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QUALITY MANAGEMENT
Date: Oct 09, 2009
CA / PA BASIC TOOLS
CA/PA BASIC TOOLS Rev 01 10.08.09
ROOT CAUSE ANALYSIS
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For most of us, it's a lot easier to jump
to solutions, isn't it?
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Objectives
Module 1:
Participants will learn how to:
• Create and use Pareto chart in the
analysis of a problem
• Implement steps for carrying out
effective RCA
• Select and apply tools that support
RCA
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Objectives
Module 2:
Participants will be able to:
• Define and explain the 8 – D as a
Problem Solving Method
• Apply the 8 Disciplines and
Concepts
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HOME PAGE
• INTRODUCTION
• MODULE 1
• MODULE 2
• APPLICATION
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I N TR OD U CTI ON
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Introduction
v Definition of Terms
v What it is
v Why use it
v RCA Process
v How to use it
Introduction MODULE 2MODULE 1
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Terms and Definition
Cause (causal factor) - a condition or event that results
in an effect
Direct Cause - cause that directly resulted in the
occurrence
Contributing Cause - a cause that contributed to the
occurrence, but by itself would not have caused the
occurrence
Root Cause - cause that, if corrected, would prevent
recurrence of a non-conformity and similar
occurrences
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RCA Definition
Root Cause Analysis - a process
designed for use in investigating and
categorizing the root causes of
events
A process of tracing a Problem to its Origins
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Root Cause Analysis Process
Step One:
Define the Problem
Step Two:
Collect Data
Step Three:
Identify Possible Causal Factors
Step Four:
Identify the Root Cause(s)
Step Five:
Recommend and Implement Solutions
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Module 1
Digging for the Root Causes
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Module 1 Table of Contents
v Histograms and Pareto Chart
v Cause and Effect Diagram
v What it is
v How to use it
v Examples
v Summary
MODULE 1 MODULE 2 APPLICATION
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Histograms- What it is
• A chart that graphically display the
distribution of a set of data.
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Pareto Chart - What it is
It reveals that a
small number of
NCNs are
responsible for the
bulk of quality
issues,
a phenomenon
called the ‘Pareto
Principle’.
A Pareto chart allows data to be displayed as a bar chart
and enables the main contributors to a problem to be
highlighted.
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Pareto Chart – How to create it
1. Gather facts about the problem
2. Rank the contributions to the problem in order
of frequency.
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Pareto Chart – How to create it
(cont’n)
3. Draw the value as a bar chart.
5. Review the chart
6. Redefine classifications if necessary.
4. add a line showing the cumulative
percentage of errors
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• Chart 1 : The chart gives summary information and starts the cumulative % count at
the top of the first bar:
Cmpt Damaged
Component Faulty
Cmpt Missing
W
rong Comp. Fitted
Cmpt not Meet Elect. Spec.
Deformed Joint
Joints not Soldered
Cmpt Touching Heatplane
Component Misfitted
Legs not through Board
Long Leads
Link W
ire Missfitted
Beyond Economic Repair
Precautionary Removal
Thiokol Problem
Solder Short
Faulty Connector
Contamination
Others
141 139 69 52 22 20 20 17 17 17 16 13 10 10 10 8 6 5 29
23 22 11 8 4 3 3 3 3 3 3 2 2 2 2 1 1 1 5
23 45 56 65 68 71 75 77 80 83 85 87 89 91 92 94 95 95 100
0
100
200
300
400
500
600
0
20
40
60
80
100
Defect
Count
Percent
Cum %
Percent
Count
Pareto of D3 Small Engine Card Faults
Pareto Analysis Example
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• Example 2 : a series of Pareto charts drill down to more detail:
Desig
n
Com
ponent
Build
Other
57 13 4 2
75.0 17.1 5.3 2.6
75.0 92.1 97.4 100.0
0
10
20
30
40
50
60
70
0
20
40
60
80
100
Defect
Count
Percent
Cum %
Percent
Count
Fault by Main Cause
Connect M
odule
Torque
M
otors
Cold
Start
Transducer
M
odule
A
S
IC
Calibratio
n
IO
P
Im
on
21 10 8 8 5 3 2
36.8 17.5 14.0 14.0 8.8 5.3 3.5
36.8 54.4 68.4 82.5 91.2 96.5 100.0
0
10
20
30
40
50
0
20
40
60
80
100
Defect
Count
Percent
Cum %
Percent
Count
Design Faults
1st level Analysis
gives “Design”
as main cause of
failure
2nd level Analysis gives
breakdown of “Design”
Pareto Analysis Example
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• Example 3 : if the original Pareto is very flat, be prepared to cut the defects in a
different way, here, it is 40:60
KDCC788
KDCC646
KDCC777
KDCC780
KDCC782
KDCC795
40-564-8116-10
40-666-7823
40-564-7274-47E
Others
18 13 11 11 11 10 9 9 8 138
7.6 5.5 4.6 4.6 4.6 4.2 3.8 3.8 3.4 58.0
7.6 13.0 17.6 22.3 26.9 31.1 34.9 38.7 42.0 100.0
0
100
200
0
20
40
60
80
100
Defect
Count
Percent
Cum %
Percent
Count
Pareto Chart for Child11
Pareto Analysis Example
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How it helps
Pareto Analysis is a useful tool to:
• identify and prioritize major problem areas based on frequency of
occurrence;
• separate the ‘vital few’ from the ‘useful many’ things to do;
• identify major causes and effects.
The technique is often used in conjunction with Brainstorming and Cause and
Effect Analysis.
HINT !
The most frequent is not
always the most important! Be
aware of the impact of other
causes on Customers or goals.
Pareto Analysis Example
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Summary
Pareto Charts provide a visual representation of
the variables which contribute to problems or
issues.
Pareto Charts can be used as a prioritization tool
to aid in focusing on the top issues which
contribute to specific conditions.
Pareto analysis is an approach which ranks the
contributing factors and identifies which are the
ones which have the most impact on a problem or
issue. Often referred to as an approach for
“separating the vital few from the trivial many”,
sometimes referred to as the “80-20 rule”
Process StepsA method for showing the distribution of
quantitative data and identifying those
with the greatest impact.
Pareto Chart and Analysis
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CAUSE AND EFFECT
Ishikawa/Fish Bone Diagram
Problem
PeopleProcedures
Equipment Materials
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Cause and Effect
• Cause and Effect Analysis is a tool for
identifying all the possible causes associated
with a particular problem
Valuable for:
• Focusing on causes not symptoms
• Providing a picture of why an effect is happening
• Establishing a sound basis for further data gathering
and action
• Identifying all of the areas that need to be tackled
to generate a positive effect
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Cause and Effect Sources of Variation
Sources of Variation is categorized as
follows
1. People
2. Method
3. Machine
4. Material
5. Environment
6. Measuring System
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How to do it
• 1. Identify the Problem/Issue
• 2. Brainstorm
3. Draw fishbone diagram
Place the effect at the head of the “fish”
Include the 6 recommended categories shown below
Problem or
Issue
Method Machine
Environment Measurement System
People
Material
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How to do it (cont’n)
• 4. Align Outputs with Cause Categories
• 5. Allocate Causes
• 6. Analyze for Root Causes
• 7. Test for Reality
Tip !
The 6 categories recommended will address almost all scenarios. However, there is no
one perfect set of categories. You may need to adapt to suit the issue being analyzed.
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Sources of Variation - People
People
• The activities of the workers.
• Variations caused by skill, knowledge,
competency and attitude
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Sources of Variation - Method
Method
• The methods used to produce the
products.
• Variations caused by inappropriate
methods or processes.
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Sources of Variation - Machine
Machine
• The equipment used to produce the
products.
• Variations caused by temperature,
tool wear and vibration.
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Sources of Variation - Material
Material
• The "ingredients" of a process.
• Variations caused by materials that
differ by industry, product
and stage of production.
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Sources of Variation - Environment
Environment
• The methods used to control the
environment.
• Variations caused by temperature
changes, humidity etc.
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Sources of Variation – Measurement System
Measurement System
• The methods and instruments used to
evaluate products.
• Variations caused by measuring
techniques, or calibration and
maintenance of the instruments.
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Cause and Effect Analysis Example
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• Jumping to conclusion
• Failure to define problem
• Failure to find the root cause
• Weak problem solving
• No execution of corrective action
PROBLEM SOLVING FAILURE
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- Problem is clearly defined.
- Problem is accepted
- As an opportunity/challenge to improve
- True root cause is found
- Implemented an effective and
irreversible corrective and preventive
action
- Problem did not re-occur
PROBLEM SOLVING SUCCESS
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Summary
The development of the cause and effect
Fishbone diagram is credited to Kaoru
Ishikawa, who pioneered quality management
processes in the Kawasaki shipyards.
The cause and effect diagram is used to
explore potential causes (or inputs) that
result in a single undesirable effect (UDE, or
output). Causes are categorized under six
headings, namely Machinery, Methods,
Measurement, Manpower, Materials, and
Environment. Potential causes can be
arranged according to their level of
importance or detail, resulting in a depiction
of relationships and hierarchy of events. It is
the hierarchy that creates a map that looks
somewhat like fish bones, hence the name.
The Ishikawa Fishbone Diagram is intended
help you brainstorm and search for potential
root causes or identify areas where there may
be problems by questioning the existence of
causes under each of the six categories.
Ishikawa Fishbone Template
UDE
MaterialsMaterialsManpowerManpower
MachineryMachineryMethodsMethodsMeasurementMeasurement
EnvironmentEnvironment
Causes, inputs,
or sources
of variation
A UDE is an UnDesireable Effect
Cause and Effect Diagram (Ishikawa)
A visual brainstorming tool used to help identify and categorize potential root causes named
for Kaoru Ishikawa.
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$$$
Action Reflection
Wait! I think I missed
something
It isn’t that they
cannot see the
solution,
It’s that they can’t see
the problem.
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TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E
CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09
TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E
CA/PA BASIC TOOLS Rev 01 10.08.09
Created by:
Sid Calayag – Lead Auditor
Quality Management System
Presented by: Sid Calayag

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Crash course rca training rev 01

  • 1. QUALITY MANAGEMENT Date: Oct 09, 2009 CA / PA BASIC TOOLS CA/PA BASIC TOOLS Rev 01 10.08.09 ROOT CAUSE ANALYSIS
  • 2. 2 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 For most of us, it's a lot easier to jump to solutions, isn't it?
  • 3. 3 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Objectives Module 1: Participants will learn how to: • Create and use Pareto chart in the analysis of a problem • Implement steps for carrying out effective RCA • Select and apply tools that support RCA
  • 4. 4 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Objectives Module 2: Participants will be able to: • Define and explain the 8 – D as a Problem Solving Method • Apply the 8 Disciplines and Concepts
  • 5. 5 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 HOME PAGE • INTRODUCTION • MODULE 1 • MODULE 2 • APPLICATION
  • 6. 6 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 I N TR OD U CTI ON
  • 7. 7 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Introduction v Definition of Terms v What it is v Why use it v RCA Process v How to use it Introduction MODULE 2MODULE 1
  • 8. 8 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Terms and Definition Cause (causal factor) - a condition or event that results in an effect Direct Cause - cause that directly resulted in the occurrence Contributing Cause - a cause that contributed to the occurrence, but by itself would not have caused the occurrence Root Cause - cause that, if corrected, would prevent recurrence of a non-conformity and similar occurrences
  • 9. 9 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 RCA Definition Root Cause Analysis - a process designed for use in investigating and categorizing the root causes of events A process of tracing a Problem to its Origins
  • 10. 10 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Root Cause Analysis Process Step One: Define the Problem Step Two: Collect Data Step Three: Identify Possible Causal Factors Step Four: Identify the Root Cause(s) Step Five: Recommend and Implement Solutions
  • 11. 11 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Module 1 Digging for the Root Causes
  • 12. 12 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Module 1 Table of Contents v Histograms and Pareto Chart v Cause and Effect Diagram v What it is v How to use it v Examples v Summary MODULE 1 MODULE 2 APPLICATION
  • 13. 13 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Histograms- What it is • A chart that graphically display the distribution of a set of data.
  • 14. 14 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Pareto Chart - What it is It reveals that a small number of NCNs are responsible for the bulk of quality issues, a phenomenon called the ‘Pareto Principle’. A Pareto chart allows data to be displayed as a bar chart and enables the main contributors to a problem to be highlighted.
  • 15. 15 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Pareto Chart – How to create it 1. Gather facts about the problem 2. Rank the contributions to the problem in order of frequency.
  • 16. 16 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Pareto Chart – How to create it (cont’n) 3. Draw the value as a bar chart. 5. Review the chart 6. Redefine classifications if necessary. 4. add a line showing the cumulative percentage of errors
  • 17. 17 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 • Chart 1 : The chart gives summary information and starts the cumulative % count at the top of the first bar: Cmpt Damaged Component Faulty Cmpt Missing W rong Comp. Fitted Cmpt not Meet Elect. Spec. Deformed Joint Joints not Soldered Cmpt Touching Heatplane Component Misfitted Legs not through Board Long Leads Link W ire Missfitted Beyond Economic Repair Precautionary Removal Thiokol Problem Solder Short Faulty Connector Contamination Others 141 139 69 52 22 20 20 17 17 17 16 13 10 10 10 8 6 5 29 23 22 11 8 4 3 3 3 3 3 3 2 2 2 2 1 1 1 5 23 45 56 65 68 71 75 77 80 83 85 87 89 91 92 94 95 95 100 0 100 200 300 400 500 600 0 20 40 60 80 100 Defect Count Percent Cum % Percent Count Pareto of D3 Small Engine Card Faults Pareto Analysis Example
  • 18. 18 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 • Example 2 : a series of Pareto charts drill down to more detail: Desig n Com ponent Build Other 57 13 4 2 75.0 17.1 5.3 2.6 75.0 92.1 97.4 100.0 0 10 20 30 40 50 60 70 0 20 40 60 80 100 Defect Count Percent Cum % Percent Count Fault by Main Cause Connect M odule Torque M otors Cold Start Transducer M odule A S IC Calibratio n IO P Im on 21 10 8 8 5 3 2 36.8 17.5 14.0 14.0 8.8 5.3 3.5 36.8 54.4 68.4 82.5 91.2 96.5 100.0 0 10 20 30 40 50 0 20 40 60 80 100 Defect Count Percent Cum % Percent Count Design Faults 1st level Analysis gives “Design” as main cause of failure 2nd level Analysis gives breakdown of “Design” Pareto Analysis Example
  • 19. 19 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 • Example 3 : if the original Pareto is very flat, be prepared to cut the defects in a different way, here, it is 40:60 KDCC788 KDCC646 KDCC777 KDCC780 KDCC782 KDCC795 40-564-8116-10 40-666-7823 40-564-7274-47E Others 18 13 11 11 11 10 9 9 8 138 7.6 5.5 4.6 4.6 4.6 4.2 3.8 3.8 3.4 58.0 7.6 13.0 17.6 22.3 26.9 31.1 34.9 38.7 42.0 100.0 0 100 200 0 20 40 60 80 100 Defect Count Percent Cum % Percent Count Pareto Chart for Child11 Pareto Analysis Example
  • 20. 20 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 How it helps Pareto Analysis is a useful tool to: • identify and prioritize major problem areas based on frequency of occurrence; • separate the ‘vital few’ from the ‘useful many’ things to do; • identify major causes and effects. The technique is often used in conjunction with Brainstorming and Cause and Effect Analysis. HINT ! The most frequent is not always the most important! Be aware of the impact of other causes on Customers or goals. Pareto Analysis Example
  • 21. 21 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Summary Pareto Charts provide a visual representation of the variables which contribute to problems or issues. Pareto Charts can be used as a prioritization tool to aid in focusing on the top issues which contribute to specific conditions. Pareto analysis is an approach which ranks the contributing factors and identifies which are the ones which have the most impact on a problem or issue. Often referred to as an approach for “separating the vital few from the trivial many”, sometimes referred to as the “80-20 rule” Process StepsA method for showing the distribution of quantitative data and identifying those with the greatest impact. Pareto Chart and Analysis
  • 22. 22 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 CAUSE AND EFFECT Ishikawa/Fish Bone Diagram Problem PeopleProcedures Equipment Materials
  • 23. 23 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Cause and Effect • Cause and Effect Analysis is a tool for identifying all the possible causes associated with a particular problem Valuable for: • Focusing on causes not symptoms • Providing a picture of why an effect is happening • Establishing a sound basis for further data gathering and action • Identifying all of the areas that need to be tackled to generate a positive effect
  • 24. 24 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Cause and Effect Sources of Variation Sources of Variation is categorized as follows 1. People 2. Method 3. Machine 4. Material 5. Environment 6. Measuring System
  • 25. 25 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 How to do it • 1. Identify the Problem/Issue • 2. Brainstorm 3. Draw fishbone diagram Place the effect at the head of the “fish” Include the 6 recommended categories shown below Problem or Issue Method Machine Environment Measurement System People Material
  • 26. 26 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 How to do it (cont’n) • 4. Align Outputs with Cause Categories • 5. Allocate Causes • 6. Analyze for Root Causes • 7. Test for Reality Tip ! The 6 categories recommended will address almost all scenarios. However, there is no one perfect set of categories. You may need to adapt to suit the issue being analyzed.
  • 27. 27 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Sources of Variation - People People • The activities of the workers. • Variations caused by skill, knowledge, competency and attitude
  • 28. 28 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Sources of Variation - Method Method • The methods used to produce the products. • Variations caused by inappropriate methods or processes.
  • 29. 29 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Sources of Variation - Machine Machine • The equipment used to produce the products. • Variations caused by temperature, tool wear and vibration.
  • 30. 30 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Sources of Variation - Material Material • The "ingredients" of a process. • Variations caused by materials that differ by industry, product and stage of production.
  • 31. 31 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Sources of Variation - Environment Environment • The methods used to control the environment. • Variations caused by temperature changes, humidity etc.
  • 32. 32 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Sources of Variation – Measurement System Measurement System • The methods and instruments used to evaluate products. • Variations caused by measuring techniques, or calibration and maintenance of the instruments.
  • 33. 33 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Cause and Effect Analysis Example
  • 34. TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 0 09.01.09CA/PA BASIC TOOLS Rev 0 09.01.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 0 09.01.09 • Jumping to conclusion • Failure to define problem • Failure to find the root cause • Weak problem solving • No execution of corrective action PROBLEM SOLVING FAILURE
  • 35. 35 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 - Problem is clearly defined. - Problem is accepted - As an opportunity/challenge to improve - True root cause is found - Implemented an effective and irreversible corrective and preventive action - Problem did not re-occur PROBLEM SOLVING SUCCESS
  • 36. 36 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Summary The development of the cause and effect Fishbone diagram is credited to Kaoru Ishikawa, who pioneered quality management processes in the Kawasaki shipyards. The cause and effect diagram is used to explore potential causes (or inputs) that result in a single undesirable effect (UDE, or output). Causes are categorized under six headings, namely Machinery, Methods, Measurement, Manpower, Materials, and Environment. Potential causes can be arranged according to their level of importance or detail, resulting in a depiction of relationships and hierarchy of events. It is the hierarchy that creates a map that looks somewhat like fish bones, hence the name. The Ishikawa Fishbone Diagram is intended help you brainstorm and search for potential root causes or identify areas where there may be problems by questioning the existence of causes under each of the six categories. Ishikawa Fishbone Template UDE MaterialsMaterialsManpowerManpower MachineryMachineryMethodsMethodsMeasurementMeasurement EnvironmentEnvironment Causes, inputs, or sources of variation A UDE is an UnDesireable Effect Cause and Effect Diagram (Ishikawa) A visual brainstorming tool used to help identify and categorize potential root causes named for Kaoru Ishikawa.
  • 37. 37 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 $$$ Action Reflection Wait! I think I missed something It isn’t that they cannot see the solution, It’s that they can’t see the problem.
  • 38. 38 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09CA/PA BASIC TOOLS Rev 01 10.08.09 TA IK IS H A P H IL IP P IN E S , IN C O P E N C H A L L E N G E Q U IC K R E S P O N S E CA/PA BASIC TOOLS Rev 01 10.08.09 Created by: Sid Calayag – Lead Auditor Quality Management System Presented by: Sid Calayag