1. Root Cause Analysis

4. Improvement vs. Fire Fighting Sporadic Chronic Gain Time Performance Good Bad

10. Definitions - Continued Cause: “Something” that happened to produce a deviation of the actual from the expected or desired. Proved reason for existence of problem. Often “multiple causes”. Dominant or Root Cause: a major contributor to existence of problem which must be fixed before there is an adequate solution. Remedy: a change that can successfully eliminate or neutralize the cause of a problem.

12. Diagnosis for Improvement Diagnostic Journey: 1. Study the symptoms surrounding the problem to serve as a basis for theorizing about causes. 2. Theorize the causes of these symptoms. 3. Collect data and do analysis to test the theories and determine the causes. When the problem can be switched on & off at will - the journey is over!

17. Tool Example - Ask Why 5 Times Generate Theory: Follow with Remedy! Failures from Supplier A are 2X the industry average. There is excessive damage in transit. Packaging is insufficient. Packaging specifications are incomplete. Why? Why? Why? Why? Real Root Cause There are no technical specifications for packaging available. Why?

18. Tool Example - Cause & Effect Generate Theory: Follow with Test of Theories based on priorities Out of Date Not Manufacturable Part Problem Cutting oil Bar Stock Capability Scheduling cpk Tolerances Procedures Set-up Maintenance Cost Inaccurate Training Engineering Support Operator Errors Adjustments Materials Machinery Methods Manpower Wrong Material Over Sized Wrong Oil Packaging Print Inaccurate

19. Tool Example - Structure Tree Elbow Failures Problem Subproblems Theories Most Likely Root Causes Crimp makes inadequate contact Cross Thread Pin not fully seated Cable not fully seated Defective Elbow Operator Material Methods Tools & Equipment Guide Thread Lack of Verification for Alignment # of Revolutions not counted

22. Tool Example - Histogram & Run Chart Test Theory: Follow with Remedy! Histograms: Run Charts:

26. Diagnostic Journey Root Cause Analysis Begins with Collecting Data on Symptoms Ends with agreement on Cause(s)

27. Why Find the “Root Cause”?

29. Management by Fact (MBF) Remedies Root Cause Analysis Diagnosis Direction Setting Direction Deployment Management Process Policy Deployment & Management by Fact Policy Deployment Monitor Performance Gap Detected No Yes

31. MBF Form Root Cause Analysis/Diagnosis Remedies PROBLEM STATEMENT/OBJECTIVES & PERFORMANCE TRENDS: (indicate a brief statement of fact here) Insert graph of performance over time here (e.g., Pareto Chart / Current State vs. Goal) Insert graph of more detailed information here (Supportive Info. as necessary - e.g., Costs associated with the problem statement)