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Root-Cause-Analysis.pptx
Root cause analysis (RCA) aims to identify the underlying causes of problems in order to develop effective solutions. The key principles of RCA are to correct root causes rather than symptoms, perform analysis systematically using evidence, and identify multiple root causes that may require multiple solutions. The general RCA process involves defining the problem, gathering data, identifying contributing issues and root causes, developing recommendations to prevent recurrence, implementing changes, and ensuring effectiveness. Tools for RCA include cause mapping, 5 whys, Pareto charts, fishbone diagrams, and charts/graphs. Effective RCA requires thorough information gathering and an understanding of the sequence of events.
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Overview of Root Cause Analysis (RCA) emphasizing problem-solving methods to identify root causes.
Principles of effective RCA focusing on systematic analysis and evidence-based conclusions. General process steps outlined.
Explanation of cause mapping including defining issues and visually analyzing causes to prevent recurrence.
Introduction to various RCA tools: 5 Whys, Pareto Chart, Fishbone Diagram, used to identify potential causes.
Application of the 5 Whys technique in a case study showcasing logical progression to uncover root causes.
Use of Pareto Charts and other graphs to define problems and prioritize efforts based on frequency or impact.
Seven best practices for effective RCA emphasizing information quality, knowledge gaps, and investigation techniques.
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Root-Cause-Analysis.pptx
- 1. RCA – RootCause Analysis
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- 3. RCA • Root Cause:The most basic reason for an undesirable condition or problem which, if eliminated or corrected, would have prevented it from existing or occurring.
- 4. Definition • Root causeanalysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. • RCA is based on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms.
- 5. Principles of RCA? •Aiming corrective actions at root causes is more effective than just treating the symptoms of a problem. • To be effective, RCA must be performed systematically and conclusions must be backed up by evidence. • There is usually more than one root cause for any given problem and therefore there may be more than one corrective action.
- 6. General process forperforming root cause analysis 1. Define the problem. 2. Gather data/evidence. 3. Identify issues that contributed to the problem. 4. Find root causes. Identify which causes to remove or change to prevent repeated problem. 5. Develop solution recommendations that effectively prevent repeating the problem. 6. Implement the recommendations / changes. 7. Observe the recommended solutions/changes to ensure effectiveness of eliminating the problem.
- 9. Cause Mapping ofRoot Cause Analysis • “ROOT” refers to the causes beneath the surface. It is the system of causes that shows all the options for solutions. • Do not focus on a single cause as this can limit the solutions set resulting in missing a better solution. • A Cause Map provides a simple visual look at all the elements that produced the problem.
- 10. Root Cause Analysis Problemor Unwanted Event Occurrence Symptoms Apparent Cause Root Cause Problem or Unwanted Event Recurrence Prevent
- 11. Three Basis Stepsof Cause Mapping 1. Define the issue by its impact to overall goals 2. Analyze the cause in a visual map. 3. Prevent or mitigate any negative impact of the goals by selecting the most effective solutions.
- 13. 5 whys Pareto Chart Fishbone or Ishikawa Diagram Chart and/or Graphs Why? Why? Why? Why? Why? Detail Detail Detail Detail Detail Detail Detail Detail Detail Detail Detail Detail Product Processes Procedures People The Problem Promotion Detail Detail Detail Policies Detail Detail Detail Price Detail Detail Detail Place/Plant Detail Detail Detail 80% 10% 5% 5% 50% 25 0 0% Incidences Tools for RCA
- 15. Ishikawa or FishboneDiagram (Cause and effect) Problem Method Machine Materials Environment Management System Man
- 16. Brain storm possiblecauses Problem Method Machine Materials Environment Management System Man Cause A Cause B Cause C Cause D Cause E Cause F
- 17. 5 Whys • Why •Why • Why • Why • Why • Basis for even the 20 million questions
- 18. Five Whys Event: Youare operating a tug that is towing a Vessel in Gulfstream . Suddenly, the tug becomes uncontrollable, which causes the tow hitch to break and extensive damage to the aircraft nose gear results. 1. Why did the aircraft become damaged? - Because the tow bar hit the aircraft. 2. Why did the tow bar hit the aircraft? - Because the tow hitch broke. 3. Why did the tow hitch break? - Because the tug was uncontrollable.
- 19. Five Whys 4. Whydid the tug become uncontrollable? - Because the aircraft was being pulled with a tug rated below 10K draw bar pull. 5. Why was a tug with a rating that was below minimum being used ? - Because the tug operator was unaware of the guidance. 6. Why wasn’t the tug operator aware of the guidance? - Because the tug operator was new and had not been trained on the guidance. - Because the operator was unaware of the guidance. 7. Why hadn’t the employee been trained? - Because there are no procedures for processing new employees. This process can go on if it is determined, via logical progression, that additional factors have a direct bearing on the outcome.
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- 21. Defining the problem Thetackle is the one that has the highest score. This one will give you the biggest benefit if you solve it.
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- 23. 7 Best Practicesto Remember 1. Your root cause analysis is only as good as the info you collect. 2. Your knowledge (or lack of it) can get in the way of a good root cause analysis. 3. You have to understand what happened before you can understand why it happened. 4. Interviews are not about asking questions. 5. You can’t solve all human performance problems with discipline, training, and procedures. 6. Often people can’t see effective corrective actions even if they can find the root cause. 7. All investigations do not need to be equal (but some steps can’t be skipped).
Editor's Notes
- #14 Root Cause Analysis is critical to eliminating non-conformance and non-compliance. In this portion of the training, I'll give you some tools to use. First, I'd like to give you and example of why root cause analysis is critical. I once did an audit on a plant that had a delivery dock. The delivery dock was located so that every time it rained, the dock became wet and very slippery. One of the workers fell and hurt himself while running across the slippery dock. The immediate response was to send him to training about safety precautions. In other words, “Don't run on the dock. Take your time.” The dock was also coated with a non-slip material. Six months later the man fell and was very seriously injured. He sued the company. Problem: The root cause was not discovered the first time. When finally asked why he was always in such a hurry, the man explained that his boss was always “ragging” him for being slow. He had been afraid of repercussions when injured the first time. Since no one asked him the first time, he decided to take the training and keep his mouth shut. It was also discovered that the anti-slip material had worn away. No preventive-action had been taken.
- #16 This is yet more detailed with 6 bones.