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3.

RCA METHODS
5WHYS
Cause

Effect
5WHYS
WHY 1 :Why my car had stopped ?
No petrol in tank
WHY 2 :Why i did not have a petrol in my tank ?
I did not buy in the morning on my way to work WHY 3 :Why i
did not buy a petrol ?
No money in my pockets
WHY 4 : Why no money i my pockets?
Evening poker
WHY 5 : Why i did not win a poker game?
I do not know how to bluff!
CAUSE AND EFFECT ANALYSIS (MAP)
Masalah dalam perusahaan menjadi kemunduran yang mengarah
pada suatu kegagalan. Itu semua tergantung pada bagaimana kita
memulai memecahan masalah.
Cara yang baik untuk mencegah terjadinya hal-hal yang tidak
diinginkan adalah dengan analisis yang tepat mengenai situasi bisnis,
identifikasi akar permasalahan (root cause) dan penyelesaian situasi.
Oleh karena itu kebutuhan untuk memiliki cause and effect analysis
yang efisien dan efektif.
Dalam bab ini kita akan mencari akar permasalahan dengan
menggunakan tools cause and effect anaalysis.
3 LANGKAH DASAR CAUSE AND EFFECT
MAPPING
1. Goals (The Outline)

2. Causes

3. Solutions
WHAT IS A CAUSE MAP?
A Cause Map memberikan penjelasan visual tentang
mengapa suatu insiden terjadi. Hal ini menjelaskan
hubungan sebab-akibat individu untuk mengungkapkan
sistem penyebab (cuse map) dalam suatu masalah/
problem. Cause Map bisa sangat mendasar dan bisa
sangat rinci tergantung pada masalahnya.
HOW TO READ A CAUSE MAP
Start on the left. Read to the right saying "was caused by" in place of
the arrows. Investigating a problem begins with the problem and then
backs into the causes by asking Why questions.

The questions begin, "Why did this effect happen?" The response to
this question provides a cause (or causes), which is written down to the
right.
Writing down 5-Whys, shown below, is a great
way to start an investigation because it's so simple.
In the Cause Mapping method, a problem within an organization is
defined by the deviation from the ideal state. A Cause Map always
begins with this deviation which is captured as the impact to the
organizations overall goals.
In addition to the standard Why questions, which tend to create linear cause-
and-effect relationships, the Cause Mapping method also asks "What was
required to produce this effect?" Anything that is required to produce an effect
is a cause of that effect. This question, "What was required?," builds a detailed
Cause Map that provides a more complete representation of the actual issue.
5-WHYS ON A CAUSE MAP
Problems within an organization are typically not singular. In the real world, a
problem typically impacts more than one goal. The Cause Map starts with the
impact to the goals even if more than one goal is impacted. If the causes are all
part of one incident then the causes and the goals will all be connected on one
Cause Map.
SOME CAUSES ARE LINKED WITH
AND IN BETWEEN
ANDs show where more than one cause is required. When an effect
has more than one cause, both causes are placed on the Cause Map.
Each cause is connected to the effect with an AND placed inbetween.
These causes are independent of each other, but they are both
required to produce that effect. An AND is needed when people
provide different, yet valid, explanations of a cause.
MIND MAP OF CAUSE MAPPING
TITANIC SHIP CAUSE MAP SAMPLE
TITANIC SHIP CAUSE MAP SAMPLE
4.ISHIKAWA FISHBONE
DIAGRAM
FISHBONE DIAGRAM (FBD)
Teknik FBD ini bertujuan untuk mendapatkan root cause
dan bukan hanya gejala.
Kaoru Ishikawa, pelopor Quality Jepang,
memperkenalkan diagram 'Fishbone' yang sangat visual
membantu seluruh tim fokus pada hal ini dan cepat
mencapai tujuan. Diagram ini:
FISHBONE DIAGRAM (FBD)
FISHBONE DIAGRAM STEPS
1. Problem Statetement
Tentukan masalah yang akan dicari rootc cause. Letakan “The Problem” pada kepala
ikan (head of the fish)
2. Potential Casuse of Problem Identification
Lakukan identifikasi penybab masalah (the cause of problem) dengan melakukan
inverstisigasi dan pneulusuran dokumen terkait.
3. Cause Categories
Lakukan klasifikasi penyebab masalah sesuai dengan kategori. Letakan pada rusuk
ikan (fishbone)
4. Root Cause Analysis
Lakukan analisa pada semua “cause” dan tentuka akar masalahnya
5. Give Solution
Berikan solusi unutk mencegah akar masalah terulang lagi.
TITANIC SHIP FBD SAMPLE
5.FAULT TREE ANALYSIS
FAULT TREE ANALYSIS
Digunakan untuk reliability engineering and system safety engineering
Dikembangkan 1961 untukUS ICBM program dipublikasikan 1981
Digunakan hampir disemua displin engineering
APPLYING FAULT TREE ANALYSIS
Tetapkan top event (fault)
Buat cabang dari berupa list faults dari sistem yang
mungkin menyebabkan top event terjadi
Pertimbangkan urutan ,parallel or atau kombinasi
dari faults
gunakan Boolean algebra untuk menqualifikasi
quantify fault tree with event probabilities
Tentukan probability of top event
FAULT TREE LOGIC

Use logic gates menunjukan


bagaimana peristiwa terjadi
Top event adalah hasil dari semua
peristiwa
FAULT TREE SYMBOLS
Simbol utama Simbol Gate
AND
Basic Event
OR
Conditioning Event
Exclusive OR
Undeveloped Event
Priority AND

External Event Inhibit

Intermediate Event SymbolTransfer Symbols


Transfer IN Transfer OUT
UNION
No Current A=B + C
A
A=B Union C
B OR C must occur
for event A to occur

B C
Switch A Battery B
Open 0 Volts
INTERSECTION
Over-heated D=E * F
D Wire
D= E Intersection F
E AND F must occur
for D to occur

E F
5mA Current Power Applied
in System t >1ms
COMMON MISTAKES IN
FAULT TREES
Inputs with small probabilities
Passive components
Does quantified tree make sense
Don’t fault tree everything
Careful with Boolean expressions
Independent Vs dependent failure modes
Ensure top event is high priority
All failures cause faults; not all
faults are caused by failures
FAULT TREE ANAYSIS
Graphical model that displays the various combinations of equipment
failures and human errors that can result in the main system failure of
interest.
Identification/assessment of risk is derived
by first identifying faults/hazards. A top down approach.
CONTOH KASUS

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