Root Cause Analysis Training Ver 0

QUALITY MANAGEMENT

ROOT CAUSE ANALYSIS

By: Sid Calayag Date: September 11, 2009

Training Description Root Cause Analysis training is consist of

lectures and practices (application) that provide participants with a practical understanding of how to do an analysis in identifying the root cause of a problem.

This presentation has two modules. The second module is deleted from this presentation. The hands-on training exercises and samples were also excluded in this presentation.

Presentation set-up Module 1 will guide participants in the creation and use of histograms, Pareto chart and Fishbone diagram. Module 2 will guide participants in the process of creating a good 8 – D Report

Application Section is part of both modules, however, it will require knowledge gained in Module 2 to apply advance application such as the 8 – D Report.

Objectives Module 1: Participants will learn how to: • Create and use Pareto chart in the analysis of a problem • Implement steps for carrying out effective RCA • Select and apply tools that support RCA

Objectives Module 2:

Participants will be able to: • Define and explain the 8 – D as a Problem Solving Method • Apply the 8 Disciplines and Concepts

HOME PAGE

• INTRODUCTION • MODULE 1 • MODULE 2

• APPLICATION

INTRODUCTION

To ROOT CAUSE ANALYSIS

Introduction Introduction

MODULE 1

 Definition of Terms  What it is

 Why use it

 RCA Process  How to use it

MODULE 2

Terms and Definition Cause (causal factor) - a condition or event that results in an effect Direct Cause - cause that directly resulted in the occurrence

Contributing Cause - a cause that contributed to the occurrence, but by itself would not have caused the occurrence Root Cause - cause that, if corrected, would prevent recurrence of a non-conformity and similar occurrences

RCA Definition Root Cause Analysis - a process designed for use in investigating and categorizing the root causes of

events

A process of tracing a Problem to its Origins

Root Cause Analysis Process Step One: Define the Problem

Step Two: Collect Data Step Three: Identify Possible Causal Factors

Step Four: Identify the Root Cause(s)

Step Five: Recommend and Implement Solutions

Module 1 Digging for the Root Causes

Module 1 Table of Contents MODULE 1

MODULE 2

APPLICATION

 Histograms and Pareto Chart  Cause and Effect Diagram  What it is  How to use it  Examples

 Summary

Histograms- What it is

• A chart that graphically display the distribution of a set of data.

Pareto Chart - What it is A Pareto chart allows data to be displayed as a bar chart and enables the main contributors to a problem to be highlighted. It reveals that a small number of NCNs are responsible for the bulk of quality issues, a phenomenon called the „Pareto Principle‟.

Pareto Chart – How to create it 1. Gather facts about the problem 2. Rank the contributions to the problem in order of frequency.

Pareto Chart – How to create it (cont’n)

3. Draw the value as a bar chart. 4. add a line showing the cumulative percentage of errors

5. Review the chart 6. Redefine classifications if necessary.

Pareto Analysis Example • Chart 1 : The chart gives summary information and starts the cumulative % count at the top of the first bar:

600

100

500

80

400

Percent

Count

Pareto of D3 Small Engine Card Faults

300

60 40

200 20

100

Defect

ec . Sp

ir ne pla ar d epa v al t. edat lteecd egdh Bo d R Remo ic t H e E t e y i m t r r t t i t f l t ge oi u F e s u f n y i n d i t 0 o . l e r a c to s d r o nho em F mgp toiM ion E not tMth Mscis tiona rnt ne n Juo t ciS obl angeent o o e o r d o o d s e n C d m T n h u r P nat n n n a s i C i t i e a g S oLe ec a ptst peogs yW rinm kol m t oDmpo optnM m e m tam eurlty k o r r o g pC p C i o f n d C B n o l er s L P i a n h m m e o C L T C CW D J C Lo SoF Oth

Count Percent Cum %

141 139

69

52

22

20

20

17

17

17

16

13

10

10

10

8

6

5

29

23

22

11

8

4

3

3

3

3

3

3

2

2

2

2

1

1

1

5

23

45

56

65

68

71

75

77

80

83

85

87

89

91

92

94

95

0

95 100

* This is a sample output from Minitab Statistical Software

Pareto Analysis Example • Example 2 : a series of Pareto charts drill down to more detail: Fault by Main Cause 100

1st level Analysis gives “Design” as main cause of failure

70 80

60

Percent

40 30

60 40

20 20 10

Defect Count Percent Cum %

ign Des

57 75.0 75.0

2nd level Analysis gives breakdown of “Design”

0

ent pon Com

er Oth

d Buil

13 17.1 92.1

4 5.3 97.4

2 2.6 100.0

Design Faults 100 50 80 40

Percent

0

Count

Count

50

30 20

Defect Count Percent Cum %

40 20

10 0

60

dule t Mo nec Con 21 36.8 36.8

rs Moto que Tor 10 17.5 54.4

le odu on rM r ati uc e alib rt Sta r ans d IC C T AS Cold 8 14.0 68.4

8 14.0 82.5

5 8.8 91.2

0 IOP 3 5.3 96.5

n Imo 2 3.5 100.0

* This is a sample output from Minitab Statistical Software

Pareto Analysis Example • Example 3 : if the original Pareto is very flat, be prepared to cut the defects in a different way, here, it is 40:60 Pareto Chart for Child11 100 80

Percent

Count

200

100

60 40 20

0

Defect Count Percent Cum %

788 646 777 780 CC CC CC CC KD KD KD KD

0 47E 6- 1 3 74811 782 64- 72 2 5 4 6 8 9 6 7 7 66 40- 5 CC CC 40- 5 40KD KD

0 er s Oth

18

13

11

11

11

10

9

9

8

138

7.6 7.6

5.5 13.0

4.6 17.6

4.6 22.3

4.6 26.9

4.2 31.1

3.8 34.9

3.8 38.7

3.4 42.0

58.0 100.0

* This is a sample output from Minitab Statistical Software

Pareto Analysis Example How it helps Pareto Analysis is a useful tool to: •

identify and prioritize major problem areas based on frequency of occurrence;

•

separate the „vital few‟ from the „useful many‟ things to do;

•

identify major causes and effects.

The technique is often used in conjunction with Brainstorming and Cause and Effect Analysis. HINT ! The most frequent is not always the most important! Be aware of the impact of other causes on Customers or goals.

Pareto Chart and Analysis A method for showing the distribution of quantitative data and identifying those with the greatest impact.

Summary Pareto Charts provide a visual representation of the variables which contribute to problems or issues. Pareto Charts can be used as a prioritization tool to aid in focusing on the top issues which contribute to specific conditions. Pareto analysis is an approach which ranks the contributing factors and identifies which are the ones which have the most impact on a problem or issue. Often referred to as an approach for “separating the vital few from the trivial many”, sometimes referred to as the “80-20 rule”

Process Steps Pareto

Identify the problem and the potential direct or contributing causes

Collect data about each of the potential direct or contributing causes

Construct the Pareto Chart: Causes on Horizontal Axis Frequency of events on Vertical Axis

Identify the Vital Few (those with the highest number of occurrences)

Develop Corrective Action or Improvement Action Plans for those identified as the Vital Few

Coffee Break 15 Minutes Break Only



CAUSE AND EFFECT

Ishikawa/Fish Bone Diagram Procedures

People

Problem

Equipment

Materials

Cause and Effect • Cause and Effect Analysis is a tool for identifying all the possible causes associated with a particular problem Valuable for: • Focusing on causes not symptoms • Providing a picture of why an effect is happening • Establishing a sound basis for further data gathering and action • Identifying all of the areas that need to be tackled to generate a positive effect

Cause and Effect Sources of Variation Sources of Variation is categorized as follows 1. People 2. Method

3. Machine 4. Material 5. Environment

6. Measuring System

How to do it • 1. Identify the Problem/Issue • 2. Brainstorm 3. Draw fishbone diagram Place the effect at the head of the “fish” Include the 6 recommended categories shown below People

Method

Machine

Problem or Issue

Material

Environment

Measurement System

How to do it (cont’n) • 4. Align Outputs with Cause Categories

• 5. Allocate Causes • 6. Analyze for Root Causes • 7. Test for Reality

Tip ! The 6 categories recommended will address almost all scenarios. However, there is no one perfect set of categories. You may need to adapt to suit the issue being analyzed.

Sources of Variation - People

People •

The activities of the workers.

•

Variations caused by skill, knowledge, competency and attitude

Sources of Variation - Method

Method

• The methods used to produce the products. •

Variations caused by inappropriate methods or processes.

Sources of Variation - Machine

Machine •

The equipment used to produce the products.

•

Variations caused by temperature, tool wear and vibration.

Sources of Variation - Material

Material

• The "ingredients" of a process. •

Variations caused by materials that differ by industry, product and stage of production.

Sources of Variation - Environment

Environment • The methods used to control the environment.

• Variations caused by temperature changes, humidity etc.

Sources of Variation – Measurement System

Measurement System • The methods and instruments used to evaluate products.

• Variations caused by measuring techniques, or calibration and maintenance of the instruments.

Cause and Effect Analysis Example

Cause and Effect Diagram (Ishikawa)

A visual brainstorming tool used to help identify and categorize potential root causes named for Kaoru Ishikawa.

Summary The development of the cause and effect Fishbone diagram is credited to Kaoru Ishikawa, who pioneered quality management processes in the Kawasaki shipyards. The cause and effect diagram is used to explore potential causes (or inputs) that result in a single undesirable effect (UDE, or output). Causes are categorized under six headings, namely Machinery, Methods, Measurement, Manpower, Materials, and Environment. Potential causes can be arranged according to their level of importance or detail, resulting in a depiction of relationships and hierarchy of events. It is the hierarchy that creates a map that looks somewhat like fish bones, hence the name. The Ishikawa Fishbone Diagram is intended help you brainstorm and search for potential root causes or identify areas where there may be problems by questioning the existence of causes under each of the six categories.

Ishikawa Fishbone Template

Measurement Measurement

Methods Methods

Machinery Machinery

UDE

Causes, inputs, or sources of variation

Manpower Manpower

Materials Materials

Environment Environment

A UDE is an UnDesireable Effect

Module 2

APPLICATION

Application Table of Contents MODULE 1

MODULE 2

APPLICATION

 ISO 9001:2000 CA/PA & IQA Report  Eight Discipline  What it is  How to use it  Examples  Summary

Different Action to Improve Performance Corrective

- the action taken to eliminate the cause of a detected non-conformity (and prevent its recurrence.)

Preventive

– the action taken to eliminate the cause of a potential nonconformity and to prevent its occurrence. After

Before

Action 2 Action 1

Time

Different Action to Improve Performance Continual Improvement

Breakthrough P e r f o r m a n c e

Continual

Continuous

TIME

Corrective Action Steps to Complete Document plan for implementing C/A

Implement Containment Action

Implement the Corrective Actions

Remove the Containment Actions

Verify the Corrective Actions Overtime

V- Verify Corrective Actions

Your Guide in verification 1. Are SOLUTIONS and not PATCHES 2. Are Doable and Time-bounded

3. Will not introduce a new problem or effect

Verify Effectiveness

3 Steps in Verifying Effectiveness 1. The “after” condition eliminates the problem. 2. There is a difference between the “before” and “after” condition. 3. The “after” condition does not create another effect

PROBLEM SOLVING FAILURE

•

Jumping to conclusion

•

Failure to define problem

•

Failure to find the root cause

•

Weak problem solving

•

No execution of corrective action

PROBLEM SOLVING SUCCESS -

Problem is clearly defined. Problem is accepted As an opportunity/challenge to improve - True root cause is found - Implemented an effective and irreversible corrective and preventive action - - Problem did not re-occur

PROBLEM SOLVING SUCCESS Action Reflection -

Which principle or technique will I apply $$$when I get right away back to work?

Your Guide to Conformance • Say what you do – Document the system

• Do what you say – Implement the system

• Prove it – Demonstrate implementation

Use our Standard Form

PREVENTIVE ACTION

PA INITIATIVES The PA initiative may be derived from sources such as: •

Lessons learned USING BENCHMARKING

•

Lessons learned from any other performance issues.

•

Review of preventive/predictive maintenance data records.

•

Analysis of defect trends and outlier fallouts.

•

Lessons learned from actual field failures and customer COMPLAINTS

Preventive Action Process Flow 1. Identify an Opportunity/Initiative based on gathered information, -define the success criteria Control Chart

Day3

Day5

Day1

Day2

Bent Lead

3

0

2

2

9

Damaged Leads

2

0

4

2

5

1

Joggled Leads

0

0

9

0

2

7

Defects

Day4

Day6 4

Wrong symbol

4

3

15

0

1

2

Mixed device

5

5

5

8

7

0

Chipped package

0

5

0

9

1

1

Illegible symbol

2

0

3

2

0

1

15

Scrap

Rework 10

Check Sheets

5

0 21 1

3

5

7

9 11 13 15

17 19

23 25 27 29 31 33 35 37 39 41 43 45

Histogram

Pareto Diagram

Scatter Diagrams

Preventive Action Process Flow 2. Identify an Opportunity based on gathered information - Root cause Analysis considers the potential problem and its future risk - Use error-proofing actions whenever possible - Consider resource needs and costs

3. Identify and Implement Preventive Actions - Verify effectiveness of PA - Document actions into specs, Engineering designs etc. - Confirm that the success criteria was met - did the performance metric improve? - plan to fan-out- create the implementation timeline/roadmap chart

SUMMARY Symptom

Problem (Is & Is Not)

X

What ? Where ? When ? How Big ?

Preventive Actions What about ...

Corrective Actions Occur Cause

Containment

Root Cause

Escape Cause Occur Cause

Escape Cause

Created by: Sid Calayag – Lead Auditor for Taikisha Phils., Inc Quality Management System

Presented by: Sid Calayag “Sorry I don’t accept donation” “I only did it for the love of my company” But CASH is still acceptable if you will not tell anybody about it …”

By: Anonymous

End of Presentation