Root Cause and problem root Analysis.ppt

Root Cause and identifying source of the proble is the significant soultion of problem

1. Root Cause Tutorial
2013

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More on Hazard Identification Techniques
1.Identify potential hazards that could threaten the safety of your
employees, customers, passengers, company facilities, company
assets, customer property.
2.Rank the severity of hazards.
3.Identify current control measures.
4.Evaluate the effectiveness of each control measure.
5.Identify additional control measures.
One example of a system to proactively identify hazards is to
establish groups to identify safety hazards by following five
simple steps:

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Hazard Identification Program: Assess & Rank
Assess The Risk
Critically assess the risk associated with the hazard.
Factors to consider are the likelihood of the occurrence
and the severity of the consequences.

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Hazard Identification Program: Hazard Controls
Identify The Hazard Control
Once the hazards are identified and the associated risk
approximately ranked, hazard controls should be identified.
The following illustrate how a hazard can be controlled.
–To prevent an unoccupied vehicle from rolling into an aircraft:
Require all vehicles to be chocked, with the parking brake applied
and in placed in “Park.”
–To prevent a fire at the fuel farm: “No Smoking” signs, routine
inspections for electrical connections, leaks and debris, an effective
foam suppression system, an emergency shutoff system, fire
extinguisher, etc.
–Hazards identified at a particular airport: Ensure that operating
procedures are properly documented and implemented.

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Hazard Identification Program
Evaluate The Hazard Controls
The appropriateness of the hazard control should be
assessed.
–How effective is the hazard control?
–Does it prevent the occurrence (e.g., does it remove the hazard and
eliminate or minimize the risk), or does it minimize the likelihood or
the consequence?
–A control, once implemented, must be evaluated to ensure it
minimizes the hazard and likelihood of occurrence.
–Example: Fire extinguishers are placed onboard an aircraft. Is the crew
trained on their use and are the fire extinguishers properly maintained?

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Hazard Identification Program
Identify the need for hazard elimination, avoidance, or for further
controls.
Each hazard and its control(s) should be critically
examined to determine whether the associated risk is
appropriately managed or controlled.
–If it is, the operation may continue.
–If not, improve the hazard control, or remove or avoid the hazard.
In some instances, a range of solutions to a risk may be
available.
–Some may be engineering solutions (e.g., redesign), which are
generally the most effective, but can be expensive.
–Others involve control (e.g., operating procedures) and personnel
(e.g., training) and may be less costly. A balance must be found
between the cost and practicality of the various solutions.

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Safety Risk Management & Safety Assurance Process
System/Task
Analysis (5.1)
Identify
Hazards (5.2)
Analyze Safety
Risk (5.3)
Control/
Mitigate Safety
Risk (5.5)
Assess Safety
Risk (5.4)
Nonconformity
Preventive/
Corrective
Action (6.5)
Production/
Operational
System
System
Assessment
(6.4)
Potential New Hazard
or
Ineffective Control
Conformity
S
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Information Acquisition 6.3
Investigation
(6.2.5)
Auditing
(6.2.2, 6.2.3,
6.2.4)
Continuous
Monitoring
(6.2.1)
Unacceptable
Acceptable
Analysis of
Data/
Information
(6.3)
Oversight
Involvement?
NoYes
Send to
Oversight
Employee
Reporting &
Feedback
(6.2.6)

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Root Cause Analysis: IntroductionRoot Cause Analysis: Introduction
Fatigue origin of the failed tail rotor
drive shaft coupling
ROOT CAUSE

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Root Cause Analysis
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.
Wilson, Dell, and Anderson (1993), “Root Cause Analysis.”
Decision-Makers
Line Management
Organizational Preconditions, i.e.,
Company Culture
Line Activities

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Root Cause Analysis
Wilson, Dell, and Anderson (1993), “Root Cause Analysis.”
Problem or
Unwanted
Event
Occurrence
Symptoms
Apparent Cause
Root Cause
Problem or
Unwanted
Event
Recurrence
Prevent

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Root Cause Analysis
There are many analytical methods and
tools available for determining root
causes to unwanted occurrences and
problems.

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Root Cause Analysis
The “5 Whys” Model
Fishbone Diagrams
Failure Modes Effects Analysis (FMEA)
TapRooT® Analysis
Useful Tools for Determining Root Cause

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Root Cause Analysis
For efficiency and ease of use, we will discuss:
• “5 Whys”
• Fishbone Method
Suggested Tools

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Root Cause Analysis

1.As a group, write down the problem
and describe it completely.
2.Ask why the problem occurs and
write down the answer.
3.If the answer you just provided
doesn't identify the root cause of the
problem that you documented in step
1, ask why again and write that
answer down.
4.Return to step 3 until the team is in
agreement that the problem's root
cause has been identified.
–This process may take fewer or more
than five whys.
The “5 Whys”

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Root Cause Analysis: “5 Why” Example
Event: You are operating a tug that is towing a Gulfstream
IV. 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.

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Root Cause Analysis: “5 Why” Example
4. Why did 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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Root Cause Analysis: “5 Why” Example
As you can see from the preceding
example, asking why is an extremely
simple and effective way to determine
root cause.

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Root Cause Analysis: Fishbone Diagrams
Man
(People)
Machines
Mother Nature
(Environment)
Methods
Materials
Measurements
Fishbone diagrams help to identify the “6 Ms”
(potential causes) that may have contributed
to the undesirable condition or problem.

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Root Cause Analysis: Fishbone Method
Great brainstorming tool!
Focuses on the cause, not the symptoms.
Identifies areas that may need further
investigation.
Process can be enhanced by adding “5 whys.”

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Root Cause Analysis: Fishbone Diagram
Aircraft is
damaged
1.Draw the diagram with the issue to be studied as the fish “head.”

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Aircraft is
damaged
2.Label each “bone” of the fish.
ManMachineMethods
Mother
Nature
Materials Measures
Root Cause Analysis: Fishbone Diagram

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Aircraft is
Damaged
3.Through brainstorming, identify factors in each category
that could affect the undesirable occurrence.
ManMachineMethods
Mother
Nature
Materials Measures
Gauge
Tug
Maintenance
Tools
Rain
Training
Driving
Tow Bar
Behavior
Manuals
Wind
Speed
Root Cause Analysis: Fishbone Diagram

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4.Upon completion of the fishbone, analyze the
results.

5.Then, list the items that were identified in priority
order.
This brainstorming technique, when properly
applied, can be helpful in determining a root
cause to an undesirable condition or problem.
Root Cause Analysis: Fishbone Diagram

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Root Cause Analysis
Remember, the objective of root cause analysis is to
identify the real cause of a problem, not the symptoms.
Hopefully, these simple tools will help you to do just that!