Rcapresentationfromdeepak 130131204454-phpapp01

Prepared By – Mr. Deepak Kumar Sahoo
Root Cause Analysis
Prepared and Presented by :-
Mr. Deepak Kumar Sahoo
RCA
Excellence in Problem Solving

Root Cause Analysis is an in-depth process or
technique for identifying the most basic
factor(s) underlying a variation in
performance (problem).
 Focus is on systems and processes
 Focus is not on individuals
What is RCA ?

• Safety-based RCA
 Investigating accident , occupational safety and health.
 Root causes:- unidentified risks, or inadequate safety engineering, missing safety
barriers.
• Production-based RCA
 Quality control for industrial manufacturing.
 Root causes:- non-conformance like, malfunctioning steps in production line.
• Process-based RCA
 Extension of Production-based RCA.
 Includes business processes also.
 Root causes:- Individual process failures
• Systems-based RCA
 Hybrid of the previous types
 New concepts includes:- change management, systems thinking, and risk
management.
 Root causes:- organizational culture and strategic management
Types of RCA

Whether we know the Cause?
Cause Known Cause Not Known
SolutionKnownSolutionNotKnown
Task Force
Brain Storm / Seek
Expert Help
Root Cause Analysis
Trial & Error
Root Cause Analysis

By eliminating the root cause…
You save time and money!
• Problems are not repeated
• Reduce rework, retest, re-inspect, poor quality costs, etc…
• Problems are prevented in other areas
• Communication improves between groups and Process
cycle times improve (no rework loops)
• Secure long term company performance and profits
RCA Benefits :-

When we need RCA
FREQUENCY
IMPACT
OBSERVATION MINOR MAJOR
5 WHY’s Cause Mapping

A standard process of RCA is as follows:
 Identifying a problem
 Containing and analyzing the problem
 Defining the root cause
 Defining and implementing the actions required to eliminate
the root cause
 Validating that the corrective action prevented recurrence of
problem
RCA Process

RCA Process
Validate
Follow
Up Plan
Complete
Plan
Action
Plan
Root
Cause
Immediate
Action
Identify
Team
Identify
Problem
Problem
Solving
Process
1
2
3
4
5
6
7
8

Identify the Problem
• Clearly state the problem the team is to solve
– Teams should refer back to problem statement to avoid getting off track
• Use 5W2H approach
– Who? What? Why? When? Where? How? How Many?
5W2H
Who? Individuals/customers associated with problem
What? The problem statement or definition
When? Date and time problem was identified
Where? Location of complaints (area, facilities, customers)
Why? Any previously known explanations
How? How did the problem happen (root cause) and how will the problem be
corrected (corrective action)?
How Many? Size and frequency of problem
RCA Process : Step - 1
It’s the most
important step.

Identify Team
When a problem cannot be solved quickly by an individual,
use a team!
 Should consist of domain knowledge experts
 Small group of people (4-10) with process and product
knowledge, available time and authority to correct the
problem
 Must be empowered to “change the rules”
 Should have a designated Team leader.
 Membership in team is always changing!
RCA Process : Step - 2

Key Ideas for Team Success
 Define roles and responsibilities
 Identify external customer needs
 Identify internal customer needs
 Appropriate levels of organization present
 Clearly defined objectives and outputs
 Solicit input from everyone!
 Good meeting location - Near work area for easy access to information.
Roles and Responsibilities
 Team Leader: Mentor, guide and direct teams, advocate to upper management
 Leader: day-to-day authority, calls meetings, facilitation of team, reports to TL.
 Record Keeper: Writes and publishes minutes
 Participants: Respect all ideas, keep an open mind, know their role within team
RCA Process : Step – 2 (Continue..)

Immediate Action
 Must isolate effects of problem from customer
 Only temporary until corrective action is implemented
 Must also verify that immediate action is effective
Verify Immediate Action
 Immediate action = activity implemented to screen, detect and/or contain
the problem.
 Must verify that immediate action was effective
 Run Pilot Tests
 Make sure another problem does not arise from the temporary solutions
 Ensure effective screens and detections are in place to prevent further impact
to customer until permanent solution is implemented.
RCA Process : Step – 3

Finding Root Cause
• Brainstorm possible causes of problem with team
• Organize causes with Cause and Effect Diagram
• Use 5 Why? method to further define the root cause of
symptoms
– May involve additional research/analysis/investigation to get
to each “Why?”
• Must identify the process that caused the problem
– if root cause is company-wide, elevate these process issues
(outside of team control) to upper management to address

Most commonly use :-
– The “5 Whys”
– Brainstorming
– Fish bone Analysis or Ishikawa Diagram
– Cause Mapping or Cause and Effect Analysis
– FMEA or FMECA
Other RCA tools :-
RCA Process : Step – 4 RCA Tools.
 Process Maps
 Barrier Analysis
 Pareto Charts
 pie chat
 Tree Diagrams
 Benchmarking
 Run Chart
 Change Analysis
 Affinity Diagrams
 Control Plans
 Scatter Diagram
 Event and Causal
Factor Analysis
 Risk Tree Diagrams
 Histograms
 Interrelationship
Diagram
 Force Field Analysis
 Flowcharts
 MORT Analysis

Problem - Flat Tire
 Why? Nails on garage floor
 Why? Box of nails on shelf split open
 Why? Box got wet
 Why? Rain thru hole in garage roof
 Why? Roof shingles are missing
Why-Why Analysis.

 It should be done within 24 hours of problem
occurrence
 Person who was present when the problem occurred
should be part of why-why analysis
 Why-Why analysis should be done at the location
where the problem has occurred
 Stop when the answers become less important.
 Stop when the root cause condition is isolated.
 Ask “Why?” 5 times can extend maximum 7 times. If
you will not find the possible solution then use Other
RCA tools.
TIPS for Why-Why Analysis.

Why-Why Analysis Examples
Why
• RAVANA KILLED
Why
• He Kidnapped SITA
Why
• She was in the Forest
Why
• Her Father in law King Dhasaratha Promised to one
of his wife Kaikeyee
Why
• One day King Dhasaratha Roaming with his chariot Vehicle it
wheel lock pin was damaged and Kaikeyee was put her finger in
to the Pin hole and saved King Dhasaratha
Why
• The chariot vehicle wheel lock pin was damaged.

Why-Why Analysis Examples
Why
• The chariot vehicle wheel lock pin was damaged
Why
• Poor maintenance
• No PPM & no FMEA carried out. 
• Think …..
• Because EMCO was not there on that time
If EMCO was at that time and King Dhasaratha gave
maintenance contracts to EMCO History might Change.
Ravana life also might be saved. 
Why
Root
Cause

More about Cause-Effect Diagram :
Environment Effect
ManMachine
MethodsMaterials
NOTE: Causes are not limited to the 5 listed categories, but serve as a starting point
Steps used to create a Cause-Effect Diagram:
 Define the issue or problem clearly
 Decide on the root causes of the observed issue or problem
 Brainstorm each of the cause categories
 Write ideas on the cause-effect diagram.

Fish Bone Analysis
Materials
Incorrect Quantity
Incorrect BOL
Wrong Destination
Methods
Late Dispatch
Shipping Delay
Spillage
Environment
Shipping
Problems
Traffic Delays
Weather
Machine
Wrong Equipment
Dirty EquipmentBreakdown
Man
Driver
Attitude
Dispatcher
Wrong Directions

Corrective Action Plan
• Must verify the solution will eliminate the problem
– Verification before implementation whenever possible
• Define exactly…
– What actions will be taken to eliminate the problem?
– Who is responsible?
– When will it be completed?
• Make certain customer is happy with actions
• Define how the effectiveness of the corrective action will be measured.
Verification vs. Validation
Verification
– Assures that at a point in time, the action taken will actually do what is intended without
causing another problem
Validation
– Provides measurable evidence over time that the action taken worked properly, and
problem has not recurred

3 types of Corrective Action:
• Immediate action
– The action taken to quickly fix the impact of the problem so the
“customer” is not further impacted
• Permanent root cause corrective action
– The action taken to eliminate the error on the affected process or product
• Preventive (Systemic) root cause corrective action
– The action taken to Prevent the error from recurring on any process or
product
Types of Corrective action.

Corrective Action Examples
Immediate (step #3)
Permanent (step #5)
Preventive (step #5)
All current batch of paperwork re-inspected by
another worker for same type of problem
Form changed to mandate completion of certain fields
Similar forms with same fields used all over in
company are changed to “mandatory”

Complete Action Plan
 Make certain all actions that are defined are completed as
planned
 If one task is still open, verification and validation is pushed
back
 If the plan is compromised, most likely the solution will not be
as effective

Follow Up Plan
 What actions will be completed in the future to ensure that the
root cause has been eliminated by this corrective action?
 Who will look at what data?
 How long after the action plan will this be done?
 What criteria in the data results will determine that the problem
has not recurred?

Validate and Celebrate
• What were the results of the follow up?
• If problem did reoccur, go back to Step #4 and re-evaluate root
cause, then re-evaluate corrective action in Step #5
• If problem did not reoccur, celebrate team success!
• Document savings to publicize team effort, obtain customer
satisfaction and continued management support of teams

Identify Problem
A manager walks past the assembly line and notices a puddle of
water on the floor. Knowing that the water is a safety hazard,
she asks the supervisor to have someone get a mop and clean up
the puddle. The manager is proud of herself for “fixing” a
potential safety problem.
Immediate Action
Knowing that the water is a safety hazard, the manager asks the
supervisor to have someone get a mop and clean up the puddle.
But What is the Root Cause?
The supervisor looks for a root cause by asking 'why?’
RCA Example - 1

Leak in overhead pipe
RCA Example – 1
Puddle of water on the floorWHY
WHY
Water pressure is set too highWHY
Water pressure valve is faultyWHY
Valve not in PPM programRoot Cause

Corrective Action
 Permanent – Water pressure valves placed in
preventative maintenance program.
 Preventive - Developed checklist form to ensure new
equipment is reviewed for possible inclusion in
preventative maintenance program.
RCA Example – 1

Identify Problem
Customers are unhappy because they are being shipped
products that don't meet their specifications.
Immediate Action
Inspect all finished and in-process product to ensure it
meets customer specifications.
Find out the root cause
RCA Example – 2

Manufacturing schedule is not available for sales person to provide
realistic delivery date.
RCA Example – 2
Product doesn’t meet specificationsWHY
Manufacturing specification is different from what customer and sales
person agreed.WHY
Sales person tries to expedite work by calling head of manufacturing
directly.WHY
WHY
Confidence in manufacturing schedule is not high enough to
release/link with order system
Parts sometimes not available thereby creating schedule changes
Expediting and priority changes consume parts not planned for
Manufacturing schedule does not reflect realistic assembly and test
time.
No ongoing review of manufacturing standards.
WHY
WHY
WHY
WHY
Root Cause

Corrective Action
• Permanent – Manufacturing standards reviewed and
updated.
• Preventive - Regular ongoing review of actuals vs
standards is implemented.
RCA Example – 2

Identify Problem
Part polarity reversed on circuit board
Immediate Action
 Additional inspection added after this assembly
process step to check for reversed part defects.
 Last 10 lots of printed circuit boards were re-inspected
to check for similar errors.
RCA Example – 3

Worker not sure of correct part orientation.
RCA Example – 3
Part reversed.WHY
WHY
Part is not marked properly.WHY
Engineering ordered it that way from vendorWHY
Process didn’t account for possible
manufacturing issues
Root Cause

Corrective Action:-
• Permanent – Changed part to one that can only be
placed in correct direction (Mistake proofed). Found
other products with similar problem and made same
changes.
• Preventive - Required that any new parts selected
must have orientation marks on them.
RCA Example – 3

Identify Problem
Department didn’t complete their project on time.
Immediate Action
 Additional resources applied to help get the project
team back on schedule
 No new projects started until Root Cause Analysis
completed
Now we will find the root cause
RCA Example – 4

RCA Example – 4
Didn’t complete project on timeWHY
Didn’t complete
project on time
MachineMaterials
ManMethod
Lack of worker
knowledge
Poor project
management
skills
Inadequate
computer
programs Inadequate
computer system
Lack of resources

Didn’t complete project on timeWHY
Resources unavailable when needed.WHY
Took too long to hire Project Manager
Lack of specifics given to
Human Resources Department.
No formal process for submitting job opening
WHY
WHY
Root Cause
RCA Example – 4

Corrective Action
 Permanent – Hired another worker to meet needs of
next project team
 Preventive - Developed checklist form with HR for
submitting job openings in the future.
RCA Example – 4

 Why People turnover is high in EMCO?
 Why work load is more in QF?
 Why PPM in QF is not so effective ?
 Why Rajnikant is to too famous?
 Why CM has reduced in QF from EMCO side ?
More on Why-Why analysis ?

Why-Why Analysis (multiple cause Examples)
Why? Why? Why? Why? Why?
Employees
are leaving
for other jobs
Employees
are not
satisfied
Employees
feel that they
are
underpaid
Other
employers
are paying
higher
salaries
Demand for
such
employees
has increased
in the market
Employee turnover rate has been
increasing

Thank you !!!
Connect With Me @
Mobile :- +974 – 3370 8982
Email :- dksahoo2@gmail.com
LinkedIn :- www.linkedin.com/in/dksahoo
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Twitter :- www.twitter.com/defydeepak
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