Root Cause Analysis - Overview

Root Cause Analysis and Corrective Action (RCCA)

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RCCA - Learning Objectives

The purpose of this module is to: Apply the 5-why technique in problem solving analysis. Identify and understand the direct, contributing and root cause of a problem. Learn the 2 types of corrective action. Utilize a Corrective Action Matrix form to track and drive action item completions.
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Root Cause Analysis - An Overview

Root Cause Analysis and Corrective Action (RCCA) is a process for : Finding the true cause(s) of an event Identifying and implementing corrective actions Assessing the effectiveness of corrective actions Preventing recurrence of the events
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Why Root Cause Analysis ?

Integral part of Continuous Improvement
If we do not take action on problems, we will be wasting our time and all involved will lose interest.

Our Customers expect it ! ISO 9001-2000 requirement Makes good Business sense Keeps us from passing on problems to internal and external CUSTOMERS
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DMAIC process applied to RCCA

Quantify Problem Control
Standardize Improvement

Form Team Scope project RCCA

Make Improvement Analyze

Investigate Root Cause freeleansite.com

Measure
(Customer complaints, Audit findings, Production, Inspection Data, Product returns, Warranty etc)

Understand and State the Problem

Understand the Problem From the event, what is the problem to be solved, or what is the customers concern?
More than one Problem? An event could have more than one problem, with a root cause for each problem.
If you cannot say it simply, you do not understand the problem!
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A Cause . . .
Is a set of circumstances or conditions that: Allows a condition to exist or an event to happen, Or Makes a condition exist or an event happen

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The Critical Five

Direct Cause: The cause that directly resulted in the event. (The first cause in the chain.) Contributing Cause: The cause(s) that contributed to an event but, by itself, would not have caused the event. (The cause after the direct cause.) Root Cause: The fundamental reason for an event, which if corrected, would prevent recurrence. (Last cause in the chain.)
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The Critical Five

Specific Corrective Action: Action(s) taken to correct or improve conditions noted in the event, by changing the direct cause or, The direct cause and the effect.

Preventative Corrective Action: Action(s) taken that prevent recurrence of the condition noted in the event. (Preventive actions must directly address the root and contributing causes to be effective.)
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Root Cause/ Corrective Action

The process requires complete honesty and no predetermined assumptions.

Follow the Data! Dont try to lead it.

A common cop-out: Operator error Why do people not comply? Improper instructions Worn-out tools Improper training Lost expectations
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Root Cause/ Corrective Action

Dont limit the search !
What role did management systems play? Are you looking beyond your own backyard? Remember the 80/20 rule.

Be attentive to causes that show up frequently!

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Root Cause/ Corrective Action

Utilize 5 Whys technique for determination of cause and effect Ask Why? 5 times.
Most problems, even the most serious or complex, can be handled by using the 5 Why technique when coupled with cause chain diagrams.

So, why use the 5 Why technique?

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Root Cause/ Corrective Action

Just keep asking
Why did it happen? Didnt get to work on time. Car wouldnt start. Battery was dead. Dome light stayed on all night. Why? Why? Why? Why?

Kids played in car, left door ajar. .. Why?

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Root Cause/ Corrective Action

The 5 Whys another example Problem: Customers complain about waiting too long to get connected to staff during lunch hours. Why does the problem happen?
Backup operators take longer to connect callers. Backup operators dont know the job as well as the regular operator/ receptionist do. There is no special training, no job aids to make up for the gap in experience and on-the-job learning for back-ups.

Why does it take backup operators longer? Why dont backup operators know the job as well?

Why dont they have special training or job aids?

In the past, the organization has not recognized this need.

The organization has no system to identify training needs.
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Why hasnt the organization recognized the need?

Decomposition Diagram
What it is:
Involves the use of tree structures to break down the area/process under study A tree diagram where all items are included (comprehensively exhaustive) and not repeated (mutually exclusive)
Poor control of manuf. process Don't know how to control the process Didn't achieve spec. first time Large volume of rework in PCB manufacture The designs have been through several iterations Didn't understand implications of spec.

Boards difficult to make

They're designed like that

When to use it:

Can be used as an analysis structure
Operations take no responsibility for their work Operators make lots of mistakes freeleansite.com

Benefits:
Depicts a single dimension of hierarchy

Operators poorly trained?

They rely upon 100% inspection

Why - Why (5 Whys) Analysis

Problem Why?
Poor control of manufacturing process

Why?
Don't know how to control the process

Why?

Why?

Why?

Large volume of rework in PCB manufacture

Boards difficult to make

They're designed like that

The designs have been through several iterations

Didn't understand Didn't achieve spec. implications of spec. first time

Operators make lots of mistakes

Operators take no responsibility for their work They rely upon Operators poorly 100% inspection trained?

suited to both Repetitive and Non-Repetitive Processes

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Why - Why (5 Whys) Analysis

What it is:
A combination of a decomposition diagram and cause and effect diagram in tree diagram format that shows the linkages between an effect and its root cause

When to use it:

When a cause and effect diagram has been built and the primary causes have been identified, the 5 whys is used to delineate the causal linkages between the final effect and the originating root cause. ** Dont be limited to only 5 whys: the end point is the root cause

Benefits:
Establishes the evidence chain (or the hypothesis thereof) so that confirming facts and data can be collected to substantiate the sequence and the critical dependencies between relationships and time sequences Disciplines the problem solving team to critically examine assumptions and evidence in order to support the relationships between each link. How do you know??
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Case of a Broken Photocopier

Why - Why Diagram
Waiting too long Impatience Misuse Not trained Too slow Wrong machine No budget No plan No trainer No plan to replace

MACHINE BROKEN
WHY?

No budget Age "Old reliable"

No perceived need No one responsible Non-business

Too many copies Overuse WHY? No limits WHY?

Wrong type machine Deadlines Not obvious needed No one responsible

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Root Cause/ Corrective Action

Direct Cause: The cause that directly resulted in the event. (The first cause in the chain.)
THIS IS THE ANSWER TO YOUR FIRST QUESTION. (YOUR PROBLEM STATEMENT)

Contributing Cause: The cause(s) that contributed to an event but, by itself, would not have caused the event. (The cause after the direct cause.)
Note: For a simple problem there may not be any contributing causes.

Root Cause: The fundamental reason for an event, which if corrected, would prevent recurrence. (Last cause in the chain.)
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RCCA

The Cause Chain

Root Cause

Contrib. Cause Direct Cause Contrib. Cause EVENT

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Root Cause Analysis

Lets expand on a problem Cause and Effect
Received ticket for safety violation - Car exhaust too loud - Muffler knocked loose from tailpipe - Daughter hit pot hole - Pot holes in road - Winters damage roads - Congress wont approve extra money for better roads - Congress doesnt have extra money - Congress spend money on pork barrels - Too many lawyers in Congress

Solution? Drive in Sweden, where there are fewer Lawyers.

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Root Cause Analysis

Utilize appropriate toolset with the team. Uncover the root cause. Test and formulate corrective action.
Examples:
Brainstorming, Pareto analysis, Cause and Effect analysis, X-Y matrix Process audit, Benchmarking Consensus, mistake proofing (poka-yoke) Statistical analysis, quality function deployment Opportunity for simplification - Integration and standardization (refer to VE & VA module)
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Root Cause/ Corrective Action Corrective Action:

A set of planned activities (actions) implemented for the sole purpose of permanently resolving the problem.

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Root Cause/ Corrective Action

Two types of Corrective Action:

Specific Preventive
These two types of corrective action are quite different in how they are applied and what they do. Not understanding this leads to serious mistakes in fixing problems.
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Root Cause/ Corrective Action

Specific Corrective Action:

Action(s) taken to correct the direct cause. (Corrects, or improves the condition noted in the event, by changing the direct cause, or the direct cause and effect.)

Sometimes called containment Only used to correct the DIRECT cause Does not prevent recurrence !
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Root Cause/ Corrective Action

Preventive Corrective Action:

Preventive corrective actions focus on changing the root cause and any contributing cause(s). You probably wont get a 100% effective fix at just one point (the root cause). You often have to consider two or more contributing causes to ensure the chain is broken.
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Root Cause/ Corrective Action Preventive Corrective Action:

Action(s) taken prevent recurrence of the condition noted in the event. (Preventive actions must directly address the root and contributing causes to be effective.)

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Preventive Corrective Action

Root Cause

Contrib. Cause

Direct Cause Contrib. Cause

EVENT
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Root Cause/ Corrective Action Test the specific solutions to ensure they are valid:
Do the corrective actions eliminate or control the direct cause?

Are the results desirable?

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Root Cause/ Corrective Action Example (ask Team)

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Root Cause/ Corrective Action

Preventive Action Test:

If these preventive corrective actions were in place, would the event have occurred? Are there adverse effects caused by implementing the corrective actions that make them undesirable? Do the preventive corrective actions lower the risk factor of the event to an acceptable level?
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Root Cause/ Corrective Action

Basic elements of reporting:

Restatement of the problem/ event/ objective Data (who, what, where, why, how, etc.) Team (natural work group, qualified) Causes (root, direct, contributing) Corrective Actions (specific, preventive, plant-wide) Milestone dates (Analysis complete, C/A initiated, C/A implemented, Corrective Action Report closed) Follow Up (Is implementation, solution acceptable?)
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Tracking Form - example Basic tracking form Corrective Action Matrix (CAM) Refer to - webpage (tools)

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Tracking Form - example

NOTE: Blank form located on free lean site

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Root Cause/ Corrective Action

Follow-up
A review must be conducted in sufficient detail to assess whether the corrective actions that have been implemented are effective as implemented and are truly preventing recurrence of the event.

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Root Cause/ Corrective Action Effectiveness Measures

The criteria used to evaluate if the corrective actions achieved the desired outcome.
Examples:
Scrap quantities significantly reduced Print was not manufactured to print tolerance. After corrective action, part meets print. Design could not be manufactured with current technology. After corrective action, part can be manufactured with current technology. Parts would not assemble properly. After corrective action, parts would assemble properly.
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Root Cause/ Corrective Action

Did corrective actions work?

Some additional things to consider:
If corrective action implemented differs from proposed, find out why. If better or alternate corrective actions were implemented, document the changes. Periodic checks may be necessary to be sure the corrective actions are still in place. Document using the proper forms.

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Root Cause Analysis - Overview

Root Cause Analysis and Corrective Action (RCCA)

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