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This is the first part of the training presentation for Root Cause Analysis that I conducted in our company last September 11, 2009.
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QUALITY MANAGEMENT
By: Sid Calayag
Date: September 11, 2009
ROOT CAUSE ANALYSIS
Training Description
Root Cause Analysis training is consist of
lectures and practices (application) that provide participants with a practical understanding of how to do an analysis in identifying the root cause of a problem.
This presentation has two modules. The second module is deleted from this presentation.
The hands-on training exercises and samples were also excluded in this presentation.
Presentation set-up
Module 1 will guide participants in the creation
and use of histograms, Pareto chart and
Fishbone diagram.
Module 2 will guide participants in the process of
creating a good 8 – D Report
Application Section is part of both modules,
however, it will require knowledge gained in
Module 2 to apply advance application such
as the 8 – D Report.
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
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
HOME PAGE
• INTRODUCTION
• MODULE 1
• MODULE 2
• APPLICATION
I N T R O D U C T I O N
T o
R O O T C A U S E A N A L Y S I S
Introduction
Definition of Terms
What it is
Why use it
RCA Process
How to use it
Introduction MODULE 2MODULE 1
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
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
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
Module 1
Digging for the Root Causes
Module 1 Table of Contents
Histograms and Pareto Chart
Cause and Effect Diagram
What it is
How to use it
Examples
Summary
MODULE 1 MODULE 2 APPLICATION
Histograms- What it is
• A chart that graphically display the
distribution of a set of data.
Pareto Chart - What it is
It reveals that a
small number of
NCNs are
responsible for the
bulk of quality
issues,
a phenomenon
called the „Pareto
Principle‟.
A Pareto chart allows data to be displayed as a bar chart and enables the main contributors to a problem to be highlighted.
Pareto Chart – How to create it
1. Gather facts about the problem
2. Rank the contributions to the problem in order of frequency.
Pareto Chart – How to create it (cont’n)
3. Draw the value as a bar chart.
5. Review the chart
6. Redefine classifications if necessary.
4. add a line showing the cumulative percentage of errors
• Chart 1 : The chart gives summary information and starts the cumulative % count at
the top of the first bar:
Cmpt Damaged
Component Faulty
Cmpt Missing
Wrong Comp. Fitte
d
Cmpt not M
eet Elect. S
pec.
Deformed Jo
int
Joints not Soldered
Cmpt Touching Heatplane
Component Misfitt
ed
Legs not through Board
Long Leads
Link Wire
Missfitted
Beyond Economic Repair
Precautionary Removal
Thiokol Problem
Solder Short
Faulty Connector
Contamination
Others
141 139 69 52 22 20 20 17 17 17 16 13 10 10 10 8 6 5 29
23 22 11 8 4 3 3 3 3 3 3 2 2 2 2 1 1 1 5
23 45 56 65 68 71 75 77 80 83 85 87 89 91 92 94 95 95 100
0
100
200
300
400
500
600
0
20
40
60
80
100
Defect
Count
Percent
Cum %
Per
cent
Cou
nt
Pareto of D3 Small Engine Card Faults
Pareto Analysis Example
* This is a sample output from Minitab Statistical Software
• Example 2 : a series of Pareto charts drill down to more detail:
DesignComponent
BuildOther
57 13 4 2
75.0 17.1 5.3 2.6
75.0 92.1 97.4 100.0
0
10
20
30
40
50
60
70
0
20
40
60
80
100
Defect
Count
Percent
Cum %
Perc
ent
Coun
t
Fault by Main Cause
Connect Module
Torque Motors
Cold Start
Transducer Module
ASIC Calibration
IOP Imon
21 10 8 8 5 3 2
36.8 17.5 14.0 14.0 8.8 5.3 3.5
36.8 54.4 68.4 82.5 91.2 96.5 100.0
0
10
20
30
40
50
0
20
40
60
80
100
Defect
Count
Percent
Cum %
Perce
nt
Coun
t
Design Faults
1st level Analysis
gives “Design”
as main cause of
failure
2nd level Analysis gives
breakdown of “Design”
Pareto Analysis Example
* This is a sample output from Minitab Statistical Software
• Example 3 : if the original Pareto is very flat, be prepared to cut the defects in a
different way, here, it is 40:60
KDCC788
KDCC646
KDCC777
KDCC780
KDCC782
KDCC795
40-564-8116-10
40-666-7823
40-564-7274-47E
Others
18 13 11 11 11 10 9 9 8 138
7.6 5.5 4.6 4.6 4.6 4.2 3.8 3.8 3.4 58.0
7.6 13.0 17.6 22.3 26.9 31.1 34.9 38.7 42.0 100.0
0
100
200
0
20
40
60
80
100
Defect
Count
Percent
Cum %
Perc
ent
Coun
t
Pareto Chart for Child11
Pareto Analysis Example
* This is a sample output from Minitab Statistical Software
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.
Pareto Analysis Example
Summary
Pareto Charts provide a visual representation of
the variables which contribute to problems or
issues.
Pareto Charts can be used as a prioritization tool
to aid in focusing on the top issues which
contribute to specific conditions.
Pareto analysis is an approach which ranks the
contributing factors and identifies which are the
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”,
sometimes referred to as the “80-20 rule”
Process StepsA method for showing the distribution of quantitative data and identifying those with the greatest impact.
Identify the problem and the potential
direct or contributing causes
Develop Corrective Action or
Improvement Action Plans for those
identified as the Vital Few
Identify the Vital Few (those with the
highest number of occurrences)
Construct the Pareto Chart:
Causes on Horizontal Axis
Frequency of events on Vertical Axis
Collect data about each of the potential
direct or contributing causes
Pareto
Pareto Chart and Analysis
Coffee Break
15 Minutes Break Only
CAUSE AND EFFECT
Ishikawa/Fish Bone Diagram
Problem
PeopleProcedures
Equipment Materials
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
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
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
Problem or
Issue
Method Machine
Environment Measurement System
People
Material
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.
Sources of Variation - People
People
• The activities of the workers.
• Variations caused by skill, knowledge,
competency and attitude
Sources of Variation - Method
Method
• The methods used to produce the
products.
• Variations caused by inappropriate
methods or processes.
Sources of Variation - Machine
Machine
• The equipment used to produce the
products.
• Variations caused by temperature,
tool wear and vibration.
Sources of Variation - Material
Material
• The "ingredients" of a process.
• Variations caused by materials that
differ by industry, product
and stage of production.
Sources of Variation - Environment
Environment
• The methods used to control the
environment.
• Variations caused by temperature
changes, humidity etc.
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.
Cause and Effect Analysis Example
Summary
The development of the cause and effect Fishbone diagram is credited to Kaoru Ishikawa, who pioneered quality management processes in the Kawasaki shipyards.
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 headings, namely Machinery, Methods, Measurement, Manpower, Materials, and 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 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 be problems by questioning the existence of causes under each of the six categories.
Ishikawa Fishbone Template
UDE
MaterialsMaterialsManpowerManpower
MachineryMachineryMethodsMethodsMeasurementMeasurement
EnvironmentEnvironment
Causes, inputs,or sourcesof variation
A UDE is an UnDesireable Effect
Cause and Effect Diagram (Ishikawa)
A visual brainstorming tool used to help identify and categorize potential root causes named
for Kaoru Ishikawa.
Module 2
APPLICATION
ISO 9001:2000 CA/PA & IQA Report
Eight Discipline
What it is
How to use it
Examples
Summary
Application Table of Contents
MODULE 1 MODULE 2 APPLICATION
Different Action to Improve Performance
Corrective
BeforeAfter
Action 1
Action 2
Time
BeforeAfter
Action 1
Action 2
Time
BeforeAfter
Action 1
Action 2
Time
- 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.
Continual
Continuous
TIME
Performance
Breakthrough
Continual Improvement
Different Action to Improve Performance
Document plan for implementing C/A
Implement Containment Action
Implement the Corrective Actions
Remove the Containment Actions
Verify the Corrective Actions Overtime
Steps to Complete
Corrective Action
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
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
• Jumping to conclusion
• Failure to define problem
• Failure to find the root cause
• Weak problem solving
• No execution of corrective action
PROBLEM SOLVING FAILURE
- 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
PROBLEM SOLVING SUCCESS
PROBLEM SOLVING SUCCESS
$$$
Action Reflection
- Which principle or technique will I apply right away when I get back to work?
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
PREVENTIVE ACTION
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
Preventive Action Process Flow
Pareto DiagramScatter Diagrams
Check Sheets
Defects
Bent Lead
Damaged
Leads
Joggled
Leads
Wrong
symbol
Mixed device
Chipped
package
Illegible
symbol
Day1 Day2 Day3 Day4 Day5 Day6
3
3
3
2
2
15
7
1
4
5
8
9
0 2
2
2
2
2
0
0
0
0
0
0
0
0
9
9
4
4
5
5 5 5
00
2
1
1
7
1
1
Scrap
Histogram
Rework
Control Chart
1 3 5 7 9 11 13 15 1719
21
23 25 27 29 31 33 35 37 39 41 43 45
0
5
10
15
1. Identify an Opportunity/Initiative based on gathered
information,
-define the success criteria
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
SUMMARY
Symptom Problem (Is & Is Not)
What ?
Where ?
When ?
How Big ?
Containment
X
Root Cause
Occur Cause Escape Cause
Corrective Actions
Occur Cause Escape Cause
Preventive Actions
What about ...
Created by:
Sid Calayag – Lead Auditor for
Taikisha Phils., Inc Quality Management
System
Presented by: Sid Calayag
“Sorry I don’t accept donation”
But CASH is still acceptable if you will not tell anybody about it …”
By: Anonymous
“I only did it for the love of my company”
End of Presentation