Root Cause Analysis By Monica

8/13/2019 Root Cause Analysis By Monica

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Root Cause

Analysis A Tool for

Improvement


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ABC of RCA

Agenda

A. What is RCA?

B. Why do we need to perform RCA?

C. How to do RCA?

D. MQ Template and some other useful tools

E. Q&A


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A.What is RCA?

What is a problem?

Examples:

Person in office suddenly start feeling

giddy, lot of sweating

Car going on a road suddenly starts

coughing, engine dies down slowly

B&CRM generates a wrong bill


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Characteristics of any problem

What is seen in any problem?

Problem statement contains

• Symptoms

• Effects (sometimes)

What is not seen?

• Causes

• Root Causes

Severity? - Is Not always seen at the first instance


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Copyright@2013 SURE! All Rights Reserved.

How do we resolve a problem?

We do a correction. Knowledge & Experience

Example:

Give some cool water to the person un-well, make him sit under a fan

Does this solve the problem?

May be or may be not. Same thing may happen after another couple of hours


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hWhat is RootCause?


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Why correction does not work?

Correction attempts to cure thesymptoms/effects.

But what about causes?

To address causes, we must understandthem

And we understand causes throughRCA


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h

Why to

conduct

RCA?


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Why do we need to perform RCA?

Let us understand the 3 terms associated with Problem Solving

Correction

Corrective Action

Preventive Action


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Problem Solving

Example Correction Corrective Action Preventive Action

Patient:

Make the patient

comfortable and give first

aid

Patient has high BP.

Prescribe a set of

medicines for next few

days

Prescribe some exercises,

diet changes ………

CarFilling water in the

coolant container

Go to a nearest store and

fill up Coolant

Find out why coolant has

disappeared, is there any

leakage, fix that

B&CRM

Generate the correct bill

by doing necessary

changes in data/code

Analyze what other bills

could have gone wrong or

can go wrong. Make sure

that all such bills are re-

generated

How the wrong

program/data came into

system? Improve test

cases, update code

review checklist, train

people ………

Imp

To be done immediately:

making sure the system

restarts, symptom

disappears (at least for

the time being)

Problem is lying

undetected in some other

places. Fix them.

Attempts are made to

prevent the problem from

recurrence


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What are Preventive Actions?

Preventive Action are

Changes to an existing process

Train people

Better process adherence

New process

Tools

Preventive Action are NOT

Blame any person

Blame acts of God


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Corrective & Preventive Action Process?

Audits MonitoringEmployee

SuggestionsIncidentReports

Other Sources

Corrective & Preventive Action Process(es)

Objectives &Targets

TrainingOperational

ControlsMonitoring

Communication

T r a c k i n g


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Correction and Corrective actions are to fix the problemsalready reported or lying undetected.

• To prevent them, we need to remove the root causes.

•

Without RCA, we cannot remove root causes.


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h

How to

conduct

RCA?


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Tools

FISH BONE

BRAINSTROMING

5 WHY?

WHY?

WHY?

WHY?

WHY?

WHY?


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5 WHY?

Root Cause Analysis is asking “why”the problem occurred, and then

continuing to ask “why” that

happened until we reach the

fundamental process element that failed.

Usually we can reach the root cause after the 3rd or 4th Why.

5 whys?

Ask ‘Why this happened’ You will get

an answer: This could be the cause or

even the effect

Ask again.

Ask again


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FISH BONE


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Brainstorming


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h

Documents

Root Cause Analysis By Monica