2014 root cause 4_asq

or
True Story of the Car
Which Did Not Like
Vanilla Ice Cream
© 1996-2014 Quexx International Ltd. 1-604-728 3373

Operational Excellence Series “ROOT CAUSE”
Presenter
QUEXX
A.W.(Arc) Rajtar M.Eng.(Mech.)
PROFESSIONAL PROFILE
35 years of professional experience
FIAT, TOYOTA, SPECTRUM, MIVI, LEVELTON
QA/QC, TPS - LEAN, ISO 9001-series
ex
Supplier Quality Supervisor
Quality Assurance Manager
Purchasing Engineering Manager
TOYOTA AUSTRALIA
Quality Assurance Specialist
LEVELTON Consultants Ltd.
Managing Partner
QUEXX International Ltd.
Integrated Quality Management Systems
Supply Chain Optimization
LEAN Techniques
© 1996-2014 Quexx International Ltd. 1-604-728 3373 Page: 2

ROOT CAUSE
QUEXX

QUEXX Operational Excellence Series “ROOT CAUSE”
Definition
In plain English …
“Root Cause"
is a "cause"
(harmful factor)
that is "root"
(deep, basic, fundamental, etc)
[Wikipedia]

QUEXX
THE STORY

… a truly puzzling
story of a car …

… which did not
like vanilla
ice cream.
The Weird

OK

NOT OK

Complaint
QUEXX
“A flavor of ice cream
being transported
affects my car.
Every time vanilla is
the chosen flavour,
my car stalls…
The Owner”

QUEXX
THE INVESTIGATION

The engine in my car always stalls
when I buy vanilla ice cream?
BECAUSE:
…the car does not like
the vanilla ice cream.
WHY #1
QUEXX
1 x WHY
WHY?

The car does not like waiting
for the vanilla ice cream?
BECAUSE:
…it takes long time to get vanilla ice cream
and the car always runs out of fuel,
or… just feels like it...
WHY #2
QUEXX
2 x WHY
WHY?

The car feels like it run out of fuel?
BECAUSE:
…there seems to be no fuel supplied to the engine.
WHY #3
QUEXX
3 x WHY
WHY?

No fuel in the the carburetor?
BECAUSE:
…of a “vapor lock” in the fuel line.
WHY #4
QUEXX
4 x WHY
WHY?

The fuel line develops “vapor lock”?
BECAUSE:
… it overheats.
WHY #5
QUEXX
5 x WHY
WHY?

The fuel line overheats?
BECAUSE:
…of the design.
WHY #6
QUEXX
6 x WHY
WHY?

WHY?
WHY #7
QUEXX
7 x WHY
…design is responsible for the overheating…
BECAUSE:
… fuel line close to the exhaust gets hot
… poor airflow = insufficient cooling
…small diameter = small volume
 = “vapor lock”

QUEXX
GOOD EXAMPLES

Problem:
Car “jumping”
on uneven
pavement
Reason:
Missing rear shock
absorbers
Possible Cause(s):
Not fitted. Stolen.
Example
QUEXX
1
Root Cause:
Symptom: Shortage of personnel at the assembly line.
Reason: Bleaching of the toilet paper.
Corrective Action:
1) Change toilet paper
2) 2) Double the doublers 3) Implement procedure

Problem:
Police unable
to read
registration
plates
Reason:
License plate horizontal
Possible Cause(s):
Fuel inlet cover broken, weak spring ,damaged, purposefully distorted
Example
QUEXX
2
Root Cause:
Symptom: Swelling of non-fuel-resilient fuel filler cup rubber seal.
Reason: Non-fuel-resistant rubber used.
Corrective Action:
1) Random test the rubber
2) Buffer stock 3) Change supplier

Problem:
Vehicle engine
compartment fire
Reason:
Freon of A/C
system ignited
Possible Cause(s):
Defective or sub-standard parts,
assembly error, damage during servicing, excessive flammability
Example
QUEXX
3
Root Cause:
Symptom: Automatic transmission oil dipstick too short.
Reason: Machine setup not confirmed.
Corrective Action:
1) Use “sealed sample” to verify machine setup
2) Confirm machine setup at the end of production run

BAD EXAMPLES
QUEXX

Root Cause?!
QUEXX
Problem:
Misplaced
steel beam.
Description:
The subcontractor
has changed the location
of the mounting plate
and embedded it in the concrete
without approval from the Designer.
1
Root Cause
The plate was shifted without authorization.
Corrective Action:
The contractor to be reminded any changes must be approved by the Designer.

Root Cause?!
QUEXX
Problem:
Deck drainage
installed
incorrectly.
Description:
The drain housings
were installed
at the incorrect elevations.
2
Root Cause
The decision was made in a hurry.
Corrective Action:
The supervisor to take an extra day to review the setup prior to the site QC review.

Root Cause?!
QUEXX
Problem:
Unspecified
welds of “fraction
critical” beam.
Description:
Additional, not required
welds on 4 different beams
of the same critical component.
Some welds affect one joint,
some two joints, some three.
Vary from beam to beam.
3
Root Cause
CNC machine performed the wrong operation.
Corrective Action:
Machine has been fixed and adjusted.

ADVICE
QUEXX

Why?
Ask ” “
5 - 7x min!

A1
Define
QUEXX
C
C1
C2
C2
A B
A2
D
Define
Organize

C
D1
C2 A
Focus
Define
Organize
D
B
C1
A1
B1

CAUTION #1
Correction
of the root cause
prevents
the problem recurring.
Correcting of the “true root cause”
may be not economical and/or not practical.

CAUTION #2
Complete prevention
by one corrective action
may be not always possible.
Multiple corrective actions may need
proper coordination and sequencing.

CAUTION #3
QUEXX
Management
and the root cause
of many problems
are often connected.

This presentation was delivered by…
Management Consultants
Integrated Management Systems
Supply Chain Optimization
LEAN Techniques
Cel.: (604) 728 3373
Ph.: (604) 469 6002
Fax.: (604) 469 6070
E-mail: mail@quexx.com
Web: www.quexx.com

Coming in October 2014 from…
Management Consultants
www.Cruise-and-Learn.com
for more details check
http://www.cruiseshipcenters.com/en-CA/ArcRajtar/home

2014 root cause 4_asq

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Editor's Notes