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You_Exec_-_Root_Cause_Analysis_Toolbox_Light_Free (1).pptx
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- 2. CAUSE AND EFFECT ANALYSIS (ISHIKAWA/FISHBONE) Drop in app usage MARKETING SUPPORT INFRASTRUCTURE TRENDS USABILITY COMPETITION Company reputation Inadequate market New to market Small security breach Lack of quality documentation Little public forum support Inadequate support Chat Chatbot Call center Email Performance Lack of adequate IT resources File servers Database Users have moved on Users want different technologies Users want to better integrate With other systems Platform Features Few new features Not intuitive Poor navigation Poor performance Sucks up resources OS updates APP Crashing Poor coding Larger budget More aggressive marketing More cutting edge Better product More polished reputation
- 3. FAILURE MODE &EFFECTS (FMEA) ANALYSIS Process Step/Input Potential Failure Mode Potential Failure Effects SEVERITY (1-10) Potential Causes OCCURANCE (1-10) Current Controls DETECTION (1-10) RPN Action Recommended Responsible Actions Taken SEVERITY (1-10) OCCURANCE (1-10) DETECTION (1-10) RPN What is the process step or feature under investigation? In what ways could the step or feature go wrong? What is the impact on the customer if this failure is not prevented or corrected? What causes the step or feature to go wrong? (how could it occur?) What controls exist that either prevent or detect the failure? What are the recommended actions for reducing the occurrence of the cause or improving detection? Who is responsible for making sure the actions are completed? What actions were completed (and when) with respect to the RPN? Fill carafe with water Wrong amount of water Coffee too strong or weak 8 Faded level marks on carafe 4 Visual Inspection 4 128 Replace old carafes Mel Carafe replaced 9/15 8 1 3 24 8 Water spilled from carafe 5 None 9 360 Train employees Flo Trained on 9/20 8 2 7 112 Water too warm Coffee too strong 8 Faucet not allowed to run cool 8 Finger 4 256 Train employees Flo Trained on 9/20 8 2 6 96 8 Employee unaware of need for cool water 7 None 7 392 Train employees Flo Trained on 9/20 8 1 8 64 Unclean carafe Foreign objects in coffee 10 Carafe not washed 4 Visual Inspection 4 160 Appoint inspector before storage Alice Vera appointed 9/21 10 1 4 40 Bad tasting coffee 10 Carafe stored improperly 7 Training 5 350 Create storage & instructions Alice Bin & visual instructions done 9/25 10 2 3 60
- 4. Airspeed anomaly: blocked probe Keyhole wasp ecology & behavior Keyholewasp ecology & behavior Keyhole wasp ecology & behavior Training Hardware systems/ alerting technology Pilot rejects takeoff Training Hardware systems/ alerting technology Pilot rejects takeoff Training Hardware systems/ alerting technology Pilot rejects takeoff- failed recovery Training Hardware systems/ alerting technology Pilot rejects takeoff- failed recovery BOW TIE ANALYSIS Low speed rejected takeoff B2 B2 B1 D1 Runaway overrun C5 B3 C3 C4 Return to land C4 B3 B2 C2 High speed rejected takeoff B2 B3 B1 D1 Keyhole wasp Research project Wasp control Airport inspections Awareness raising Pitot covers Pitot design Pitot heating Pitot covered Maintenance inspection Covers removed
- 5. PARETO ANALYSIS (80/20RULE) Wrong supplier Excess count Too few count Wrong size Wrong instrument set Missing item Damaged item Other 0 20 40 60 80 100 -20% 0% 20% 40% 60% 80% 100% Frequency Cumulative percentage USEFUL MANY VITAL FEW
- 6. Situation Appraisal A PROCESS KEY Problem Analysis B Decision Analysis C Potential problem analysis D Potential opportunity analysis E Performance System F 8DANALYSIS What is the problem or change? What do we need to know to resolve it? What did change to cause a loss of oxygen and power? Recognize team efforts Select and verify corrective actions Implement permanent corrective actions Prevent recurrence Identify opportunities for continuous improvement What should change to restore oxygen & power? What could change on the way home that would jeopardize their safe arrival? What could change on the way home that would enhance their safe arrival Deviation(s) defined Assemble a team Describe the problem Implement containment actions Identify and verify root causes C D5 D D6 D D7 E D8 F Y A D0 A D1 B D2 D D3 B D4 Problem
- 7. EVENTS FAILURE CAUSEANALYSIS The management fearing any negative consequences from an inspector's report Inspector inspects the home or school Do not challenge the report, but appraise the inspector Inspector interprets compliance with the standards Actively encouraging and promoting a no restraint policy Child leaves the hose Inspector provides subjective advice on the use of retrain Inspector not trained or operationally competent to do so Manager not trained or operationally competent to do so Staff fear discipline/ precautions Staff don’t stop the child from leaving Advises that children cannot be stopped or restrained Child is harmed Secondary Events Primary Events Secondary Events Systematic and/or casual factors Systematic and/or casual factors
- 8. Mis-allocation No clear rules Chartof accounts “messy” Growth is not planned Missing efficiencies in business Lack of clear management lines Information lagging – not in real time Weak budgeting Need to measure and report on actual and not perceived profitability MIND MAPPING FOR ROOT CAUSE Need for clarity of what is delivering profit to the business Business Structure Overheads Reporting
- 9. Requirements - WHATs Importance Rating Inputs – HOWs Admissions interview procedure Fields available for admissions use Statement design Coding procedures Admissions training Coders Training Patient charts readability Statement printing and mailing Admitting department Discharging department Responsibleparty accurate High +++ ++ +++ ++ Insurance accurate High +++ +++ +++ ++ Charity Qual. Identified Medium +++ +++ ++ +++ ++ Insurance payment status High +++ + Amount due clear Medium +++ + Due date correct Low +++ + Procedure coded correct High ++ +++ ++ ++ ++ Submitted for proper insurer High +++ ++ +++ ++ + Insured info accurate High +++ +++ +++ ++ + Easy to read statement Low +++ + CAUSE AND EFFECT MATRIX
- 10. WASTE DEFINITION EXAMPLEOF POTENTIAL WASTE WASTE LEVEL DESCRIPTION OF ISSUES Skills Waste from making more product than customers' demand Wasted time, resources, and costs when unnecessarily moving products and materials Wastes resulting from excess products and materials that aren't processed Waste from a product or service failure to meet customer expectation Wastes related to more work or higher quality than is required Wasted time and effort related to unnecessary movements by people Waste from time spent waiting for the next process step to occur Wastes due to underutilization of people's talents, skills and knowledge • Excess WIP • Unstable production schedules • Inaccurate forecasts and demand information • Materials moved multiple time without adding value • WIP moved from workstation to stores then to workstation • Excessive raw materials in stores • Excess volume of WIP on shop floor • Excess volume of finished goods • Poor quality control at production level • Poor machine repair • Lack of process standards and controls • Not understanding the customers' needs • Human error • Poor communication • Too much physical movement to achieve desired outcome • Poor workstation layout resulting in excess movement • Unplanned down time of machines • Poor planning of production to forecast errors • Poor management • Lack of training • Poor communication LOW LOW MEDIUM LOW MEDIUM LOW HIGH MEDIUM There were no excess WIP or raw materials, everything was being produced to order (JIT style) Workflow is well optimized with minimal excess movement of materials Some of the 'standard' items not manufactured inhouse have excess quantity compared to current forecast Good quality control throughout the production process with multiple checks being carried out Everything was flowing through production, however, there were lack of work instructions on some workstations Workstations have been optimized for operator efficiency; flowline has been optimized At time of review, one of the feed bowl systems was down need to improve preventive maintenance plan Most operators did not know all of the production steps, therefore staff rotation is limited 8 WASTES TABLE FOR RCA Date of Evaluation Feb 15, 20XX Process Area Under Review Production of new product part Waiting Motion Over-processing Defects Inventory Transportation Over-production
- 11. FIVE WHYS ANALYSIS Inadequateproject management Cadre not specified System downtime Task done manually due to system downtime Project deadline missed Report not submitted Suppliers not paid Late delivery of goods Team failed to complete tasks on time No one to run the report Late delivery Dispatch delayed Task priorities were not well-defined Person responsible on leave Job took too long Magazines not ready on time Project manager didn’t communicate clearly No person to cover Ran out of paper Delay in supply of materials Lack of regular project progress reviews No support staff Incorrect ink used Wrong specification sent to supplier Over-reliance on informal communication methods No recruitment Incorrect ink in store Mix-up by purchasing division ISSUE WHY 1 WHY 2 WHY 3 WHY 4 WHY 5 ROOT CAUSE
- 12. • Influence oflocal trade unions resisting foreign brands • Market control by a few large distribution networks • Local elites prefer established, incumbent brands • Local customers are hesitant to trust foreign brands • Valuing personal relationships over digital interactions • Restrictive import taxes increased product costs • Local content Bureaucratic delays in obtaining licenses and permits • Weak partnerships with local distributors or influencers • Inadequate localization of messaging and brand positioning. • Inadequate local training programs for new users • Poor integration of local payment methods. • Poor availability of customer support in local languages • Inconsistent supply chain for timely product distribution POWER ROOT CAUSE REGULATION ROOT CAUSE MINDSET ROOT CAUSE CONNECTION ROOT CAUSE COMPONENT ROOT CAUSE RESOURCE ROOT CAUSE Potential customer base in new market demonstrated interest in our offerings, yet sales figures failed to meet projection by more than 50%. PROBLEM MINDSET ROOT CAUSE What local beliefs, values, or attitudes may have caused the problem? RCA MAP CONNECTION ROOT CAUSE How have the current connections and exchanges between local customers and organizations caused the problem? RESOURCE ROOT CAUSE How is the availability and quality of local resources causing the problem? REGULATION ROOT CAUSE What policies or regulatory measures caused the problem, and how? COMPONENT ROOT CAUSE How is the design and delivery of local programs or services causing the problem? POWER ROOT CAUSE In what ways do local power dynamics cause the problem?
- 13. 11 8 276 2 28 19 Total ISSUE CHECK SHEET Wrong orders Reworked orders Late deliveries Shipping damage Late payments Monday Tuesday Wednesday Thursday Friday Saturday Sunday
- 14. ISSUE REPORT ROOT CAUSEVerified By Verified Date 1 Revision: Reinspection by QE showed discrepant tools (2) are s lightly longer (.437) than nondiscrepant tools of lot. Also noted was EDM pattern displayed over etch condition causing a wash-out or rounding of the features. A Osbourn 1/12/2012 2 Sampling size by Final Inspection not adequate to screen out discrepant tools. A Osbourn 1/12/2009 3 Revision: EDM operator did not adjust machine or hit target during EDM burn causing the Discrepancy. Operator burn too deep on part and did not verify the depth. Machine allows for manual adjustments during processing to hit the target A Osbourn 1/12/2009 CORRECTIVE ACTION Owner Date Done? Verified By Verified Date 1 Revision: Retrain EDM operators for proper adjustment and verification of EDM machine and target depth. M. Hernandez 1/8/2012 ✓ A Osbourn 1/8/2012 CONTAINMENT Owner Date Done? Verified By Verified Date 1 Locate, remove from stock, and quarantine all units from referenced build. M. Hernandez 1/8/2012 ✓ A Osbourn 1/8/2012 2 Inspect all remaining parts: fourteen (14) parts pulled from stock for applicable "T" dimension E Miller 1/8/2009 A Osbourn 1/8/2009 3 Reinspection (see item 2 above) found one (1) additional tool that exhibited the referenced discrepancy. Tool was segregated and scrapped E Miller 1/8/2009 ✓ A Osbourn 1/8/2009 4 Revision 100% inspection of stock, shipping and Final Inspection for 'T' parameter of referenced tool. Y Chavez 1/11/200 9 ✓ A Osbourn 1/12/2009 CUSTOMER PROBLEMS “T” size is out of specification COMPANY’S FINDINGS Measurement of referenced tool confirms customer complaint of T“ dimension not conforming to 0.0032”+/-0.0003”s specification, is 0.00365”
- 15. ROOT CAUSE EVIDENCE VALIDATION Cause 1.1 Cause 2.1 Cause 2.2 AND Cause 2.1.1 Cause 2.1.2 Cause 2.1.3 Cause 1 Cause2 Cause 3 Evidence in favor of cause 1 Evidence against of cause 1 Evidence in favor of cause 2 Evidence against of cause 3 Evidence against of cause 3 Evidence in favor of cause 2.1 Evidence against of cause 2.1 Evidence in favor of cause 2.2 Evidence against of cause 2.1.3 Evidence against of cause 2.1.2 Evidence in favor of cause 2.1.1 This cause is necessary but not sufficient. i.e., all the causes must happen to trigger the parent cause This cause is not necessary but sufficient. i.e., it can trigger the parent cause but if it does not occur, the parent cause can still be triggered This cause is necessary and sufficient What is the cause of this effect?
- 16. FROM ROOT CAUSESTO PROPOSED ACTIONS Current consequences Criteria Potential consequences Gap(s) Cause(s) Root Cause(s) Observation(s) (Condition) Root cause-based recommendation(s) Observation based recommendation Root cause-based remedial action(s) Corrective action(s) OPINION / RATING PRIORITIES / OWNERS / MILESTONES BEST DISCUSSED OBSERVATIONS AGREED ACTIONS RECOMMENDATIONS
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- 19. Related Root Cause AnalysisProblem-Solving Frameworks Risk Management Six Sigma The following resources are related to this framework and can save you hours of work. If you’re a free or paid member, log into You Exec first for a better download experience.