Root Cause Analysis - RCA Training Module

This Module will help you to,
Learn what Root cause Analysis is
Learn why Root Cause Analysis has to be followed
Learn When Should Root Cause Analysis be Performed?
Learn How to Determine the Real Root Cause
Learn the Tools used for Root Cause Analysis & how to use those tools for analysis.
Learn Common Errors of Root Cause

1. Root Cause Analysis
Training on
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2. Objective of this Training
•Learn what Root cause Analysis is
•Learn why Root Cause Analysis has to be
followed
•Learn When Should Root Cause Analysis be
Performed?
•Learn How to Determine the Real Root Cause
•Learn the Tools used for Root Cause Analysis &
how to use those tools for analysis.
•Learn Common Errors of Root Cause
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3. What is Root Cause Analysis?
Root Cause Analysisis an in-depth process or
technique for identifying the mostbasicfactor(s)
underlying a variation in performance (problem).
•Focus is on systems and processes
•Focus is not on individuals
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4. Why Determine Root Cause?
Prevent problems
from recurring
Reduce possible injury
to personnel/mission
failure
Reduce rework and
scrap
Increase
competitiveness
Promote happy
customers and
stockholders
Ultimately, reduce
cost and save money
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5. Look Beyond the Obvious
Invariably, the root cause
of a problem is not the
initial reaction or
response.
It is not just restating the
Finding, as it is only the
problem trouble shooting
& not the finding out the
real root cause
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6. Often the Stated Root
Cause is the Quick, but
Incorrect Answer
For example, a normal response is:
•Equipment Failure
•Human Error
Initial response is usually the symptom,
not the root cause of the problem. This is
why Root Cause Analysis is a very useful
and productive tool.
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7. Most Times Root Cause
Turns Out to be Much More
Such as:
•Process or program failure
•System or organization
failure
•Poorly written work
instructions
•Lack of training
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8. When Should Root Cause Analysis be
Performed?
Significant or consequential
events
Repetitive human errors are
occurring during a specific
process
Repetitive equipment failures
associated with a specific
process
Performance is generally below
desired standard
May be SCAR (Supplier
Corrective Action Request), or
CPAR (Corrective Preventive
Action Request) driven
Customer returns (RMA)
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9. How to Determine the Real Root Cause?
8
Assign the task to a person (team if necessary) knowledgeable of the systems
and processes involved
Define the problem
Collect and analyze facts and data
Develop theories and possible causes -there may be multiple causes that are
interrelated
Systematically reduce the possible theories and possible causes using the
facts
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10. How to Determine the Real Root Cause? (continued)
9
Develop possible solutions
Define and implement an action plan (e.g., improve communication, revise processes
or procedures or work instructions, perform additional training, etc.)
Monitor and assess results of the action plan for appropriateness and effectiveness
Repeat analysis if problem persists-if it persists, did we get to the root cause?
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11. Useful Tools For Determining Root Cause
are:
THE “5 WHYS”
PARETO ANALYSIS
(VITAL FEW,
TRIVIAL MANY)
BRAINSTORMING
AND CAUSE AND
EFFECT DIAGRAM
PROCESS
MAPPING
FAULT TREE
ANALYSIS.
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12. 5 Why’s (or Gemba Gembutsu)
•5 Why’s can sometimes be referred as Gemba Gembutsu
(which literally means place and real thing in Japanese)
•5 Why’s typically refers to the practice of asking, five times,
why the failure has occurred in order to get to the root
cause/causes of the problem.
•No special technique or form is required, but the results
should be captured in the work sheet.
•5 why’s are best used when tackling a simple RCA.
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13. Example of
Five Whys for
Root Cause
Analysis
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14. Example of
Five Whys for
Root Cause
Analysis
Cause --Poor Quality of Component
Sl.
No.Why Questions
3W2H Answers
(What, When, Where, How,
How much) Evidence Solution
1
Why Poor
Quality Terminals are contaminatedComponent fallen down
2
Why terminals
are
contaminated?Due to Environmental Issues
Not monitoring Temp.&
Humidity
3
Why
Environmental
Issues?
Before sending to Assembly,
Packing done improper
Staticshield bag (Non
airtight) & No HIC card
found
Vacuumseal it before
sending it to Assembly
4
Why Packing
done improper?
Packingprocedure is not
mentioned in detail in WI on
vacuum sealing it.
WI mentioned with Static
shield bag, which is not
airtight bag
Need to update the
procedure with
Vacuum sealing
process
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15. 2.Pareto diagram
A Pareto diagram is one which Separates the Vital few problems
from the Trivialmany.
Vital -Means very important.
Trivial -Means not so important
or less important. Priority need not
be given now.
0
10
20
30
40
50
60
70
80
90
100
EDBCAFGH
14
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16. 43
31
16
7
3
2
0 0
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
0
5
10
15
20
25
30
35
40
45
50
No
oscillation
PIVIElectrical
test
Final test
and Tap
test
Prebase
test
Crystal
assembly
Base
assembly
Before
SLT
Percentage
Qty
Defect Code
Pareto Chart-Wk-20
Qty
Cum sum
SI No
Defect
descriptionQty
%
Problems
in the
rejects
Cum
sum
1No vibration 43 42.1642.16
5 PI3130.3972.55
3 VI 1615.6988.24
2
Electrical
test
76.8695.10
4
Final test
and Tap test
32.9498.04
6
Precompone
nttest
21.96100.00
7
Component
assembly
00.00100.00
8
Base
assembly
00.00100.00
9
Before
Testing
0.00100.00
102100.00
Pareto diagram-sample data using pareto
15

17. Process Mapping
•This basically involves the
use of primary questions –
WHAT, HOW, WHEN,
WHERE, and WHO.
•Firstly define what is
actually happening, (DOES),
before moving onto
identifying alternatives,
(COULD), and
•Finally deciding (SHOULD).
PRIMARY QUESTIONSWHY?
SECONDARY
QUESTIONS
SELECTION
PURPOSE -
What is achieved
WHY?
What else could be
achieved?
WHAT SHOULD be achieved?
MEANS -
How is it achieved?
WHY THAT
WAY?
How else could it be
achieved?
HOW SHOULD it be achieved?
SEQUENCE -
When is it achieved?
WHY THEN?
When could it be
achieved?
WHEN SHOULD it be achieved?
PLACE -
Where is it achieved?
WHY THERE?
Where else could it be
achieved?
WHERE SHOULD it be achieved?
PERSON -
Who achieves it?
WHY THAT
PERSON?
Who else could achieve
it?
WHO SHOULD achieve it?
The table below outlines the approach taken.
Examine your process maps and ask the following questions.
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18. Brainstorming or
Interviewing:
Most of them are familiar with
brainstorming techniques, however
here are a few reminders:
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19. Cause and Effect
Diagram -
(Fishbone/Ishikawa
Diagram)
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20. Cause and Effect Diagram –Example:
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21. Fault
Tree
Analysis
ResultCause/Result Cause/Result Cause
Result Primary
Causes
Secondary
Causes
Tertiary
Causes
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22. Fault Tree
Analysis -An
Example
Result Cause/Result Cause/Result Cause
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23. Common Errors of Root Cause
•Looking for a single cause-often 2 or 3
which contribute and may be
interacting
•Ending analysis at a symptomatic
cause
•Assigning as the cause of the problem
the “why” event that preceded the
real cause
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24. Successful application of the analysis and
determination of the Root Cause should
result in elimination of the problem
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25. Where Can I Learn More?
•“Solving a Problem & Getting Along: Toward the
Effective Root Cause Analysis”, Khaimovich,1998.
•“The Quality Freeway”, Goodman, 1990
•“Potential Failure Modes & Effects Analysis: A
Business Perspective”, Hatty& Owens, 1994
•“In Search of Root Cause”, Dew, 1991
•“Solving Chronic Quality Problems”, Meyer, 1990
•“The Tools of Quality, Part II: Cause and Effect
Diagrams”, Sarazen, 1990
•“Root Cause Analysis: A Tool for Total Quality
Management”, Wilson, Dell & Anderson, 1993
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26. Recall:
Why determine Root Cause?
What Is Root Cause Analysis?
When Should Root Cause Analysis be performed?
How to determine Root Cause.
•Five Whys
•Pareto Analysis
•Process Mapping
•Cause and Effect Diagram
•Fault Tree Analysis (FTA)
Useful Tools to Determine Root Cause.
Common Errors of Root Cause.
Where can I learn more?
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27. Thank You
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