Root Cause Techniques

Presentation
Prepared by: Engr. Mohsin
 SHARE RESULTS
Meetings/Discussions

RESULTS & PROCESS DEFINE PROBLEM

Data & Facts
EVALUATION
PDSA Cycles

Steps of Root
Cause Analysis
DATA COLLECTION

TEST SOLUTIONS & & ANALYSIS

Pareto Chart
IMPLEMENTATION
Flow Chart
PDSA Cycles

ROOT CAUSE ANALYSIS

Fishbone Diagram
 Root Cause Analysis Methods

Casual Factor The 5 Whys

Management Failure Mode
Tree Analysis Effect Analysis
Oversight
Change
Analysis

Risk Tree

Fishbone
Diagram Fault-Tree
Barrier
Analysis
analysis
 Causal Factor Tree Analysis

Apparent Problem

Symptom of Problem Symptom of Problem Symptom of Problem

Possible Root Cause Possible Root Cause Possible Root Cause Possible Root Cause Possible Root Cause

ACTUAL ROOT CAUSE

 Fishbone Diagram

No job description Incorrect collection time Staff careless in storage

No written guideline Staff not well-trained Lack of motivation system

No procedure for order description No funds Lack of equality

No procedure for collection Wrong blood-coagulant ratio
Insufficient payment
No job variety Staff not trained

EFFECT
Staff performing
JOB EXPECTATION PERFORMANCE FEEDBACK SKILLS & KNOWLEDGE ENVIRONMENT & TOOLS MOTIVATION ORGANIZATIONAL SUPPORT
unnecessary
repeat lab tests

Poor disposable equipment

Irregularity of data Poor quality, no funds

No supervision system
Inadequate information Not properly selected

Material scanty Damaged equipment Lack of support in cont. Improvement

Not enough collected Poor maintenance Insufficient budget

No feedback Unskilled personnel, no funds No supervision system

 01
Incident
Situation Some Factors to Consider:
05 06
03 04 Evaluate
Who What Where When
Integrate into
Set down differences for
Compare Investigation Work Conditions Triggering Events Resources
Differences effect on
Process
02 incident Management Control Procedures Tasks

Comparable
incident-free
situation

Evaluate by Asking These Questions:

Change Analysis Why now and not before? Why here and not there?

What was Different about this time from all the other times the same hardware
operated without a problem or the same task or activity was carried out without error?
 Barrier Analysis

Policy, Legal & Institutional & Capacity

Technical Barrier Economic & Financial
Regulatory of Organization

• Variation of reheating • High cost investment • Efficiency energy policy and • Lack of institution which
furnace type regulation only for industry have capacity to help
• Revenue loss due to long
that used energy >6000 TOE industry to install RBCS
• Long period installation time furnace shutdown
• Voluntary for <6000 TOE • Lack of institution which
• Main component of RBCS • No financial mechanism for
have capacity to do testing,
still import RBCS technology
modification and innovation
implementation
• Lack of qualified engineers for RBCS technology.
who have expertise on RBC
• Absence of standardization
Technology
and certification of
equipment related RBCS
 Why did this Why did problem Why was the problem
problem occur? go undetected? not prevented?

The main pulley responsible

WHY
for rotating the belt is not Carelessness of the workers At this stage it was unavoidable
has the conveyor
belt stopped? functioning properly.

WHY Because it’s not getting

Lack of clue There was no clue
is the main pulley not enough power from the motor

Five Why’s Analysis functioning correctly?

WHY Because the motor has

Problem : The project supposed to be finished in 6 Unnoticed incident Incident was unnoticed
is it not getting enough stopped working
months but our company failed to meet the deadline. power from the motor?

WHY Because the motor was Carelessness of the

Indifference to problem
has the motor loaded beyond it’s capacity management
stopped working?

Instructions about the

WHY Carelessness of the Lack of initiative of
motor’s maximum load
was the motor management management
overloaded? weight was missing.
 Five Why’s Analysis

DESCRIPTION POTENTIAL IMPACT

01 Why has the conveyor belt stopped?
The main pulley responsible for rotating the belt is not
The main machine might get crashed
functioning properly.

Why is the main pulley not functioning

02 correctly? Because it’s not getting enough power from the motor Decrease in number of output

Why is it not getting enough power

03 from the motor?
Because the motor has stopped working Fail to meet expected performance

Because the motor was loaded beyond it’s capacity Risk of failure in the operation
04 Why has the motor stopped working?

Instructions about the motor’s maximum load weight

The machine will stop working
was missing.

05 Why was the motor overloaded?

 Five Why’s Analysis

WHY? WHY? WHY? WHY? WHY?

ON THE SURFACE HUMANS HARD TRUTH STATUS QUO ORIGINS

They fail to find the product Entrepreneurs don’t have enough Product or service that the Most startups don’t have enough Entrepreneurs jump into the
market fit. time, resources or experience to startup is offering is not something time to mature & self sustain startup adventure with many
make it work on time. that the market wants or needs. before they can hit desirable high unknowns and limited resources.
They fail to make money or raise
growth matrices that the current
money Startups often fail to address the
investor eco-system favors.
root causes of their eco-system.
Customers are bombarded with Startup teams are unable to build
many competing products in the a product that is valuable for their
market & won’t trust a starter target market fast enough. Startups by nature travel an
brand easily. uncharted territory. There is no
OPPORTUNITY
single formula to success. Only FOR SOLUTIONS
Startup teams fail to tell the story guidance and anecdotes from
Investors don’t bet on products of their product accurately to previous success and failure A centralized space for startups
that show high growth and high reach the customers. stories.
to establish their business strategy
ROI potential.
from the get go, follow the
original visions evolution and
Competitors or established
scale up with self-awar3eness
players steal the new startup’s
and control.
slice of the pie.
 Language Barrier Educational Level

Customs Barrier Pay & Benefit

Communication problem Personnel Quality
Legal systems differences Turnover

Technology Dedication

Funding Standard Cost itemization failure

Technology trends Elevated cost

Hardware Deficiency Cost Factor
Staff Knowledge International currency bottleneck

Management backing Inconvenient payment plans

Funding Logistics

Software trends Delivery companies

Staff Knowledge
Software Deficiency
Risk Tree Delivery Time
Adverse events

Management backing Alternate Delivery Methods

Education Reliability

Compensation Financial soundness

Managerial Quality Client Perceptions
Retention Relationship history

Commitment Public Relations

Growth rates Expansion Planning

Interest rates Recruitment

Macro Economic Factor Local Service Reps Missing
Commodity prices Turnover

Regulatory environment Compensation

 Fault-Tree Analysis

AUDIT FAILURE

OR

Audit Objective Audit Resource

Audit Process Failure
Failure Failure

OR OR OR

Objective Objective Objective Failure of Audit Failure of Other

Type I Error Type II Error Audit Failure
Unattainable Incorrect Unidentified Process Element Resources

OR AND AND OR

System
System
Compliance/
Objective Objective Audit Process Compliance/ Audit Process Audit Process Audit Process
Suitability
Ambiguous Obsolete Failure Suitability Failure Failure Failure
Error Doesn’t
Error Exists
Exist
 Q3

Procedures

Poor leadership
or management Q2
Inadequate
Extreme heat Maintenance Poor
(Environment)

Human Error and

(Organization) communication
of safety

Lack of training Absence of management

Management Oversight
(Organization) Warnings
Q1 (Design)

No SOPs in place, no
EVENT Equipment
Q1 Error/ Violation Occurred clear safety procedures,
malfunction/
safety rules not enforced
adequacy of
(Organization) Poor quality
feedback (Design)
Q2 Human Factors Present control

Poor teamwork, Too many

Safety rules ignored, controls that
Q3 Root Cause Analysis Fatigue, high
Poor safety poor record keeping contradict each
culture (Organization) time on task, other (Design)
excessive time
pressure
(Organization) Poor system
integration

Inadequate manning/
organization of
personnel resource
 Failure Mode Effect Analysis

May be a product, assembly, Initial Development of the Improvement Post-Improvement

subassembly, or part Failure Mode Effect Analysis Activities Activities

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

POTENTIAL POTENTIAL
PROCESS POTENTIAL CURRENT RISK PRIORITY ACTION RISK PRIORITY
FAILURE FAILURE SEVERITY OCCURRENCE DETECTION RESPONSIBLE ACTIONS TAKEN SEVERITY OCCURRENCE DETECTION
STEP/INPUT CAUSES CONTROLS NUMBER RECOMMENDED NUMBER
MODE EFFECTS

DET= Detection Resp= Responsible SEV= Severity

OCC= Occurrence RPN= Risk Priority Number FMEA= Failure Mode Effect Analysis
 Failure Mode Effect Analysis:
Three-Path Model

PATH 01 PATH 02 PATH 03

What are the Functions, How can the causes / FM be

What are the causes?
Features or Requirements? detected?

• No Functions
Can this be prevented? What is How good is this method at
• Partial/Over Function/
the occurrence? detecting it?
Degraded Over Time
• Intermittent Function
• Unintended Function

What are the effect?

• Design Changes • Mistake Proofing

• Process Changes • Changes to Standards,
ACTIONS • Error Proofing Procedures, or Guides
How bad is it?
• Special Controls
 Root Cause Analysis Template

ISSUE LIKELY ROOT CAUSE POSSIBLE SOLLUTION

Description Source Criticality Description Likelihood Information Description Risks Measure of Success

Level (High/ Level (High/ Tests to

Rationale Description Likelihood Mitigation Test Results
Medium/ Low)) Medium/ Low)) Clarify

Simplify info
Does not affect Agree detail
Client not Status reports required for Client feels Check with
delivery but Check with level for new
aware of Client Medium not being issued High report so less report lacks Medium client after four TBA
damaging to program Office report with
project status weekly time consuming detail weeks
account clients
for PM

Makes it tough Budget is not

HR did not get Check with Budget report HR did not get Budget to be
HR Medium to meet being issued High High N/A TBA
the budget yet Finance prioritized budget report sent to HR
deadline weekly

Report to be
Project report Creates project Management Check with Project report to Manager did
Manager High High Medium sent to Talk to Manager Report Sent
not done weakness Fault Management be cleared not get report
Manager

Deadline Client Management Check with Did not meet Project Talk to
Client High High Client meeting High TBA
couldn’t be met Dissatisfaction Fault Management deadline Prioritized Management
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