This is another example of Demings’ PDCA in action. Discuss that many time in an improvement process only certain elements are used resulting in continuous fire fighting rather than continuous improvement. Collecting DATA and Analyzing it without making a DECISION or taking ACTION does not improve the process. Collecting DATA, ANANLYZING that Data, making a DECISION,taking ACTION on the DECISION - then starting over again is the way to make incremental corrections to continually improve the way things are done at Sunrise Medical.
Everyone one on the team is a problem solver. The Facilitator and Team leader may be the same person - but whoever is appointed should be somewhat removed form the situation to maintain perspective. The main objective of the LEAD is to keep the team focused on the problem. The LEAD and FACILITATOR decide who should be on the team and what experts are required to solve problems. Publish an AGENDA ahead of time. Establish an environment to achieve the greatest discretionary effort from each individual.
It is KEY to identify the experts that should be on the team. Groups tend not to bring in experts and want to solve problems themselves. As a rule nobody does anything wrong because they want to do something wrong…it is generally the process
This is another good time for you to bring in examples from your experience where a SPORADIC EVENT caused a major quality problem and tie you experiences in with how you investigated and gathered data.
1. Put things in a logical order - from start to finish - assure the order. This process is critical to ROOT CAUSE or you are dealing with symptoms. Don’t rush to judgement. Going through the process will provide valuable insights.
Separate cause from effect and get it all on paper.
The tendency is to grab hold of too large a problem - when that happens divide the problem. One suggestion is to start each session with a little training session to describe the intentions of the meeting and the expected outcomes. This assures that people know what to do and how to do it in each problem solving session. Be comfortable with silence. Learn to wait through the silence as people process information. The tendency is to start fixing. Remember in this situation there is no waste in process.
It is critical to agree and get consensus on STEP 1.
Get down every possible cause for the problem. Record jokes also…even if the finger is pointed at the Supervisor or another person. Things said in jest are often subconscious causes of the problem. Feelings are magical in that they identify things the brain hasn’t integrated.
When people have had allot of exposure to brainstorming - mind mapping can be another alternative to approach creative solutions to problems.
There is always the tendency not to establish the Risk priority. Ranking is very important to identify biggest problems. Ranking systems occurs on the following page.
Is the occurrence SPORADIC or CHRONIC? Walk your class through this ranking to identify frequency.
Use this formula for every problem identified on the FISHBONE to establish priority.
Give an example from your experience of how this has helped.
Keep your information - don’t throw it away - odds are you will not solve all of your problems the first time you use the CAUSE & EFFECT DIAGRAM.
S.O.D. Severity of Occurrence Detection
Without systems in place the process will drift away!