Root Cause Analysis & Action Planning
Root Cause Analysis & Action Planning
Strictly Private
and Confidential
1 June 2013
Check Sheets
Histogram
Problem
Solving
Tools
Stratification
Pareto
Diagram
Scatter
Diagram
1 June 2013
2
1 June 2013
3
Concept
Example
1.
Machine Breakdown
1 June 2013
4
Concept
1 June 2013
5
Professor Reasons logic was so widely received that he became one of the leading innovators of tools for improving patient safety in
the health care industries.
Hindustan Zinc Limited RCA Workshop
PwC
1 June 2013
7
Concept
Problem
(Break down,
delay etc)
Corrective action
Normal
state
Root Cause
Preventive action
1 June 2013
7
RCA Tools
1 June 2013
9
Procedure
Problem ...Why
because... Cause
because...
Why
Cause
Why
because... Cause
Why
because... Cause
Why
Why
Problem
Cause 2
Cause 3
9
Why 1
Why 2
Why 3
Root Cause
Hindustan Zinc Limited RCA Workshop
PwC
1 June 2013
10
*The 5-Why approach, created by Sakichi Toyoda (1867 - 1930), the founder of Toyota, is a simple way to begin any investigation
1 June 2013
10
11
PwC
Example
WHY
BECAUSE
Countermeasure: The owner will read the owners manual to become familiar with the
recommended maintenance. The owner will also refer to the manual every 10,000 miles.
Hindustan Zinc Limited RCA Workshop
PwC
1 June 2013
12
1 June 2013
13
Example
Example 2
BECAUSE
14
PwC
Examples
Example 2 Continued..
BECAUSE
ACTION
Standardize repairs
Standardize repairs
Yes
15
PwC
1 June 2013
14
1 June 2013
15
Example
Excessive
stress
No cleaning
schedule
Worn out
bearing
No change as per
PM
New mechanic.
Unfamiliar with
line changes
Conveyor in-house
line modification
After modification
the new conveyor
not added to PM
Inaccurate
inventory
Sprocket
Broke
Wrong
Sprocket
Correct
sprocket was
out of stock
Why-Why
1 June 2013
16
Example
Countermeasures
Conveyor not
included in cleaning
schedule
Modify the
cleaning schedule
to include the
conveyor.
Add to
PMS/CMMS
System failed to
document part usage.
Timely order was not
placed
Regular
documentation
/Implement parts
usage form to be
used on all shifts.
Designate
responsibility for
cleaning.
Min. Inventory
level and Re order
levels to be
defined.
1 June 2013
17
1 June 2013
18
Concept
Problem
Ca t egory 3
Ca t egory 1
Problem
Ca t egory 4
Ca t egory 3
Ca t egory 2
Ca t egory 1
Problem
Ca t egory 3
Ca t egory 2
Ca t egory 1
Problem
Ca t egory 4
Ca t egory 2
2 0 % of
a t tributes
con t ributing t o
8 0 % of t he
problem
21
PwC
1 June 2013
PwC
22
Project Charter
Team Name
Project Sponsor
Project Location
Ver No.
Project no.
HEMM
Project Details
Problem Statement
NL Panchal (L)
Rakesh Khurana (M)
SK.Hussain (M)
Shiva Kumar (M)
Date
FIP/Drill/-01
09.10.2012
Goal Statement
Improvement of REL Drill (no-19 to 26) availability by ~ 9% from the base line of 54%.
Constraints
1. Spares parts support from OEM , 2. Inadequate skill level of maintenance crew.
Project Scope
Dept/Function
HEMM
AO-Cell
HEMM
REL
Operational KPI:
Drill Availability : ~ 9%
In terms of meters: ~ 7812/month
Blasted inventory will
Strategic benefits increase=7812*49MT=382788MT/m
onth
PwC
Hindustan Zinc Limited RCA Workshop
Name
Role
Dept/Function
Member
Member
Activity
Start
[D] Define
[M] Measure
[A] Analyse
[I] Improve
1 June 2013
17
Measure
120%
4000
3635
100%
6000
Total SD =
29376 hrs
80%
60%
Total B/d =
11940 hrs
46%
3000
4000
2500
3000
2000
2000
1000
40%
20%
20%
0%
Total
B/d hrs
scheduled
hrs
Engine
related
failure
3500
5000
1 7 43
1 676
1 573
1 088
472
4 38
4 1 94 1 4 3 1 6
177
1 5 66 4
Engine
Maintenance
Rotary gear box
Drill tools
Hydraulic
Others
Compressor
Structural
Electrical
Undercarriage
Power transmission
Mechanical
Operation
100%
5922
Maximum breakdown
happens due to tripping
of engine (30%)
1500
1000
500
851
752
407
92
68
58
42
18
Attributes of failures
Hindustan Zinc Limited RCA Workshop
PwC
1 June 2013
18
Analyse
because
Why 3
because
Low Pump
pressure
Why 4
Note:
Rated Pressure : 3500 PSI
Required Pressure : 3300 PSI
because
External Oil
cooler chokes
Why 3
because
because
Radiator chokes
Why 3
Why 4
Oil sediments in
fin
Why 5
because
Why 6
because
PwC
Hindustan Zinc Limited RCA Workshop
Why 2
because
Why 5
Solution:
Pump with increased pressure
rating of 5000 PSI
Summary:
Commissioning of Increased
pressure rated pump and a simple
bolt with thread sealant can arrest
major part of tripping problem
Mounting bolt
becomes loose in
jerky movements
Solution - Permanent
1. Bolt with thread sealant
2. Tightening with torque wrench
and
3. CLTI calendar
1 June 2013
19
Format
Ref No:
Date:
Why-2
Why-3
Why-4
Why-5
Resp
Due Dt
Status
Preventive
maintenance
Modification
Others
Status
Agreed
Planned
Implemented
Effective
1 June 2013
20
26
Exercise
Why ?
Why ?
Guidelines
1 June 2013
22
Countermeasures
Single Point
Lesson
(Training/
Knowledge
transfer)
Checkpoint
addition/
modification
of CLTI
checklist
Inclusion in
Preventive/
Predictive
Maintenance
schedule
Equipment
Modification
Visual
Control/
Mistake
Proofing
1 June 2013
23
The method isnt necessarily repeatable; three different people applying 5 Whys to the
same problem may come up with three totally different answers.
5 Whys requires skill to use well and most important, should be grounded in
observation, not deduction.(On-the-spot observation rather than deduction is the only
correct way to answer a Why? question)
Hindustan Zinc Limited RCA Workshop
PwC
1 June 2013
28
Pit falls
error
1 June 2013
24
Headway
1 June 2013
25
1 June 2013
26
Exercise
Identify a repeatedly occurring problem that your unit is facing.
Brainstorm on the issue with your team member on your table
Present it to the rest of the team
1 June 2013
27
Action planning
1 June 2013
28
1 June 2013
29
b) Front Right
d) Back Right
1 June 2013
30
What
Task
Priority
Due
Date
Assigned
to
Assigned
Date
Status
Remarks
When
Where
How
Maximizing Aids
1 June 2013
31
Action Plan
Impact on
Idea
Throughput
Start End
Given Priority Status
Resp improvemen
Date Date
by
t (MT/mth)
In
Progre
14Bharat Priority 4
14-Apr
Bharat
13
ss - On
Jun
Time
In
Progre
30-Suryade
Verma Priority 3
14-Apr
43
ss - On
Aprv
Time
Bharat Priority 1
Y et To
20-Apr
Start
28-Bharat
Apr/ Verma
In
Availability Progre
VSC Priority 1
18-Apr Bharat
Material availability
ss - On
Time
Y et To
Performance
Bharat Priority 1
28-Apr 5-MayBharat
Start
Availability In
Cleaning time Progre
15VSC Priority 2
14-Apr
Gautam
Temperature
ss - On
May
reduction problem
Time
43
50
58
66
1 June 2013
32
Thank You
Graphs &
Control
Charts
Problem
Solving
Tools
Check
Sheets
Stratificati
on
Histogram
Pareto
Diagram
Scatter
Diagram
1 June 2013
2
Pareto Chart
Why use it?
To focus on the
problems/issues that offer
greatest potential for
improvement
140
120
120
100
100
80
80
60
60
40
40
20
20
0
C
1 June 2013
PwC
For example, the cumulative percent of total through the fifth contributor is the sum of the
effects of the first five in the rank ordering, divided by the grand total, and multiplied by 100
List the contributors from largest to smallest, going from left to right
If the contributor names are long, label the axis A,B,C, etc. and provide a separate key
1 June 2013
PwC
The height of the bars corresponds to the magnitude of that contribution as measured on the left
axis.
Title chart: Label the vital few and trivial many; and show the cumulative percent contribution
of the vital few.
1 June 2013
PwC
Graphs &
Control
Charts
Problem
Solving
Tools
Check
Sheets
Stratificati
on
Histogram
Pareto
Diagram
Scatter
Diagram
1 June 2013
48
Purpose
Makes it easier to determine a direct relationship, & hence the cause behind an effect.
Helps in taking decisions for improving the process, by providing both visual & statistical
means.
Provides both visual &statistical means to test the strength of a potential relationship.
Hindustan Zinc Limited AO Workshop
PwC
1 June 2013
49
+ve correlation
(Y Increase as
X Increases)
No correlation
(Y Has no Particular
Relationship)
-ve correlation
(Y Decrease as
X Increases )
1 June 2013
50
1 June 2013
51
Scatter Diagrams
If the variables are correlated, when one changes the other probably also changes.
Dots that look like they are trying to form a line are strongly correlated.
Sometimes the scatter plot may show little correlation when all the data are considered at
once.
1 June 2013
52
Scatter plots
Exercise:
Two different variables have been shown below
Personal Expenditure
Year
Per. Cusp.
Per. Income
1965
450
550
1966
500
600
1967
520
650
1968
560
720
1969
600
780
1970
650
850
1971
700
900
1972
780
1000
1973
850
1100
Personal income
What inference can be drawn from
1 June 2013
53
Check Sheets
Histogram
Problem
Solving
Tools
Stratification
Pareto
Diagram
Scatter
Diagram
1 June 2013
54
About Stratification
What is it?
A method for grouping data by common characteristics enabling better understanding of
trends by focusing only on relevant data.
Purpose
Focuses attention on a vital/significant subgroup
Enables a more precise analysis
Helps to verify root cause
1 June 2013
55
WHO
Department
Individual
WHAT
Type of Defect
Reason for Defect
WHEN
WHERE
Area
Section
WHICH
Product
Equipment
Examples
Complaints of System
Malfunctioning
Branch-wise
Machine-wise
Package-wise
Lot-wise
Accidents
Shop-wise
Shift-wise
Age-wise
1 June 2013
56
1 June 2013
57
1 June 2013
58