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Root cause analysis apr 2010

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Michael Sahota
Michael Sahota

Workshop on Root Cause Analysis tools: Ask Why five times and fishbone (Ishikawa) diagram. I use this to teach basic concepts and give people an experience of using the tools.

Tecnologia
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Root Cause Analysis Workshop Michael Sahota
Overview ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
Stop the Line to improve quality, reduce waste and go faster ,[object Object],[object Object],Image by http://www.exchange3d.com
Find the root cause and invent countermeasures to mitigate it ,[object Object],[object Object],[object Object],[object Object]
Caution: countermeasures obey the law of unintended consequences ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Goal is to identify the problem and find countermeasures - not to blame people ,[object Object],[object Object],[object Object],[object Object],[object Object]
Tool #1: ask “Why?” 5 times to uncover details ,[object Object],[object Object],[object Object],[object Object]
Example of Jeff Bezos – CEO at Amazon.com asking “Why?” to find the root cause ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],http://www.shmula.com/987/jeff-bezos-5-why-exercise-root-cause-analysis-cause-and-effect-ishikawa-lean-thinking-six-sigma
Countermeasures identified at Amazon ,[object Object],[object Object],[object Object],http://www.shmula.com/987/jeff-bezos-5-why-exercise-root-cause-analysis-cause-and-effect-ishikawa-lean-thinking-six-sigma
Exercise: Find a partner, pick a problem and ask why 5 times
Tool #2: fishbone (Ishikawa) diagram facilitates looking at the big picture
Demo: Fishbone with Amazon Example
Exercise: Draw, Pardner!
Additional considerations to make this work…
Go and see (Genchi Genbutsu) – Go to the source to see the facts for yourself ,[object Object],[object Object],[object Object],[object Object],[object Object]
Kaizen – continuous improvement in the pursuit of perfection ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],http://www.shmula.com/1112/the-atomic-rules-of-kaizen
Everyone needs to work towards shared goals of quality for this to be successful ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
What questions do you have?

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Root cause analysis apr 2010

Notas do Editor

  1. Example is introduction of Rabbits in Australia.
  2. - Use one persons problem for this exercise and (switch) so other person gets a chance for second exercise. - AFTER: Ask people to share analysis. 1 st time so no criticism or corrections.