RCA Tools and Techniques Presentation

TA I K I S H A P H I L I P P I N E S , I N C OPEN CHALLENGE QUICK RESPONSE

QUALITY MANAGEMENT

ROOT CAUSE ANALYSIS

CA / PA BASIC TOOLS

Presented in TPI Makati H.O.
Date: September 11, 2009
CA/PA BASIC TOOLS Rev 0 09.01.09

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

5


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

6


HOME PAGE

• INTRODUCTION

• MODULE 1

• MODULE 2

• APPLICATION
7


INTRODUCTION
To
ROOT CAUSE ANALYSIS

8


Introduction

Introduction MODULE 1 MODULE 2

 Definition of Terms
 What it is
 Why use it
 RCA Process
 How to use it

9


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

10


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

11


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

12


Module 1
Digging for the Root Causes

13


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

14


Histograms- What it is

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

15


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‟.

16


Pareto Chart – How to create it

1. Gather facts about the problem
2. Rank the contributions to the problem in order
of frequency.

17


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.
18


Pareto Analysis Example

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

Pareto of D3 Small Engine Card Faults

600 100

500 80

400

Percent
60
Count

300
40
200
20
100
ec . e r
Sp lan rd pai v al
c t. atp d Boa Re mo
lty Ee d
tFitlte He
r ed fotue h
i tg tec
tmid r y Re r
0 d Fau ee
. ting
h lde isr ni
os fo na m c to 0
ge t mp
Mg
noton Joc
T ou
n
iSo nt Mh
t Ecs
Mi ble t ne tion
ama en
n Ci
tMis s pt n t
ed o nenot
po s nd ds c autio
iee
ra Pr o horn
Co ina
t D po pg
Cmtn
ro ms
orn
fCm
t omeg iBeg
yo
WL
Pr e kol rty
lde l
S am er s
mp om W mp eJo i C L nk
n hio So au ont
C C C D L
Lo T F C Oth
Defect
Count 141 139 69 52 22 20 20 17 17 17 16 13 10 10 10 8 6 5 29
Percent 23 22 11 8 4 3 3 3 3 3 3 2 2 2 2 1 1 1 5
Cum % 23 45 56 65 68 71 75 77 80 83 85 87 89 91 92 94 95 95 100

19



• Example 2 : a series of Pareto charts drill down to more detail:

Fault by Main Cause

100
70 1st level Analysis
gives “Design”
60 80

50

Percent
60
Count

40 as main cause of
30 40

20 failure
20
10

0
ign pon
ent
er
0
2nd level Analysis gives
Des Com d

breakdown of “Design”
Buil Oth
Defect
Count 57 13 4 2
Percent 75.0 17.1 5.3 2.6
Cum % 75.0 92.1 97.4 100.0

Design Faults

100
50
80
40

Percent
60
Count

30
40
20

10 20

le
0 dule rs odu on 0
rM r ati
t Mo Moto rt uc e alib
nec que Sta r ans d IC C n
Con Tor Cold T AS IOP Imo
Defect
Count 21 10 8 8 5 3 2
Percent 36.8 17.5 14.0 14.0 8.8 5.3 3.5
Cum % 36.8 54.4 68.4 82.5 91.2 96.5 100.0

20



• 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

200
80

Percent
60
Count

100 40

20

0 - 10 7E 0
4- 4
116 823 727
788 646 777 780 782 795 564- 8 6- 7 - 564-
66 40
CC CC CC CC CC CC 40- 40- er s
KD KD KD KD KD KD Oth
Defect
Count 18 13 11 11 11 10 9 9 8 138
Percent 7.6 5.5 4.6 4.6 4.6 4.2 3.8 3.8 3.4 58.0
Cum % 7.6 13.0 17.6 22.3 26.9 31.1 34.9 38.7 42.0 100.0

21



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.

22


Pareto Chart and Analysis

A method for showing the distribution of Process Steps
quantitative data and identifying those Pareto

with the greatest impact.
Identify the problem and the potential

Summary
direct or contributing causes

Pareto Charts provide a visual representation of
the variables which contribute to problems or Collect data about each of the potential
direct or contributing causes
issues.

Pareto Charts can be used as a prioritization tool
to aid in focusing on the top issues which
Construct the Pareto Chart:
Causes on Horizontal Axis

contribute to specific conditions.
Frequency of events on Vertical Axis

Pareto analysis is an approach which ranks the
contributing factors and identifies which are the Identify the Vital Few (those with the
highest number of occurrences)
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”, Develop Corrective Action or
sometimes referred to as the “80-20 rule” Improvement Action Plans for those
identified as the Vital Few

23


24


Coffee Break

15 Minutes Break Only

25
 CA/PA BASIC TOOLS Rev 0 09.01.09


CAUSE AND EFFECT
Ishikawa/Fish Bone Diagram
Procedures People

Problem

Equipment Materials
26


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
27


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

28


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

29


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.

30


Sources of Variation - People

People
• The activities of the workers.
• Variations caused by skill, knowledge,
competency and attitude

31


Sources of Variation - Method

Method
• The methods used to produce the
products.
• Variations caused by inappropriate
methods or processes.

32


Sources of Variation - Machine

Machine
• The equipment used to produce the
products.
• Variations caused by temperature,
tool wear and vibration.

33


Sources of Variation - Material

Material
• The "ingredients" of a process.
• Variations caused by materials that
differ by industry, product
and stage of production.

34


Sources of Variation - Environment

Environment
• The methods used to control the
environment.
• Variations caused by temperature
changes, humidity etc.

35


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.

36


Cause and Effect Analysis Example

37


Cause and Effect Diagram (Ishikawa)

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

Ishikawa Fishbone Template
Summary
The development of the cause and effect
Fishbone diagram is credited to Kaoru
Ishikawa, who pioneered quality management
processes in the Kawasaki shipyards. Measurement
Measurement Methods
Methods Machinery
Machinery

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 UDE
headings, namely Machinery, Methods, Causes, inputs,
or sources
Measurement, Manpower, Materials, and of variation
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 Manpower
Manpower Materials
Materials Environment
Environment
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 A UDE is an UnDesireable Effect
be problems by questioning the existence of
causes under each of the six categories.

38


39


Module 2

40


Module 2 Table of Contents


 Five Whys and Fault Tree diagram
 What it is
 How to use it
 Examples
 Summary

41


Five Whys

• Good technique for getting past first impressions
• 5 Whys technique is simply involves being
persistent enough to go beyond the first
impressions.

Continue to investigate the details because there
is often more to the situation than meets the eye.

42


„Five Whys‟ technique is simply involves being
persistent enough to go beyond the first
impressions.

Continue to investigate the details because
there is often more to the situation than meets
the eye.

43


Five Whys

• In problem solving you will find that the first
impressions do not always reveal the real
cause.
• Study the issue, ask why, investigate, as you
get more detail keep asking why. Practice
tells us that after 5 whys you will be close to
the real answer.

44


Five Whys

Original Problem hy? InvestigateAnswer Why?
W

InvestigateAnswer Why?



InvestigateThe Real Answer

45


5 Whys Process

46


Five Whys Example

We have a problem. There is high product waste causing
downtime and low production.
Why is there high waste?
Because the machine is inconsistent. Why?
Because the air valves are sticking. Why?
Because there is water in the lines. Why?
Because … the PM was skipped.
Why would we skip a PM?
…Because we needed more production.

… In this pretend example the problem is not the high
waste. … the problem is the decision to skip the PM.
47


Five Whys
A method for rapidly determining the root cause of a problem

Summary Example
Problem: High reject rate of parts used by
The “Five Why’s” is a method for rapidly downstream aircraft assembly process
determining the root cause of a problem 1) Why? - There is bare material exposed
popularized by Taichi Ohno, the father of the
Toyota Production System. His technique was to 2) Why? - The primer paint coating does not
approach any problem and keep asking “Why” cover the whole part
until he was satisfied that the answer showed him 3) Why? - The priming process does not
what was really the source of the problem. In ensure full coverage
doing so, he then had a good idea of what needed
to be fixed to prevent the problem. He called it 4) Why? - The priming process is never done
the “Five Why’s” because he found over time that the same way twice
by asking “why” five times he usually ended up 5) Why? - The priming process has always
with the right information to go and fix the relied on word-of-mouth training and has no
problem. The Five Why’s should be used by standard process defined
individuals and teams when trying to quickly
assess and determine source of problems. Most To improve, get the primers together to create
problems can be handled this way, however more a standard work method that defines the
complex or life/mission critical problems typically exact sequence and tools for priming the
require a more formal root-cause methodology parts. This will significantly improve the
including documenting the analysis. However, process yield. They can then explore further
even the formal methodology requires asking improvements using their standard work as
“why” over and over again. the baseline.
48
48 CA/PA BASIC TOOLS Rev 0 09.01.09


Coffee Break

15 Minutes Break Only

49
 CA/PA BASIC TOOLS Rev 0 09.01.09


APPLICATION

50


Application Table of Contents


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

51


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 non-
conformity and to prevent its
occurrence.

After
Before
Action 2

Action 1
Time
52


Different Action to Improve Performance

Continual Improvement

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

TIME
53


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
54


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

55


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

56


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

58


Action Reflection
PROBLEM SOLVING SUCCESS

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

59


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

60


61


PREVENTIVE ACTION

62


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
63


Preventive Action Process Flow

1. Identify an Opportunity/Initiative based on gathered
information,
-define the success criteria
Defects Day1 Day2 Day3 Day4 Day5 Day6

Bent Lead 3 0 2 2 9 4

Control Chart Damaged
Leads
2

0
0 4

9
2

0
5

2
1

Joggled 0 7
Leads
Wrong 4 3 15 0 1 2
symbol
Mixed device 5 5 5 8 7 0
15

Chipped 0 5 0 9 1 1
package

Scrap Rework Illegible
symbol
2 0 3 2 0 1

10

Check Sheets
5

0
21
1 3 5 7 9 11 13 15 179
1 23 25 27 29 31 33 35 37 39 41 43 45

Histogram

Pareto Diagram
Scatter Diagrams

64


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

65


SUMMARY
Symptom Problem (Is & Is Not) Containment

What ?
Where ?
When ?
How Big ?
X
Preventive Actions Corrective Actions Root Cause
What about ... Occur Cause Escape Cause

Occur Cause Escape Cause



67


Feeling left-out?
Still clueless?
Friends
don’t
Nobody even
want to
wants to be with
help you?
you?
AND YOU
WONDER WHY? Just tell me where
you are . . .
And I will avoid Afterall,
that place. I am also
your
Friend.
83



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 …”

84
By: Anonymous


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