The document outlines an awareness training program focused on problem-solving through root cause analysis in accordance with ISO 9001:2008 standards. It emphasizes the importance of collecting and analyzing data related to customer satisfaction, nonconformities, and other relevant metrics to improve quality management systems. The program details steps for conducting root cause analysis, including defining problems, collecting data, identifying factors, implementing solutions, and verifying their effectiveness.

1. AWARENESS TRAINING PROGRAM ON PROBLEM SOLVING BY ROOT CAUSE ANALYSIS
Name: AJIT D BHOSALE
Designation: SR.GENERAL MANAGER – QUALITY AND SYSTEMS
Date: 31.10.2014

2. REFERENCE CLAUSES FROM ISO 9001:2008

3. CLAUSES FROM ISO 9001:2008
8.4 Analysis of data
The organization shall determine, collect and analyse appropriate data
to demonstrate the suitability and effectiveness of the quality
management system and to evaluate where continual improvement of
the effectiveness of the quality management system can be made. This
shall include data generated as a result of monitoring and measurement
and from other relevant sources.
The analysis of data shall provide information relating to
a) customer satisfaction.
b) conformity to product requirements.
c) characteristics and trends of processes and products, including
opportunities for preventive action and
d) Suppliers
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4. Analysis of Data
EMHS Data for Analysis:
• Customer Feedbacks (CSI)
• Customer Complaints
• Crane Stoppages (Lean)
• Design Concession Requests
• Plant Machinery Breakdowns
• Customer NC’s during inspection at our works
• NC’s raised during ISO 9K Internal Audits
• NC’s raised during Site Audits
• NC’s raised during internal inspection of Cranes
• Supplier Rejections
• Customer Order Loss
• Accidents, Near Miss Accidents,
• Sale Meet Minutes, Service Meet Minutes, KRA/KPI Review Meet Minutes,
etc
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5. Clauses from ISO 9001:2008
8.5.2 Corrective action
The organization shall take action to eliminate the causes of
nonconformities in order to prevent recurrence. Corrective actions
shall be appropriate to the effects of the nonconformities
encountered.
A documented procedure shall be established to define requirements
for
a) reviewing nonconformities (including customer complaints),
b) determining the causes of nonconformities,
c) evaluating the need for action to ensure that nonconformities do
not recur,
d) determining and implementing action needed,
e) records of the results of action taken and
f) reviewing the effectiveness of the corrective action taken
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6. Clauses from ISO 9001:2008
8.5.3 Preventive action
The organization shall determine action to eliminate the causes of potential
nonconformities in order to prevent their occurrence. Preventive actions
shall be appropriate to the effects of the potential problems.
A documented procedure shall be established to define requirements for
a) determining potential nonconformities and their causes,
b) evaluating the need for action to prevent occurrence of
nonconformities,
c) determining and implementing action needed,
d) records of results of action taken and
e) reviewing the effectiveness of the preventive action taken.
Tools for Preventive Actions are – PFMEA (Process Failure Modes & Effect
Analysis), DFMEA (Design Failure Modes & Effect Analysis), etc
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7. INTRODUCTION TO ROOT CAUSE ANALYSIS

8. INTRODUCTION
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In any organization numerous problems exist in all facets of its
activities. The efficiency and survival of the organization depends
on how promptly these problems are recognized and their root
causes are isolated and eliminated.
A systematic analysis of each potential problem area should be
Carried out to recognize the root causes which are responsible for
creating the problem.
Such analysis is called as Root Cause Analysis.

9. INTRODUCTION
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A root cause is a cause that once removed from the problem
prevents the final undesirable event from occurring or recurring.
Why Determine Root Cause?
• Prevent problems from occurring / recurring
• Reduce possible injury to personnel
• Reduce rework and scrap
• Increase competitiveness
• Promote happy customers and stockholders
• Ultimately, reduce cost and save money

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Follows a specific set of steps:
• Define the problem
• Collect data
• Identify possible factors
• Identify root cause(s)
• Identify & Implement solutions
• Verify the effectiveness of the
implemented solutions
ROOT CAUSE ANALYSIS STEPS

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DEFINE THE PROBLEM:
• What happened?
• When did it happen?
• Where did it happen?
• What was the impact?
STEP 1

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COLLECT DATA:
•What proof do you have that the problem
exists?
•How long has the problem existed?
•What is the impact of the problem?
STEP 2

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Cause and effect diagram (also known as
Ishikawa diagram or fishbone diagram) is an
analysis tool to analyze many potential or
actual causes of a problem in a systematic way.
It is a very effective way of improving the
quality of the product or service.
STEP 3&4: IDENTIFY THE POSSIBLE FACTORS & ROOT CAUSE
(TECHNIQUE NO.- 1)

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ISHIKAWA DIAGRAM / FISH BONE DIAGRAM
Material Environment
Men Measurement
Machine
Quality
Assemblies
Components
Suppliers
Consumables
Procedures
Policies
Accounting
Noise level
Humidity
Temperature
Lighting
Training
Experience
Skill
Attitude
Variability
Tooling
Fixtures
Technology
Instruments
Gauging
Counting
Tests
Major and Subsidiary Causes

15. EXAMPLES:
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Machine factors
• Inadequate process capability
• Incorrectly designed
• Worn components
• Poor maintenance
• Equipment effected by environmental factors such as
heat, humidity etc.
Material factors
• Use of untested materials or wrong selection of material
• Substandard material accepted on concession
because of non-availability of correct material
• Inconsistency in specifications on the part of vendors

16. EXAMPLES:
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Men factors
• Incorrect knowledge of doing settings, assembly, etc
• Careless operator and inadequate supervision
• Undue rush by the operator to achieve quality targets
• Lack of understanding of drawing instructions relating
to a process
• Operator does not posses requisite skill for handling
the equipment
Method factors
• Inadequate process controls
• Non availability of proper test equipments
• Test equipment out of calibration
• Vague inspection/ testing instructions
• Inspectors do not possess the necessary skill
• Methods / Work Instructions not defined

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ASK WHY 5 TIMES:
5 whys – Ask “why” until you get to the root of the problem
Very often, the answer to the first "why" will prompt another
"why" and the answer to the second "why" will prompt
another and so on; hence the name the 5 Whys strategy.
Benefits of the 5 Whys include:
• It helps to quickly determine the root cause of a problem
• It is easy to learn and apply
STEP 3&4: IDENTIFY THE POSSIBLE FACTORS & ROOT CAUSE
(TECHNIQUE NO.- 2)

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• For better effectiveness
• Ease of Implementation
• Return on Investment
(not always applicable especially with Safety
Incidents)
• Prevent Potential Negative Effects –
solution shall not cause other problems
Evaluate Solutions before you implement them
IDENTIFY THE SOLUTIONS:

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TYPES OF SOLUTIONS
5
What can be done to prevent the problem
from happening again?
Two types of solutions:
1. Corrective – reactive, the problem has
already occurred
2. Preventative – proactive, problem has not
happened yet
All the solutions shall be recorded.

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This is essentially the action plan -
• How will the solution be implemented?
• Who is responsible for the solution?
• Target dates for completion
Action plan to reviewed periodically for timely
implementation of solutions.
IMPLEMENTATION OF SOLUTIONS

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• It is not verification of implementation.
• It is the verification of the effectiveness of
the actions taken.
• Poor results found in effectiveness
verification often indicate - wrong Root
Cause or wrong Corrective / Preventive
Action(s).
• Consider performing audits as a
verification tool.
VERIFICATION OF EFFECTIVENESS

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• Closure can only happen after successful
verification of Corrective / Preventive
Actions
• By nature, effective Corrective / Preventive
Actions will prevent recurrence / occurrence
• If Corrective / Preventive Actions are found
to be not effective, then Root Cause Analysis
should be repeated.
• Record the date of closure.
CLOSURE OF SOLUTIONS IMPLEMENTED

23. THANK YOU FOR YOUR TIME.