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Root Cause Analysis
Module Outline ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],?
Module Objectives ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Improvement vs. Fire Fighting Sporadic Chronic Gain Time Performance Good Bad
Chronic Problems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Sporadic Problems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Improvement vs. Troubleshooting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Sequence for Breakthrough ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Focus Here Set-up Carry-out
Definitions ,[object Object],[object Object],[object Object],[object Object]
Definitions - Continued Cause:   “Something” that happened to produce a deviation of the actual from the expected or desired.  Proved  reason for existence of problem.  Often “multiple causes”. Dominant or Root Cause:   a major contributor to existence of problem which must be fixed before there is an adequate solution. Remedy:   a change that can successfully eliminate or neutralize the cause of a problem.
Definition - Diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosis for Improvement Diagnostic Journey: 1. Study the symptoms surrounding the problem to serve as a basis for theorizing about causes. 2. Theorize the causes of these symptoms. 3. Collect data and do analysis to test the theories and determine the causes.  When the problem can be switched on & off at will - the journey is over!
Studying Symptoms ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],Tools for Symptoms ,[object Object],[object Object],Check Sheet Example: Scratches IIII II II IIII I 15 Runs IIII IIII IIII IIII IIII I IIII IIII 34 Dirt IIII I IIII 11 Wrong Color IIII I I   7 Paint Peeling I    I   2 Total   32 15 22 69 Problem Total Order 1  Order 2  Order 3
Theorizing Causes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Tools for Theorizing Causes * Included in Memory Jogger II Pareto Chart Example:
Tool Example - Ask Why 5 Times Generate Theory: Follow with Remedy! Failures from Supplier A are 2X the industry average. There is excessive damage in transit. Packaging is insufficient. Packaging specifications are incomplete. Why? Why? Why? Why? Real Root Cause There are no technical specifications for packaging available. Why?
Tool Example - Cause & Effect Generate Theory: Follow with Test of Theories based on priorities Out of Date Not Manufacturable Part Problem Cutting oil Bar Stock Capability Scheduling cpk Tolerances Procedures Set-up Maintenance Cost Inaccurate Training Engineering Support Operator Errors Adjustments Materials Machinery Methods Manpower Wrong Material Over Sized Wrong Oil Packaging Print Inaccurate
Tool Example - Structure Tree Elbow Failures Problem Subproblems Theories Most Likely Root Causes Crimp makes inadequate contact Cross Thread Pin not fully seated Cable not fully seated Defective Elbow Operator Material Methods Tools & Equipment Guide Thread Lack of Verification for Alignment # of Revolutions not counted
Testing Theories to Find Cause ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Tools for Testing Theories * Included in Memory Jogger II
Tool Example - Histogram & Run  Chart Test Theory: Follow with Remedy! Histograms: Run Charts:
Tool Example - Capability Test Theory: - Structured  Experimentation Follow with Remedy! ,[object Object],[object Object],[object Object],= Total Machine Cavity Time Sample + + +
Diagnosis of Failures in Systems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosis of Failures in Systems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnostic Journey Root Cause Analysis Begins with Collecting Data on Symptoms Ends with agreement on Cause(s)
Why Find the “Root Cause”?
What is MBF Used For? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Management by Fact (MBF) Remedies Root Cause Analysis Diagnosis Direction Setting Direction Deployment Management Process Policy Deployment & Management by Fact Policy Deployment Monitor Performance Gap Detected No Yes
2.  Root Cause Categorization / Analysis (RCA ) Analyze Problem 2 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
MBF Form Root Cause Analysis/Diagnosis Remedies PROBLEM STATEMENT/OBJECTIVES & PERFORMANCE TRENDS:  (indicate a brief statement of fact here) Insert graph of performance over time here (e.g., Pareto Chart / Current State vs. Goal) Insert graph of more detailed information here (Supportive Info. as necessary - e.g., Costs associated with the problem statement)
Troubleshooting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Troubleshooting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object]

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Root Cause Analysis Presentation

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  • 4. Improvement vs. Fire Fighting Sporadic Chronic Gain Time Performance Good Bad
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  • 10. Definitions - Continued Cause: “Something” that happened to produce a deviation of the actual from the expected or desired. Proved reason for existence of problem. Often “multiple causes”. Dominant or Root Cause: a major contributor to existence of problem which must be fixed before there is an adequate solution. Remedy: a change that can successfully eliminate or neutralize the cause of a problem.
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  • 12. Diagnosis for Improvement Diagnostic Journey: 1. Study the symptoms surrounding the problem to serve as a basis for theorizing about causes. 2. Theorize the causes of these symptoms. 3. Collect data and do analysis to test the theories and determine the causes. When the problem can be switched on & off at will - the journey is over!
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  • 17. Tool Example - Ask Why 5 Times Generate Theory: Follow with Remedy! Failures from Supplier A are 2X the industry average. There is excessive damage in transit. Packaging is insufficient. Packaging specifications are incomplete. Why? Why? Why? Why? Real Root Cause There are no technical specifications for packaging available. Why?
  • 18. Tool Example - Cause & Effect Generate Theory: Follow with Test of Theories based on priorities Out of Date Not Manufacturable Part Problem Cutting oil Bar Stock Capability Scheduling cpk Tolerances Procedures Set-up Maintenance Cost Inaccurate Training Engineering Support Operator Errors Adjustments Materials Machinery Methods Manpower Wrong Material Over Sized Wrong Oil Packaging Print Inaccurate
  • 19. Tool Example - Structure Tree Elbow Failures Problem Subproblems Theories Most Likely Root Causes Crimp makes inadequate contact Cross Thread Pin not fully seated Cable not fully seated Defective Elbow Operator Material Methods Tools & Equipment Guide Thread Lack of Verification for Alignment # of Revolutions not counted
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  • 22. Tool Example - Histogram & Run Chart Test Theory: Follow with Remedy! Histograms: Run Charts:
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  • 26. Diagnostic Journey Root Cause Analysis Begins with Collecting Data on Symptoms Ends with agreement on Cause(s)
  • 27. Why Find the “Root Cause”?
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  • 29. Management by Fact (MBF) Remedies Root Cause Analysis Diagnosis Direction Setting Direction Deployment Management Process Policy Deployment & Management by Fact Policy Deployment Monitor Performance Gap Detected No Yes
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  • 31. MBF Form Root Cause Analysis/Diagnosis Remedies PROBLEM STATEMENT/OBJECTIVES & PERFORMANCE TRENDS: (indicate a brief statement of fact here) Insert graph of performance over time here (e.g., Pareto Chart / Current State vs. Goal) Insert graph of more detailed information here (Supportive Info. as necessary - e.g., Costs associated with the problem statement)
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Editor's Notes

  1. * Introduction. * Announcements. * Ask the Audience: How many of you want to make defects in your work? How many of you want to make your work perfect or defect free the first time? How many of you believe this is possible? Well - it is!!!!! And, hopefully you will all be believers after the session.