RCFA

Dr. Ir. Winarto, M.Sc. 1

Root Cause FailureAnalysis (RCFA)

Departemen Metalurgi & MaterialFakultas Teknik Univ ersitas Indonesia

Dr. Ir. Winarto, M.Sc.

ANALISA KERUSA KA N (FA)

Root Cause Analysis

RootCause Analysis is a method that is used to address a

problem or non-conformance, in order to get to the “root

cause” of the problem. It is used so we can correct or

eliminate the cause,and prevent the problem from recurring.

Traditional applications ofRootCause Analysis– Resolution of customer complaintsand returns.

– Disposition of non-conforming material (Scrap and Repair) via

the Material Review process.

– Corrective action plansresulting from internal and customer audits.



Objective

Through this training course, you will:– Understand the meaning of “RootCause”

– Know the steps used to identify the root cause ofproblems.


What is Root Cause?

Root Cause is the fundamental breakdown orfailure of a process which, when resolved,prevents a recurrence of the problem.

Or, in other words

For a particular product problem, Root Cause isthe factor that, when you fix it, the problem goesaway and doesn’t come back.

Root Cause Analysis is a systematic approachto get to the true root causes of our processproblems.



Philosophy of Root Cause Analysis

Each problem is an opportunity(“golden nugget”)because it can tell a story aboutwhy and how itoccurred.

It is critical that everyone take a personal and active rolein improving quality.

The “true” problem mustbe understood before action istaken.

– Problems are often masked for a variety of reasons To do this well,we mustbe

– Both focused and open-minded

– Both patientand quick

– Above all, we mustbe relentless


Symptom Approach vs. Root Cause

Root Cause

“Errors are the result of defectsin the system. People are onlypart of the process.”

“We need to find out why thisishappening, and implementmistake proofsso it won’thappen again.”

“This iscritical. We need to fixit for good, or it wil l come backand burn us.”

Symptom Approach

“Errors are often a result ofworker carelessness.”

“We need to train and motivateworkers to be more careful.”

“We don’t have the time orresources to really get to thebottom of thisproblem.”

If we do a poor job of identifying the root causes ofourproblems,we will waste time and resources putting bandaids on the symptoms of the problem.



How do we do Root Cause Analysis?

Said simply, Root Cause Analysis is asking whythe problem occurred, and then continuing toask why that happened until we reach thefundamental process element that failed.

The following example illustrates the basics ofRoot Cause Analysis.

Why???


Tools Used in Root Cause Analysis



Fishbone Diagram - A Useful Tool

Using a fishbone diagram while brainstormingpossible causes helps you to focus on thevarious possibilities. Some useful categories:


BrainstormingWHAT IS IT?Brainstorming isa processin which a group quickly generatesasmanyideasasit can on a particular problem and/or Subject.

WHY IS IT USEFUL?Brainstorming isuseful because it can help a group of people utilize itscollective brainpower to generate many ideasin a short period of time. Itstimulatescreativity and promotesinvolvement and participation.

WHEN IS IT USED?To help clarify mutual expectationsand devise ground rulesrelated to ateam’sway of operating.

HOW IS IT DONE?• Identify a topic, problem or issue and make sure there ismutual

understanding of the taskand objective. Write the topic on a flip chart.• Each person presentsone idea going in sequence (Round Robin). If a

person doesn’t have an idea, passand move on to the next person.



Brainstorming (Cont.)

HOW IS IT DONE?• All ideasare recorded on a flipchart.• There isno evaluation or discussion during the session.• Focusis on quantity of ideas, not the quality.• When all ideasare exhausted, take a break. When you come back,

people may have more ideasto add to the list.• Keep the idea generation separate from the evaluation or analysisof

ideas.

BRAINSTORMING GUIDELINES:• Generate asmany ideasaspossible.• Encourage free-wheeling.• No criticism isallowed, either positive or negative.• Equal opportunity to participate.• Record all ideas.• Let the ideasincubate.

During analysis ideas should be evaluated, further analyzed and refined prior to taking further action.


Fishbone DiagramWHAT IS IT?

The Fishbone Diagram (also known asthe Cause & Effect Diagram) isatechnique to graphically identify and organize many possible Causesof aproblem (effect).

WHY IS IT USEFUL?

Fishbone Diagramshelp identify the most likely ROOT CAUSES of aproblem. They can also help teach a team to reach a commonunderstanding of the problem. Thistool can help focusproblem solvingand reduce subjective decision making.

WHEN IS IT USED?

When the need existsto display and explore many possible causesof aspecific problem or condition.Thisdiagram allowsthe team tosystematically analyze cause & effect relationships. It can also help withthe identification of ROOT CAUSES.



Fishbone Diagram

WHAT DOES IT LOOK LIKE?


Fishbone DiagramHOW IS IT DONE?• Name the effect; determine the specific problem to be analyzed. Draw the

diagram with a processarrow to the effect and draw a box around it.• Decide what the major categoriesof the causesare (i.e., people,

machines, measurement, materials, methods, environment, policies, etc.).• Label categoriesimportant to your situation. Make it workfor you.• Brainstorm all possible causesand label each cause under the appropriate

category.• Post the diagram where otherscan add causesto it (i.e., experts, affected

people, processowners, etc..).• Analyze causesand eliminate trivial and/or frivolousideas.• Rankcauses & circle the most likely onesfor further consideration & study.• Investigate the circled causes. Use other techniquesto gather data and

prioritize findings.

GUIDELINES• Try not to go beyond the span of control of the group.• Promote participation by everyone concerned.• Keep chart up to date so it can be used throughout the improvementcycle.



Example: The Washing Machine


Verify the Complaint



Investigate Why


Investigate Why



Investigate Why


Investigate Why



Investigate Why


Root Cause of our Example?



Root Cause of our Example?

Documents

RCFA