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CONTENT
•Why root-cause analysis?
•Problem Solving process flow
•Defect elimination
3. General Problem solving process
• Identify and record occurrences(repeated downtime,
major downtime)
• Describe the problem: break it down into sub-issues
(5W&H)
• Specify the point of cause in the process and describe
how the problem is detected(5WHY)
• Identify countermeasures to change current
condition(CORRECTIVE ACTION)
• Select highest value counter measure and create clear
action plan
• Validate the countermeasures and solutions identified
• Implement selected countermeasures and evaluate
progress
Root-cause
analysis
4. Develop countermeasures/
corrective actions
5. Implement and standardisation
of countermeasures
4. Why we need Root-cause analysis?
• Structured approach to solving issues.
• Deeper view off the issue
• Identify the origin of a particular issue
• Determine methods to eliminate reoccurrences.
@ Kriel
• We use root-cause analysis in our defect elimination process to
identify origins of any problems and eliminate possible
reoccurrences.
• Types of causes:
– Physical causes: tangible, material that failed
– Human causes: People doing something wrong
– Organisational causes: a system, process or policy
4
5. 1Problem statement
To compile a problem statement, you have to:-
•Define the problem
•Use the defined information to compile a problem statement
Artisan
3 STEPS TO QUALITY Why Analysis
3TAKE CORRECTIVE ACTION
To take corrective action, you have to:-
•Define the root cause of the problem.
•Use the Root Cause information and make recommendations to
prevent reoccurrence of the problem.
2ESTABLISH THE POSSIBLE CAUSES
Why analysis “Why?” has the problem occurred.
6. Problem statement
• What is the problem?
• Where does it occur?
• When did this become a problem?
• Who is affected by this problem?
• Why do we need to solve this
problem?
• How big of a problem is it?
6
7. Exercise: Develop a problem statement
• Example: Connie is late to soccer
practice in Secunda every Monday
afternoon by 30 minutes
• Write a problem statement
containing all the elements
regarding Connie’s situation.
• Outcome:
Flip chart with your problem
statement.
8.
9. Why Root Cause analysis?
• Typical reactions to issues are
short-cut solutions
• We are always fighting fires
• Do not use systematic methods to
eliminate the root-cause.
• Problems occur over and over and
over.
• We need to resolve the root-
cause.
11. INCORRECT / NO “corrective action”.
Panic
Mechanic
High maintenance costs.
Poor machine and equipment
availability and reliability.
Incorrect corrective action will
result in:-
Unhappy Manager
Unsafe machines and equipment.
12. CORRECT “corrective action”.
Good machine and equipment
availability and reliability
Safe Machines and Equipment.
Low Maintenance cost
High Availability
High reliability
Correct corrective action will
result in:-
Happy
Mechanic
Happy Manager
13. Step 1.
Problem Statement
5 Why ? (Example 1.)
Sizwe does not have his lock-out lock
on site when we have to change the
CM cable. This will lead to
unauthorized entry and the crew can
be injured in the process. This
happens occasionally.
Why?
Step2.Establishthepossiblecauses.
He does not
have a it on
him
Why?
He takes it
home with
him
Why?
He doe not
have a locker
at work
Why?
There is a shortage
of lockers in the
changehouse
Why?
Root Cause of problem
The supervisor
did not order
new lockers
Step 4.
Take corrective action
• Create space in the change house
• Search for so spare lockers elsewhere
• Order more lockers
Step 3.
Before taking corrective action, one needs to validate
that there is indeed a shortage of lockers in the
changehouse. Maybe people have four lockers instead
of the two or there are broken lockers.
14. Redesign machine or add guard to cover the
screen and prevent damage. If the seal was
merely replaced, it would have soon needed
repair again as the damage repeated itself.
Step 3.
Take corrective action
Step 1.
Problem Statement
5 Why ? (Example 2.)
Why?Punch machine No2 is leaking coolant on
the boilermaker workshop floor at all times.
Step2.
Establishthepossiblecauses.
Why?Coolant is leaking
from the radiator.
Why?A seal was damaged.
Why?Metal shavings got
into the coolant.
Why?A screen on a coolant recycling
pump was broken
Root Cause of problem
The screen is located in a place
where it was likely to be damaged
by dropped parts.
15. 5 Why ? (Example 3. Tree Diagram )
Step 1.
Problem Statement
5th
level WHY
4th
level WHY
s Step 3.
Take corrective action
Re-Root hydraulic hoses
according to manufactures
standards
Root Cause of problem
Step2.Establishthepossiblecauses.
Burst Hydraulic pipe.1st
level WHY
External damage. Excessive pressure Incorrect Hydraulic hose2nd
level WHY
External damage
due to external
forces.
Excessive damage
caused by machine
operation.
3rd
level WHY
Over Burden Drill No23 traction hydraulic hoses
are leaking oil after hose replacements.
x x
x
16. Cable hooked by load Cable laying on floor
5 Why ? (Example 4. Tree Diagram)
Step 1.
Problem Statement
Root Cause of problem
Fault on MachineTransformer Switch faulty Cable faulty3rd
level WHY
5th
level WHY
x x
x
Transformer tripped2nd
level WHY
Replace faulty cable & Properly
suspend cable on hooks
Step 5.
Take corrective action
No power on machine1st
level WHY
Step3.Establishthepossiblecauses.
Shuttle car No 28 in section 400 experiences
frequent stoppages due to electrical
failures.
4th
level WHY Faulty Cable joint
Cable damaged by
mobile machines
x x
17. Corrective action
• Through brain storming, identify
possible solutions
• Choose and verify corrective
actions: Industry best practice,
tried and tested methods…
• Implement and validate corrective
actions:
• Prevent recurrence
18
18. 5 Why ? (Exercise 1.)
Step 1.
Problem Statement
Step 3.
Take corrective action
Step3.Establishthepossiblecauses.
1st
level WHY
2nd
level WHY
3rd
level WHY
5th
level WHY
4th
level WHY
Root Cause of problem
?
Facilitator notes:
What is the purpose of a problem statement?
You need to make sure the audience understands the importance of the problem statement and it's role in the problem solving process.
You might need to use examples of good and bad statements, and then their impact on the outcome of the process.
You also need an example to take them through before they do the following exercise.
Facilitator notes:
You can do two problem statements per group and go through one of them with the entire class to ensure that everyone did the right stuff.
We need to validate potential root causes and the guy higher up has to check if the causes identified is not a symptom of a process at a higher level than the artisan has visibility of.
We need to validate the cause first.
Facilitator notes:
Once we find out what the problem is, we need to take corrective measures, resolving the issue that was I dentified.
