Root cause and corrective actions - Determining

Root cause and corrective actions

1. A tradition of excellence
TR-822 REV /
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Root Cause and Corrective Action Tutorial
January 21, 2014

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Course Overview
This presentation is an introduction to performing
Root Cause and Corrective Action (RCCA).
The RCCA process includes:
₋ Clearly defining and analyzing a defect
₋ Identifying solutions
₋Carrying out solutions
₋Validating the effectiveness of applied
corrections to eliminate a defect.

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Application
RCCA applies to the activities associated with
correcting and preventing defects related to:
‒all phases of production from raw material to
finished product
‒production processes
‒all aspects of your company’s business
RCCA can be beneficially applied to all
departments and functions in a company.

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Goals
The Goals of this presentation are:
–To provide a working understanding of the roles,
responsibilities & activities associated with RCCA;
–To assist our suppliers in performing this important
function when responding to a SCAR;
–To provide tools to our suppliers that may help in
identifying and addressing defects before they are
delivered to Marvin Engineering.

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Hands on Experience
This afternoon we will provide an opportunity to
apply the concepts provided in this presentation
to:
–Conduct a problem investigation (fact finding).
–Determine the Root Causes (causal analysis)
–Define actions to eliminate the problems (identify
solutions)

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Root cause analysis
 is an
approach to identify the
underlying causes of why an
incident occurred so that
the most effective solutions
can be identified and
implemented
Root Cause Analysis
RCCA comes down to three basic
questions:
 
1.What's the problem?
2.What allowed it to happen?
3.What will prevent it in the
future?
 
The word root, in root cause analysis, refers
to the underlying causes, not the one cause.

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Root Cause Definition
Root Cause:
A condition or action that
begins a chain that ends in a
defect
There are multiple root
causes that can result in the
same problem
Addressing only 1 of many
causes won’t eliminate the
defect.
If effective RCCA is not performed, the problem will reoccur.

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Symptom vs. Root Causes
“Errors are often a result of
worker carelessness.”
“We need to train and
motivate workers to be more
careful.”
“We don’t have the time or
resources to really get to the
bottom of this problem.”
Symptom Approach
•“Errors are the result of defects in
the system. People are only part
of the process.”
•“We need to find out why this is
happening, and mistake-proof it
so it won’t happen again.”
•“This is critical. We need to fix it
for good, or it will come back and
burn us.”
Root Cause Approach
Old New

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The RCCA Process Simplified

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The RCCA Process Detailed
1.Define and confirm the problem
2.Capture (contain) all affected items
3.Restore (rework) the discrepant items to compliance
4.Find the causes of the problem
5.Develop an action plan prevent a recurrence
6.Implement the plan
7.Evaluate the effectiveness of the solutions
8.Provide Objective Evidence of the implemented
solutions

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When to initiate RCCA
Corrective Action triggers:
–Customer SCAR issued
–A Supplier Notification
–Recurring nonconformity
–Audit finding
–Sub-tier supplier defect found

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Define the Problem
A well-written problem statement
answers four simple questions:
• What is the specific problem?
• Where did it happen?
• When did it happen?
• How many or how much is involved?
Phase 1: Investigation

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Problem Statement
The statement of a documented problem (from a
Marvin Engineering SCAR)
–S/B .219 +.002/-.001 Dia. Hole, B/P sheet 3,
zone C-4, section A-A
–IS O/S to .228
Phase 1: Investigation

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Restate the Problem
Problem Restated:
–PN 1534AS1234 has an oversized hole: S/B .219
+.002/-.001 dia.; IS O/S to .228; B/P : sheet 3,
zone C-4, section A-A.
–Work orders: 216, 178 and 230
–Machines: Drill Presses #2 and #9
–Qty. = 121 pcs. on SCAR, 78 pcs. In work
Phase 1: Investigation

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Containment Action
Search to find all items affected by the problem. Isolate
them to ensure they are not processed further, or
shipped to the customer.
Investigate all areas inside and outside the company:
–Work in process
–Open P.O.s
–At outside suppliers, e.g. plating, heat treat
–Shipped to customer
Phase 1: Investigation

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Determine the Root Causes
Phase 2: Analysis
Do not sit at a desk, read the problem
statement, and then “solve” the
issue alone.
Instead, involve others who have
knowledge to offer:
•The Purchasing Agent
•The Machine Operator
•The Quality Inspector

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Work Cell or Facility
Process A
Process B
Process C
Marvin
Engineering
•An escape is movement of
a defect to the next work
area, or to the customer
Escape
E
s
c
a
p
e
Escape
PLUG THE HOLE!
Something Must Change if an Escape Occurs
Escapes

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Why Perform RCCA?
Component
Level
Assembly
Test or
Inspection
By Customer
Design
?
Defects eat your profit.
The later they are found,
the more they cost
Eliminate the defect as far up the stream as possible. At the source.

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Restore affected items
to compliance
Containment
Root Causes
Long Term
Corrective Actions
fix Root Causes and
Prevent Recurrence
Corrective Actions
Defect or
unwanted event
Short Term
Corrective Actions
fix the Defect
Corrective Actions:
Fix the nonconformity and prevent its recurrence

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Corrective Action
Short Term Corrective Action(s) fix
the immediate problem(s)
Long Term Corrective Action(s) fix
the systemic problems at the root
cause level
Generate no additional problems
Phase 3: Decision
IMPORTANT

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Not All Corrective Actions are Created Equal
Corrections that are systemic in nature, like automatic checks or
gates are significantly better than just cautioning an employee to be
more careful
Employee
Counseled
Formal
Training
Warning
on/ in tools,
instruction,
work area
Mandatory
checks &
reviews
Design,
tooling,
kitting,
shadow
boxes,
automated
checking
Control of
process
inputs,
resulting in
controlled
outputs
Corrective Action Continuum
weak STRONG

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When to use Mistake Proofing:
Human error can cause mistakes or defects to occur
The customer can make an error which affects the output
At a hand-off step in a process
Consequences are expensive or dangerous
“..mistakes will not turn into defects if errors are discovered and eliminated..” Shingo
Mistake Proofing
Phase 3: Decision
Elevator

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Verification & Validation
Verification & Validation
–Verification
•Did we do what we said we were going to do?
–Validation
•Were the actions effective in eliminating the problem and
preventing it from recurring?
•Were other problems created because of the changes?

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Objective Evidence
Each SCAR response requires that evidence of the changes made
are provided to Marvin Engineering along with the SCAR
Examples:
Training sign-in sheets for employee training on a new or
changed procedure
A copy of the new or changed procedure
The inspection data validating the First Article Inspection part
from a changed CNC program
A copy of a revised inspection sheet adding a previously
skipped characteristic

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Summary
–The fundamental Root Cause & Corrective Action
(RCCA) process involves
•Containment, Correction, Root Cause Analysis,
Corrective Action, Verification, Validation
–Effective RCCA depends upon:
•A well written problem description - define the
requirement being violated
•A robust causal analysis - use quality tools
•A diligent validation - with data showing
elimination of the root cause
Without these the defect cycle will repeat