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Root Cause Analysis - Tools, Tips and Tricks to Get to the Bottom of Root Cause
The document presents a detailed overview of root cause analysis (RCA) tools, methods, and practical examples, emphasizing the distinction between direct causes and root causes of problems in processes. It outlines a systematic approach to problem-solving focused on data-driven decisions, visual control, and methods like fishbone analysis and the 5 Whys technique. Additionally, it stresses the importance of standardization and sharing best practices to prevent recurrence of issues in operational processes.
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Root Cause Analysis - Tools, Tips and Tricks to Get to the Bottom of Root Cause
- 1. Root Cause Analysis Tools,Tips and Tricks Presented by: Sean Banayan Presented on: 8th June 2016
- 3. Sean Banayan • BusinessImprovement Manager, Etel Limited • Sean.banayan@eteltransformers.co.nz • +64 27 511 9212 • LinkedIn
- 4. Qualifications • Master ofMechanical Engineering, Auckland University of Technology, NZ • PRINCE2 Practioner, APMG Australasia, NZ • Six Sixma Black Belt Certified, Aveta Business Institute, USA • Lean Manufacturing Operations Management, Aveta Business Institute, USA • TQM(Total Quality Management), Aveta Business Institute, USA • ISO 9001 Management Systems, Telarc, NZ And… •Have learned the Japanese thinking behind Lean and its successful application across a range of industries in Lean Japan Tour, Shinka Management, Australia
- 5. Agenda •Definition •Direct Cause vs.Root Cause •Data Driven Decisions •Data Collection & Visual Control •Clarify the Problem •Quality & Data at Source •Basic Problem Solving • Practical Example •Visual Control •Problem Description •Problem Solving Steps •Identifying the Direct Cause • Fishbone (Cause & Effect Analysis) •Identifying the Root Cause (5 Why) •Sustain & Share Best Practice •Questions
- 6. Definition Root Cause Analysis(RCA) is: •A method of problem solving used for identifying the root cause of faults or problems. •Is the fundamental breakdown or failure of a process which, when resolved, prevents a recurrence of the problem. •It is a systematic approach to get to the true root causes of our process problems.
- 7. Direct Cause vs.Root Cause Direct Cause •It does not prevent its recurrence within certainty. •Usually blames someone • Its only as good as a Band-Aid
- 8. Direct Cause vs.Root Cause Root Cause •It does not attribute blame to anyone. It looks for failure in the system, or process. •It will prevent recurrence of the Direct Cause •It is a proven source of the Direct Cause
- 9. Root Cause Sample Machinethat stopped because it overloaded and the fuse blew Investigation shows that the machine overloaded because it had a bearing that wasn't being sufficiently lubricated The investigation proceeds further and finds that the automatic lubrication mechanism had a pump which was not pumping sufficiently, hence the lack of lubrication. Investigation of the pump shows that it has a worn shaft. Investigation of why the shaft was worn discovers that the Pump Cover which prevents metal scrap getting into the pump has been damaged. This enabled scrap to get into the pump, and damage the shaft.
- 10. Data Driven Decisions Reasonfor choosing the problem • Background information or KPI’s • Effect on you or your group • Links to higher level goals • Customer identified
- 11. Gather data anduse facts • Record what is happening • Manually gather information • Grasp the situation before trying to fix it Data Collection & Visual Control
- 12. Data Collection &Visual Control Collect DATA on defects, changes, incidents and other Key Performance Indicators (KPI’s) Display the DATA as graphs to display combination of standard or target with current situation Supplier Issues Defects per month (%) for 2016 - 2017 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0%
- 13. Clarify the Problem Breakdownthe initial Problem Perception to “one problem you can solve”. This should be the one which has the largest overall impact. Problem Breakdown Employees & Shift Department Category & Type Problem Prioritisation Level of Impact Level of Importance Level of Urgency
- 14. Quality & Dataat Source Quality Check Quality Check Quality Check Quality Check Quality Check •Quality is built-in to each process – Never send Quality defects to next process Data Gathering Data Gathering Data Gathering Data Gathering Data Gathering
- 15. Basic Problem Solving •A problem goes into the Problem Solving funnel Root Cause Fix • Then leaves with a Root Cause Fix PROBLEM STATEMENT
- 16. Basic Problem Solving Initial Problem Description – Explain the problem PROBLEM STATEMENT ROOT CAUSE FIX Fishbone Analysis 5 Why Investigation Follow Up Check Standardisation Share Best Practice
- 17. Basic Problem Solving(Practical Example) Please note – This is a training simulation A problem has occurred in Fabrication department! A number of jobs have failed final quality inspection due to incorrect build We will work through this problem using some basic problem solving tools during this training presentation
- 18. DATE 1 23 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 OK NG > > 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 5 4 3 2 1 Final Inspection Test Bay Other Dept Own Dept Quality AREA: FABRICATION DATE 1 MONTH/YEAR: No. of defects found during month Defect Category Sep-15 KEY - Where Defects Found Defects 132 3 4 5 6 7 14 158 9 10 11 12 Incorrect Part Position Incorrect Plasma Cutting Incorrect Folding Not to Drawing Visual Control (Practical Example)
- 19. We aregoing to use this example from our Quality Balanced Score Card in Fabrication So, what was the Problem Description….? … Jobs failing fabrication inspection due to incorrect build…(Not to Drawing) Problem Description (Practical Example)
- 20. Now thatwe have a clear Problem Description, we are going to work through the following steps – Problem Solving Steps (Practical Example) 1 • Identifying the Direct Cause 2 • Applying a short term immediate action (Band-Aid) 3 • Identifying the Root Cause 4 • Applying a long term Root Cause Fix 5 • Sustain & Sharing Best Practice
- 21. Identifying the DirectCause First we must identify the Direct Cause and implement a short term immediate action (band aid) It usually means we have to add more cost to our process by adding activities such as more inspection etc. This is a very reactive way of working, but we need to do it until a Root Cause to the problem can be found. We can use a Data Analysis graphs to look at a lot of different breakdowns to guide us to what can possibly be directly causing the problem.
- 22. Root Cause AnalysisProblem Solving Describe Describe the problem Quality Defects in Fabrication Clarify Clarify the size of the problem 0 2 4 6 8 10 12 14 16 CARS in Fabrication Defect Inspection in Fabrication 0 5 10 15 Aug/14 Sep/14 Oct/14 Nov/14 Dec/14 Jan/15 Feb-15 Farbrication Defects Fabrication Error Leaking Welds Oil Leak Welding Quality Operator error Missing ID Welded Wrong Parts 11% Missing ID 2% Missing Welds 11% Oil Leak 13% Parts Missing 6% Welded in Wrong Position 55% Welding Splatter 2% FABRICATION ERROR BREAKDOWN Base hold down brackets 4% Door locking brackets 5% Excessive Weld Splatter 5% Internal locating brackets 71% lifting lugs 5% M8 set screws on the HV door. 5% Pole mounting bracket 5% "WELDED IN WRONG POSITION" BREAKDOWN
- 23. Fishbone (Cause &Effect Analysis) This is a good Team brainstorming event which helps to bring lots of ideas forward, regarding the Direct Cause of the Effect, in a short period of time EFFECT (Problem Observed) METHOD MAN MATERIAL MACHINE Enter your Problem Description in the head of the fish Use your Problem Solving Template – Write down lots of ideas that could be causing the problem in the head of the fish Try to group your ideas into the correct categories No Procedures for Checking Parts No Std Method of Positioning Measuring Tools Torches to check inside tanks Lack of Training Drawing Not Clear Welder’s Neglecting to check Wrong Tools Attention to Details Quality Check Method Incorrect Position of Internal Locating Bracket Key Point – No Idea is a Bad Idea!
- 24. Fishbone (Cause &Effect Analysis) Get the Team to vote on what they believe are the most likely direct causes of the problem in the head of the fish. This can be done by placing a tick on the idea Incorrect Position of Internal Locating Bracket MANMETHOD MATERIAL MACHINE No procedure for checking parts Direct Cause Operators do not have standard way of positioning the Internal Locating Brackets Quality Check Method Drawing is unclear PP P P P No Std Method of Positioning P P P P P P PP P Measuring Tools Torches to check inside tanks Drawing Not Clear Wrong Tools
- 25. Fishbone – DirectCause • Remember the importance of CAPTURING DATA? Let’s enter that into our Problem Solving Template • The next thing we must do is put a short term immediate action in place to act as a band aid whilst we find the Root Cause • What could we do? Talk to the Operators? Re-train? More inspection? Manager to check that the job is correct every hour? Update your Problem Solving Template with your short term immediate action (band aid)… P P
- 26. Problem & ContainmentAction Also document the Problem Description and Short Term immediate action into the Problem, Cause, Countermeasure Sheet on the Board Q A 07 Jun Internal Locating Bracket not in correct position Re-train the operator & ask quality inspector to double check September Fabrication P
- 27. Identifying the RootCause • So, we have our Direct Cause ‘No Standard Procedure for Positing the Internal Locating Bracket’… • …we can use a tool called 5 Why to drill further into the Direct Cause to uncover the Root Cause of the problem • It is called 5 Why, but you don’t need to ask “Why” 5 times, you can use as many or as little as you like!
- 28. 5 Why Example DirectCause of problem – No Standard Method of Positioning Part •Why No Standard Method of Positioning Part? – Because operators don’t follow instruction of the drawing •Why operators don’t follow instruction of the drawing? – Because not all drawings are up to date. •Why aren’t the drawings up to date? – The Operators never feedback to engineers for drawing updates. •Why operators never feedback to engineers for drawing updates? – Because there isn’t a formal process to capture the issues and assign corrective actions against a time based plan. This is the Root Cause – If a countermeasure is applied here, it should completely eliminate the problem
- 29. 5 Why –Root Cause • Now we have our Root Cause – ‘No formal process to capture the issues and assign corrective actions against a time based plan’… Let’s enter that into our Problem Solving Template • The next thing we must do is put a Long Term preventive action in place at the Root Cause level to eliminate the problem completely – This will replace the short term immediate band aid we put in earlier! • What could we do? Update your Problem Solving Template with your Long Term Root Cause preventive action… Make sure you put a completion date! P P
- 30. Root Cause &Fix ?Now, let’s write the Root Cause & Root Cause fix action into the Problem, Cause, Countermeasure Sheet on the Board Q A 07 Jun Internal Locating Bracket not in correct position Re-train the operator & ask quality inspector to double check September Fabrication No formal process to capture the issues and assign corrective actions against a time based plan 19 JuneJ.Smith Implement a Formal Process to capture the issues… P Don’t forget to enter the Person responsible for carrying out the action… & If they aren’t there at the time, please let them know!
- 31. Direct Cause VsRoot Cause Let’s have a recap on the differences between Direct Cause & Root Cause DIRECT CAUSE Reactive Direct Cause often assigns blame to people If a countermeasure is implemented at the Direct Cause, it will not prevent a future recurrence Usually requires a short term containment action that is costly in time or resources ROOT CAUSE Preventive Root Cause does not blame anyone – The failure will always be in a system or process If a countermeasure is implemented at the Root Cause it will prevent a future recurrence of the Direct Cause The Root Cause is the proven source of the Direct Cause PO O O O P P P PO
- 32. Sustain & SharingBest Practice •Standardise Successful Processes by documenting in instruction sheets, train members and confirming. •Why do we not standardise in the beginning? Process Company’s Ideal State Standardisation in the beginning before finding the Root Cause Standardisation After finding the Root Cause
- 33.