Root cause analysis apr 2010


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Workshop on Root Cause Analysis tools: Ask Why five times and fishbone (Ishikawa) diagram. I use this to teach basic concepts and give people an experience of using the tools.

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  • Example is introduction of Rabbits in Australia.
  • - Use one persons problem for this exercise and (switch) so other person gets a chance for second exercise. - AFTER: Ask people to share analysis. 1 st time so no criticism or corrections.
  • Root cause analysis apr 2010

    1. 1. Root Cause Analysis Workshop Michael Sahota
    2. 2. Overview <ul><li>Stop the line  quality, speed </li></ul><ul><li>Root cause thinking </li></ul><ul><li>Tool #1: ask “Why?” 5 times </li></ul><ul><li>Tool #2: fishbone diagram </li></ul><ul><li>Additional considerations make this work </li></ul>
    3. 4. Stop the Line to improve quality, reduce waste and go faster <ul><li>When there is a problem </li></ul><ul><li>No problem is a problem! </li></ul>Image by
    4. 5. Find the root cause and invent countermeasures to mitigate it <ul><li>Surface problems are only symptoms </li></ul><ul><ul><li>“ Putting out the fire” will only mask the problem </li></ul></ul><ul><li>Every problem has one or more root causes </li></ul><ul><li>Find countermeasures for these so that they do not recur </li></ul>
    5. 6. Caution: countermeasures obey the law of unintended consequences <ul><li>Not helpful to think about “fixing problems” </li></ul><ul><ul><li>Not permanent; a step in working towards perfection </li></ul></ul><ul><li>Think of countermeasures that mitigate problems </li></ul><ul><ul><li>Be open to multiple possibilities </li></ul></ul><ul><li>Everything we do has consequences, so we may be introducing our next problem </li></ul><ul><li>Examples: rabbits in Australia, Streisand effect </li></ul>
    6. 7. Goal is to identify the problem and find countermeasures - not to blame people <ul><li>“ No blame” policy </li></ul><ul><ul><li>“ Everyone is doing the best they can with the resources they have” </li></ul></ul><ul><li>Systems thinking is a good model </li></ul><ul><ul><li>How has the system functioned to bring about this result? </li></ul></ul><ul><li>For this to work, people need to feel safe and trust one another </li></ul>
    7. 8. Tool #1: ask “Why?” 5 times to uncover details <ul><li>Start with the problem and ask “Why” 5 times </li></ul><ul><li>Sounds simple and takes practice </li></ul><ul><li>Requires creative thinking </li></ul><ul><ul><li>Use beginners mind to avoid the expert trap </li></ul></ul>
    8. 9. Example of Jeff Bezos – CEO at asking “Why?” to find the root cause <ul><li>Why did the associate damage his thumb? </li></ul><ul><ul><li>Because his thumb got caught in the conveyor. </li></ul></ul><ul><li>Why did his thumb get caught in the conveyor? </li></ul><ul><ul><li>Because he was chasing his bag, which was on a running conveyor. </li></ul></ul><ul><li>Why did he chase his bag? </li></ul><ul><ul><li>Because he placed his bag on the conveyor, but it then turned-on by surprise </li></ul></ul><ul><li>Why was his bag on the conveyor? </li></ul><ul><ul><li>Because he used the conveyor as a table </li></ul></ul>
    9. 10. Countermeasures identified at Amazon <ul><li>Provide portable, light tables </li></ul><ul><li>Greater focus on safety training </li></ul><ul><li>Look into accident prevention as standard work </li></ul>
    10. 11. Exercise: Find a partner, pick a problem and ask why 5 times
    11. 12. Tool #2: fishbone (Ishikawa) diagram facilitates looking at the big picture
    12. 13. Demo: Fishbone with Amazon Example
    13. 14. Exercise: Draw, Pardner!
    14. 15. Additional considerations to make this work…
    15. 16. Go and see (Genchi Genbutsu) – Go to the source to see the facts for yourself <ul><li>Often when performing root cause analysis you will not know the answer </li></ul><ul><li>Beware of data someone else has prepared </li></ul><ul><li>Get the Facts! – Go and see for yourself </li></ul><ul><li>Look, See, Understand </li></ul><ul><li>Think for yourself </li></ul>
    16. 17. Kaizen – continuous improvement in the pursuit of perfection <ul><li>&quot;A journey of a thousand miles must begin with the first step.“ - Lao Tzu </li></ul><ul><li>Ask small questions </li></ul><ul><li>Take small actions </li></ul><ul><li>Solve small problems </li></ul><ul><li>Constraints: </li></ul><ul><ul><li>Spend no Money </li></ul></ul><ul><ul><li>Add no People </li></ul></ul><ul><ul><li>Add no Steps </li></ul></ul>
    17. 18. Everyone needs to work towards shared goals of quality for this to be successful <ul><li>1 person @ 100% will not have sustained success </li></ul><ul><li>Toyota has proven 100 people @ 1% works </li></ul><ul><li>Successful companies build people </li></ul><ul><ul><li>Culture of empowerment </li></ul></ul><ul><ul><li>Ownership of problems and countermeasures </li></ul></ul>
    18. 20. What questions do you have?