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Root Cause Analysis
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- 2. 2 Objective RootCause Analysis Root Cause Philosophy of Root CauseAnalysis 5Why’s How to do Root CauseAnalysis Tools Used in Root CauseAnalysis Fishbone Diagram Example Advantages and Disadvantages Summary PresentationOutline
- 3. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 3 Through this, you will: Understand the meaning of “RootCause” Know the steps used to identify the root cause of problems. Fishbone Diagram. Objective
- 4. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 4 Root Cause Analysis is a method that is used to address a problem or non-conformance, in order to get to the “root cause” of the problem. It is used so we can correct or eliminate the cause, and prevent the problem from recurring. RootCauseAnalysis
- 5. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 5 Root Cause is the fundamental breakdown or failure of a process which, when resolved, prevents a recurrence of the problem. Or, in other words For a particular product problem, Root Cause is the factor that, when you fix it, the problem goes away and doesn’t come back. • Root Cause Analysis is a systematic approach to get to the true root causes of our process problems. RootCause
- 6. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 6 Each problem is an opportunity (“golden nugget”) because it can tell a story about why and how it occurred. It is critical that everyone take a personal and active role in improving quality. The “true” problem must be understood before action is taken. Problems are often masked for a variety ofreasons To do this well, we must be Both focused and open-minded Both patient and quick Above all, we must be relentless Philosophy of RootCauseAnalysis
- 7. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 7 The 5-Whys is a simple brainstorming tool that can help QI teams identify the root cause(s) of a problem. Once a general problem has been recognized (either using the Fishbone Diagram or Process Mapping), ask “why” questions to drill down to the root causes. Asking the 5-Whys allows teams to move beyond obvious answers and reflect on less obvious explanations or causes. 5Why’s
- 8. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 8 Said simply, Root Cause Analysis is asking why the problem occurred, and then continuing to ask why that happened until we reach the fundamental process element that failed. The following example illustrates the basics of Root Cause Analysis. How to do RootCauseAnalysis Why???
- 9. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 9 Example: WHY 1 :Why my car had stopped ? No petrol in tank. WHY 2 :Why i did not have a petrol in my tank ? I did not buy in the morning on my way to work. WHY 3 :Why i did not buy a petrol ? No money in my pockets. WHY 4 : Why no money i my pockets? Evening poker. WHY 5 : Why i did not win a poker game? I do not know how to bluff!
- 10. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 10 Example: Cause Effect
- 11. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 11 ToolsUsed in RootCauseAnalysis CONTROL CHARTS X FISHBONE DIAGRAM HISTOGRAM PARETO CHART RUN CHART START STOP ? Y N FLOWCHART UCL LCL TIME VALUE X SCATTER DIAGRAM USLLSL BRAINSTORMING TREE DIAGRAM 2 4 5 6 7 8 FACTOR A FACTOR C 1 3 - FACTOR B + - + - + DESIGN OF EXPERIMENTS
- 12. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 12 Using a fishbone diagram while brainstorming possible causes helps you to focus on the various possibilities. Some useful categories: Fishbone Diagram People PM Problem Measuring/Test Equip. Design Materials Instructions Environment Machines
- 13. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 13 WHAT IS IT? The Fishbone Diagram (also known as the Cause & Effect Diagram) is a technique to graphically identify and organize many possible causes of a problem(effect). WHY IS ITUSEFUL? Fishbone Diagrams help identify the most likely ROOT CAUSES of a problem. They can also help teach a team to reach a common understanding of the problem. This tool can help focus problem solving and reduce subjective decision making. WHEN IS ITUSED? When the need exists to display and explore many possible causes of a specific problem or condition. This diagram allows the team to systematically analyze cause & effect relationships. It can also help with the identification of ROOT CAUSES. Fishbone Diagram
- 14. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 14 WHAT DOES IT LOOK LIKE? Fishbone Diagram People PM Problem Measuring/Test Equip. Design Materials Instructions Environment Machines
- 15. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 15 HOW IS IT DONE? Name the effect; determine the specific problem to be analyzed. Draw the diagram with a process arrow to the effect and draw a box around it. Decide what the major categories of the causes are (i.e., people, machines, measurement, materials, methods, environment, policies, etc.). Label categories important to your situation. Make it work for you. Brainstorm all possible causes and label each cause under the appropriate category. Post the diagram where others can add causes to it (i.e., experts, affected people, process owners, etc..). Analyze causes and eliminate trivial and/or frivolous ideas. Rank causes and circle the most likely ones for further consideration and study. Investigate the circled causes. Use other techniques to gather data and prioritize findings. Fishbone Diagram
- 16. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 16 Example: TheWashing Machine Problem Description “Machine is 2 weeks old (Serial #2345017). When doing the fourth load of clothes, I heard a loud noise and the machine stopped! It wouldn’t re-start.” Problem Description “Machine is 2 weeks old (Serial #2345017). When doing the fourth load of clothes, I heard a loud noise and the machine stopped!It wouldn’t re-start.”
- 17. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 17 VERIFYTHE COMPLAINT Problem Verification Service technician checks washing machine operation to test procedure (#8496). The machine does not operate. ProblemVerification Service technician checks washing machine operation to test procedure(#8496). The machine does not operate. Determine the Cause.
- 18. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 18 INVESTIGATE WHY? Machine Doesn’t Work Machine Doesn’t Work Fuse Missing? Machine Unplugged? Power Off? Fuse Blown? Fuse Blown Determine theCause.
- 19. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 19 INVESTIGATE WHY? Motor Overheated Fuse Blown Fuse Blown Lightning Storm? Electrical Overload? Power Surge? Motor Overheated? Corrective Action for Specific Deficiency: Replace the Fuse Corrective Action for Specific Deficiency: Replace the Fuse Determine the Cause.
- 20. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 20 Example: TheWashing Machine Shaft Damaged Motor Overheate d Motor Overheated Motor Mis-Installed? Fly-Wheel Loose? Cooling Fan? Shaft Damaged? Determin e the Cause.
- 21. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 21 Example: TheWashing Machine Bearing Destroyed Shaft Damage d Shaft DamagedMis-Handled? Mis-Installed? Wrong Belt? Bearing Destroyed? Incorrect Tolerance/Fit? Determine theCause.
- 22. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 22 Example: TheWashing Machine Loss of Lube Cause of Failure: SealOmitted Corrective Action for Specific Deficiency: Replace the Motor Corrective Action for Specific Deficiency: Replace the Motor WasSeal Omitted?? Bearing Destroye Bearing Destroyed Bad Bearings? Bearing Loads? Seal Omitted? Wrong Bearings?
- 23. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 23 Example: TheWashing Machine But..... is it? Inadequate Appropriate Root Cause - Inadequate Work Instructions Root Cause - Inadequate Work Instructions Seal Omitte Seal Omitted Missed Operation? Operator Error? Parts Shortage Inadequate Work Instructions? FellOut?
- 24. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 24 Example: TheWashing Machine But..... is it? Root Cause - Inadequate Work Instructions Root Cause - Inadequate Work Instructions Seal Omitte Seal Omitted Missed Operation? Operator Error? Parts Shortage Inadequate Work Instructions? FellOut? Can the design be changed to eliminate the need for a seal? Can the design be changed to make it impossible to omit the seal? Can a fixture be made to make it impossible to omit theseal? Inadequate Appropriate
- 25. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Example 1 Tools Used in Root Cause Analysis Fishbone Diagram Example 2 Advantages and Disadvantages Summary 25 Case Study:
- 26. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Tools Used in Root Cause Analysis Fishbone Diagram Example Advantages and Disadvantages Summary 26 Advantages: Longer lasting solution. RealWorld Problems Safer Workplace Disadvantages: Extra Effort. Extra Time. Extra Money Advantages and Disadvantages
- 27. Objective RootCause Analysis Root Cause Philosophy of Root Cause Analysis 5Why’s How to do Root Cause Analysis Tools Used in Root Cause Analysis Fishbone Diagram Example Advantages and Disadvantages Summary 27 RootCauseAnalysis is a method to focus our efforts on the true “RootCauses” of escapes, so that we truly prevent their reoccurrence. Root CauseAnalysis helps us reduce turnbacks and frustration, maintain customer satisfaction, and reduce costs significantly. Each problem is an opportunity. It contains the information needed to eliminate the problem. But to identify the root cause, we have to ask “Why?” over and over, until we reach it. Summary
- 28. 28 Comparison: Benchmarking GQM RootCause Analysis For Both Software and Hardware. For Software only. For Both Software and Hardware. Requires data from peers. Does not require data. Does not require data. Does not tell the relation between cause and effect. Does not tell the relation between cause and effect. Tells the relation between cause and effect.
- 29. 29 References: Tore DybaProcess Improvement in Practice A Handbook for IT Companies The Kluwer International Series in Software Engineering 2004. http://www.expertbriefings.com/tips/limitations-of-5-whys-in-root-cause- analysis/ (Dated: 21/03/2017 07:30PM). http://www.apollorootcause.com/about/benefits-of-rca/ (Dated: 21/03/2017 07:30PM).
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