RCA Root Cause Analysis
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The document provides an overview of root cause analysis (RCA) used to identify and address problems. It discusses why RCA is performed, the typical steps which include identifying the problem, collecting data, identifying causal factors and the root cause, and recommending solutions. Several tools used in RCA are also outlined, such as fishbone diagrams, 5 whys, fault tree analysis, and failure mode and effects analysis (FMEA). The document provides examples of how these tools can be applied to identify root causes and prevent future issues.
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RCA Root Cause Analysis
- 1. ROOT CAUSE ANALYSIS RCA PREPARED BY:ENG.: WALEED EL SAYED “Failure is the opportunity to begin again more intelligently” Henry Ford (1863-1947) CHIEF ENGINEER MBA
- 2. PROBLEM Chronic Problem “Area of Improvement” Sporadic Problem “Defect- Troubleshooti ng” Why RCA? • There is no perfect process. • Eliminate defects continuously. • Kaizen has no end point. To Identify: • What is the problem? • Why happened? • What to do? Why RCA?
- 3. TYPES OF CAUSES Process Humman Physical RCA STEPS Identify the Problem Collect Data Identify Possible Causal Factor Identify The Root Cause Recommend A Solution
- 4. 1: IDENTIFY THE PROBLEM • Problem or Symptoms? • Specific Symptoms.
- 5. 2: COLLECT DATA • Proof that the problem exist. • How long? • Involve all people. • Be neutral.
- 7. 3: IDENTIFY CAUSAL FACTORS • Involve all again. • Be neutral again. • Ishikawa diagram. • 5 Why’s? • Identify possible cause. •What sequence of events leads to the problem? •What conditions allow the problem to occur? •What other problems surround the occurrence of the central problem? Immediate event/condition that caused accident Direct Cause Event/condition that increased probability or severity of the accident. Contributi ng Cause Event/condition that, if corrected, will prevent recurrence. Root Cause
- 8. 4: IDENTIFY THE ROOT CAUSE • Validate & differentiate. • May be multiple. • Ask? & Answer!!
- 9. 5: RECOMMEND & IMPLEMENT SOLUTIONS • Set a clear (SMART) steps for the solution. • Assign responsibility. • Go through solution assessment. • Improve again & again.
- 10. Corrective Action • Is designed to eliminate the reoccurrence of a non- conformity. Preventive Action • Is designed to eliminate the occurrence.
- 11. RCA TOOLS Cause Analysis Risk Assessme nt Fishbone Diagram 5 Why’s? Fault Tree Analysis Pareto Analysis FMEA
- 12. BRAINSTORMING
- 16. 5 WHY’S? • Why won’t the car start? The engine won’t turn over. • Why the engine won’t turn over? The battery is dead.• Why the battery is dead? The alternator is not functioning.• Why the alternator is not functioning? The belt is broken.• Why the belt is broken? The belt was not replaced according to the manufacture’s maintenance schedule.
- 17. FAULT TREE ANALYSIS • Top down analysis. • Start with the system failure & work down to the root cause. • Uses common logic symbols.
- 19. FAILURE MODE EFFECTIVE ANALYSIS “FMEA”
- 20. A STRUCTURED APPROACH TO: • IDENTIFYING THE WAYS IN WHICH A PRODUCT OR PROCESS CAN FAIL. • ESTIMATING RISK ASSOCIATED WITH SPECIFIC CAUSES. • PRIORITIZING THE ACTIONS THAT SHOULD BE TAKEN TO REDUCE RISK. • EVALUATING DESIGN VALIDATION PLAN (DESIGN FMEA) OR CURRENT CONTROL PLAN (PROCESS FMEA). • FIRST USED IN THE 1960’S IN THE AEROSPACE INDUSTRY DURING THE APOLLO MISSIONS • IN THE LATE 1970’S, THE AUTOMOTIVE INDUSTRY WAS DRIVEN BY LIABILITY COSTS TO USE FMEA • LATER, THE AUTOMOTIVE INDUSTRY SAW THE ADVANTAGES OF USING THIS TOOL TO REDUCE RISKS RELATED TO POOR QUALITY
- 21. SEVERITY, OCCURRENCE, AND DETECTION • SEVERITY • IMPORTANCE OF THE EFFECT ON CUSTOMER REQUIREMENTS. • OCCURRENCE • FREQUENCY WITH WHICH A GIVEN CAUSE OCCURS AND CREATES FAILURE MODES (OBTAIN FROM PAST DATA IF POSSIBLE). • DETECTION • THE ABILITY OF THE CURRENT CONTROL SCHEME TO DETECT (THEN PREVENT) A GIVEN CAUSE (MAY BE DIFFICULT TO ESTIMATE EARLY IN PROCESS OPERATIONS).
- 22. RATING SCALES • SEVERITY • 1 = NOT SEVERE, 10 = VERY SEVERE • OCCURRENCE • 1 = NOT LIKELY, 10 = VERY LIKELY • DETECTION • 1 = EASY TO DETECT, 10 = NOT EASY TO DETECT RISK PRIORITY NUMBER (RPN) Severity Occurrence Detection RPNX X =
- 23. Identify failure modes and their effects Identify causes of the failure modes and controls Prioritize Determine and assess actions
- 24. THANK YOU