Effective Root Cause Analysis for Problem Resolution

 
 
World Class Solutions for Global Applications
 
Riverhawk
Riverhawk
 
7/16/2024
 
Prevent problems from recurring
 
Reduce possible injury to personnel
 
Reduce rework and scrap
 
Increase competitiveness
 
Promote happy customers
 
Ultimately, reduce cost and save money
 
7/16/2024
 
Invariably, the root cause of a
problem is not the initial reaction
It is not just restating the Finding or
Symptom
 
7/16/2024
 
For example, a normal response is:
Equipment Failure
Human Error
 
 
Initial response is usually the 
symptom
, not the
root cause of the problem.  This is why Root
Cause Analysis is a very useful and productive
tool.
 
7/16/2024
 
Such as:
 
Process or program failure
System or organization failure
Poorly written work instructions
Lack of training
 
7/16/2024
 
Root Cause Analysis
 is an in-depth process or
technique for identifying the 
most
 
basic
 factor(s)
underlying a (problem).
 
  Focus is on systems and processes
  Focus is not on individuals
 
7/16/2024
 
Significant or consequential events
Repetitive human errors are occurring during
a specific process
Repetitive equipment failures associated
with a specific process
Performance is generally below desired
standard
May be MRR/SCAR driven
 
7/16/2024
 
Assign the task to a person/team knowledgeable of the
systems and processes involved
 
Define the problem
 
Collect and analyze facts and data
 
Develop theories and possible causes - there may be multiple
causes that are interrelated
 
Systematically reduce the possible theories and possible
causes using the facts
 
7/16/2024
 
Develop possible solutions
 
Define and implement an action plan (e.g., improve
communication, revise processes or procedures or work
instructions, perform additional training, etc.)
 
Monitor and assess results of the action plan for
appropriateness and effectiveness
 
Repeat analysis if problem persists- if it persists, did we get to
the root cause?
 
7/16/2024
 
The “5 Whys”
Pareto Analysis (Vital Few, Trivial Many)
Brainstorming
Cause and Effect Diagram (4 M’S)
Tree Diagram
Benchmarking (after Root Cause is found)
 
 
7/16/2024
 
Problem
 
- Flat Tire
 
Why?
    Nails on garage floor
Why?
    Box of nails on shelf split open
Why?
    Box got wet
Why?
 
Rain thru hole in garage roof
Why?
 
Roof shingles are missing
C/A         Fix Roof
 
7/16/2024
 
Pareto Analysis
 
V
i
t
a
l
 
F
e
w
 
T
r
i
v
i
a
l
 
M
a
n
y
 
60 %  of
Material
Rejections
 
7/16/2024
 
Sit down as a group and review all ideas
Sit down as a group and review all ideas
Assign someone to capture the thoughts
Assign someone to capture the thoughts
(Whiteboard)
(Whiteboard)
Everyone participates until no one can
Everyone participates until no one can
think of another “Why” to ask
think of another “Why” to ask
Don’t jump to conclusions too quickly
Don’t jump to conclusions too quickly
 
 
7/16/2024
 
Cause and Effect Diagram
(Fishbone/Ishikawa Diagrams)
EFFECT
 
S (METHODS) CAUSE
 
EFFECT (RESULTS)
 
“Four M’s” Model
 
MANPOWER -
MAN/WOMAN
 
METHODS
 
MATERIALS
 
MACHINERY
 
OTHER
 
7/16/2024
 
Cause and Effect Diagram
Loading My Computer
 
MAN/WOMAN
 
METHODS
 
MATERIALS
 
MACHINERY
 
OTHER
Cannot
Load
Software
on PC
 
Inserted CD Wrong
 
Instructions are Wrong
 
Upside Down
 
Backward
 
Not Enough Free
Memory
 
Inadequate System
 
Graphics Card Incompatible
 
Hard Disk Crashed
 
Not Following Instructions
 
Cannot Answer Prompt
Question
 
Brain Fade
 
CD Missing
 
Wrong Type CD
 
Bad CD
 
Power Interruption
 
7/16/2024
 
Tree Diagram
 
Result
 
Cause/Result
 
Cause/Result
 
Cause
 
Result
 
Primary
Causes
 
Secondary
Causes
 
Tertiary
Causes
 
7/16/2024
 
Tree Diagram
Poor Safety
Performance
Stale/Tired
Approaches
Inappropriate
Behaviors
Lack of
Employee
Attention
Lack of Models/
Benchmarks
No Outside Input
Research Not
Funded
No Money for Reference
Materials
No Funds for Classes
No Consequences
Infrequent
Inspections
Inadequate Training
No Publicity
Lack of Sr. Management
Attention
No Performance
Reviews
No Special Subject
Classes
Lack of Regular
Safety Meetings
Zero Written Safety
Messages
No Injury Cost
Tracking
 
Result
 
Cause/Result
 
Cause/Result
 
Cause
 
7/16/2024
 
Benchmarking: What is it?
"... benchmarking ...[is] ...'the process of identifying,
understanding, and adapting outstanding practices and processes
from organizations anywhere in the world to help your
organization improve its performance.'"
—American Productivity & Quality Center
"... benchmarking ...[is]... an on-going outreach activity; the goal
of the outreach is identification of best operating practices that,
when implemented, produce superior performance."
—Bogan and English, Benchmarking for Best Practices
Benchmark 
refers to a 
measure of best practice performance.
Benchmarking
 refers to the 
search for the best practices that
yields the benchmark performance
, with emphasis on how you
can 
apply the process
 to achieve 
superior results
.
 
7/16/2024
 
All process improvement efforts require a sound methodology
and implementation, and benchmarking is no different. You
need to:
Identify benchmarking partners
Select a benchmarking approach
Gather information (research, surveys, benchmarking visits)
Distill the learning
Select ideas to implement
Pilot
Implement
 
7/16/2024
 
Successful application of the analysis and
determination of the Root Cause should
result in elimination of the problem
 
7/16/2024
 
Ending analysis at a symptomatic cause
Assigning as the cause of the problem the
“why” event that preceded the real cause
Looking for a single cause- often 2 or 3
which contribute and may be interacting
 
7/16/2024
 
Why determine Root Cause?
What Is Root Cause Analysis?
When Should Root Cause Analysis be performed?
How to determine Root Cause
Useful Tools to Determine Root Cause
1.
Five Whys
2.
Pareto Analysis
3.
Brainstorming
4.
Cause & Effect Diagram
5.
Tree Diagram
6.
Benchmarking
Common Errors of Root Cause
 
7/16/2024
Slide Note
Embed
Share

In the process of determining the root cause of a problem, it is crucial to look beyond initial reactions and symptoms. Root Cause Analysis focuses on identifying underlying factors, not blaming individuals. By analyzing significant events and repetitive errors or failures, a systematic approach can lead to effective problem resolution, preventing future issues and improving overall performance.

  • Root Cause Analysis
  • Problem Resolution
  • Systematic Approach
  • Effective Solutions
  • Performance Improvement

Uploaded on Jul 16, 2024 | 1 Views


Download Presentation

Please find below an Image/Link to download the presentation.

The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.

E N D

Presentation Transcript


  1. Riverhawk World Class Solutions for Global Applications World Class Solutions for Global Applications Determining the Root Cause and Determining the Root Cause and Corrective Action of a Problem Corrective Action of a Problem 7/16/2024

  2. Prevent problems from recurring Reduce possible injury to personnel Reduce rework and scrap Increase competitiveness Promote happy customers Ultimately, reduce cost and save money 7/16/2024

  3. Invariably, the root cause of a problem is not the initial reaction It is not just restating the Finding or Symptom 7/16/2024

  4. For example, a normal response is: Equipment Failure Human Error Initial response is usually the symptom, not the root cause of the problem. This is why Root Cause Analysis is a very useful and productive tool. 7/16/2024

  5. Such as: Process or program failure System or organization failure Poorly written work instructions Lack of training 7/16/2024

  6. Root Cause Analysis is an in-depth process or technique for identifying the most basic factor(s) underlying a (problem). Focus is on systems and processes Focus is not on individuals 7/16/2024

  7. Significant or consequential events Repetitive human errors are occurring during a specific process Repetitive equipment failures associated with a specific process Performance is generally below desired standard May be MRR/SCAR driven 7/16/2024

  8. Assign the task to a person/team knowledgeable of the systems and processes involved Define the problem Collect and analyze facts and data Develop theories and possible causes - there may be multiple causes that are interrelated Systematically reduce the possible theories and possible causes using the facts 7/16/2024

  9. Develop possible solutions Define and implement an action plan (e.g., improve communication, revise processes or procedures or work instructions, perform additional training, etc.) Monitor and assess results of the action plan for appropriateness and effectiveness Repeat analysis if problem persists- if it persists, did we get to the root cause? 7/16/2024

  10. The 5 Whys Pareto Analysis (Vital Few, Trivial Many) Brainstorming Cause and Effect Diagram (4 M S) Tree Diagram Benchmarking (after Root Cause is found) 7/16/2024

  11. Problem - Flat Tire Why? Nails on garage floor Why? Box of nails on shelf split open Why? Box got wet Why? Rain thru hole in garage roof Why? Roof shingles are missing C/A Fix Roof 7/16/2024

  12. Pareto Analysis Vital Few Supplier Material Rejections May 06 to May 07 180 160 140 120 100 80 60 40 20 Trivial Many Count 0 Supplier Incorrect Material EB Incorrect Material 60 % of Material Rejections EB Other Supplier Other Other Supplier Dimensions Supplier Missing Parts Supplier Cleanliness Supplier Documentation Supplier Wrong Configuration EB Documentation EB Dimension Supplier Marking Supplier Damaged Packaging Supplier Shelf Life Exceeded Workmanship ESD Packaging Supplier Rusted, Corroded EB Marking EB Damaged Supplier Lab Test Failure Defect Count Percent Cum % 162 32 32 13934 20 19 19 15 15 27 7 4 5966 70 74 78 80 83 14 14 11 3 86 89 91 93 94 96 96 97 97 98 9 2 7 1 7 1 3 1 3 1 3 1 3 1 2 0 2 0 1 0 5 1 4 4 3 3 3 2 98 99 99100 7/16/2024

  13. Sit down as a group and review all ideas Assign someone to capture the thoughts (Whiteboard) Everyone participates until no one can think of another Why to ask Don t jump to conclusions too quickly 7/16/2024

  14. Cause and Effect Diagram (Fishbone/Ishikawa Diagrams) EFFECT (RESULTS) S (METHODS) CAUSE Four M s Model MANPOWER - MAN/WOMAN METHODS OTHER EFFECT MACHINERY MATERIALS 7/16/2024

  15. Cause and Effect Diagram Loading My Computer METHODS MAN/WOMAN Inserted CD Wrong Cannot Answer Prompt Question Not Following Instructions Instructions are Wrong Brain Fade Cannot Load Software on PC OTHER Not Enough Free Memory Power Interruption CD Missing Inadequate System Bad CD Wrong Type CD Graphics Card Incompatible Hard Disk Crashed MATERIALS MACHINERY 7/16/2024

  16. Tree Diagram Result Cause/Result Cause/Result Cause Primary Causes Secondary Causes Result Tertiary Causes 7/16/2024

  17. Tree Diagram Result Cause/Result Cause/Result Cause Lack of Models/ Benchmarks No Money for Reference Materials Stale/Tired Approaches No Outside Input Research Not Funded No Funds for Classes No Performance Reviews No Consequences Infrequent Inspections Poor Safety Performance Inappropriate Behaviors No Special Subject Classes Inadequate Training Lack of Regular Safety Meetings No Publicity Lack of Employee Attention Zero Written Safety Messages Lack of Sr. Management Attention No Injury Cost Tracking 7/16/2024

  18. Benchmarking: What is it? "... benchmarking ...[is] ...'the process of identifying, understanding, and adapting outstanding practices and processes from organizations anywhere in the world to help your organization improve its performance.'" American Productivity & Quality Center "... benchmarking ...[is]... an on-going outreach activity; the goal of the outreach is identification of best operating practices that, when implemented, produce superior performance." Bogan and English, Benchmarking for Best Practices Benchmark refers to a measure of best practice performance. Benchmarking refers to the search for the best practices that yields the benchmark performance, with emphasis on how you can apply the process to achieve superior results. 7/16/2024

  19. All process improvement efforts require a sound methodology and implementation, and benchmarking is no different. You need to: Identify benchmarking partners Select a benchmarking approach Gather information (research, surveys, benchmarking visits) Distill the learning Select ideas to implement Pilot Implement 7/16/2024

  20. Successful application of the analysis and determination of the Root Cause should result in elimination of the problem 7/16/2024

  21. Ending analysis at a symptomatic cause Assigning as the cause of the problem the why event that preceded the real cause Looking for a single cause- often 2 or 3 which contribute and may be interacting 7/16/2024

  22. 1. 2. 3. 4. 5. 6. Why determine Root Cause? What Is Root Cause Analysis? When Should Root Cause Analysis be performed? How to determine Root Cause Useful Tools to Determine Root Cause Five Whys Pareto Analysis Brainstorming Cause & Effect Diagram Tree Diagram Benchmarking Common Errors of Root Cause 7/16/2024

Related


More Related Content

giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#giItT1WQy@!-/#