RCFA

Definitions
Root Cause Deepest underlying cause(s) of positive or negative symptoms within any process that, if resolved, would eliminate or substantially reduce the symptom. Root Cause Analysis (RCA) a tool used both reactively, to investigate an adverse event that already has occurred, and proactively, to analyze and improve processes and systems before they break down (Preuss, 2003). Data Analysis the process of gathering, reviewing, and evaluating data. Symptoms the noticeable gap between expectations and reality; the red flag that draws attention to the issue.
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Why Use Root Cause Analysis (RCA)?

Root Cause Analysis:
Helps identify the problem or challenge Helps resolve the Problem Eliminates Patching Conserves Resources Facilitates Discussion (leading to solutions) Provides Rationale for Strategy Selection

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Types of RCA
Safety-based RCA - Investigating Accident and occupational safety and health. Root causes:- unidentified risks, or inadequate safety engineering, missing safety barriers. Production-based RCA - Quality control for industrial manufacturing. - Root causes:- non-conformance like, malfunctioning steps in production line.

Types of RCA
Process-based RCA - Extension of Production-based RCA. - Includes business processes also. - Root causes:- Individual process failures System-based RCA - Hybrid of the previous types - New concepts includes:- change management, systems thinking, and risk management. - Root causes:- organizational culture and strategic management

Initial RCFA
1. 2. 3. 4. 5. 6. 7. 8. 9. Reporting an Incident Incident Classification Data Gathering Design Review Application / Maintenance Review Observations and Measurements Determining the Root Cause Evaluating the Potential Corrective Actions Cost Benefit Analysis
We will look at this part We have finished This part

10. Report and Recommendations 11. Process Performance

 Scenario: Youve spent precious weeks collecting specific data on your processs operational activities:
Product Codes or Lot Numbers Dates of Production Batch or Lot Sizes Process Cycle Times Queue or Wait Times Scrap Rates; Scrapped and Reworked Units Scrap Codes Etc.

SoData, Data Everywhere! Now What!

Great! Youve got a lot of data, lots of guesses, but not a lot of extra time or resources. How do you figure out, exactly what is important?
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SoNow What? (cont)

How do you know which specific inputs or factors will drive visible, significant improvement?
First, Stratify and Segment the Data! Show Graphical Displays of the Data
Time-series Plots, Run Charts, Control Charts Histograms (and Scatter Plots, Dot Plots, Box Plots)

Perform Statistical Summaries of the Data

Mean, Median and Mode Min, Max, Range and Standard Deviation

Lets also learn about the 80/20 Rule!

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Paretos Law: The 80/20 Rule

In 1906, Italian economist Vilfredo Pareto created a mathematical formula to describe the unequal distribution of wealth in his country. Pareto observed that 20% of the people owned 80% of Italys wealth. In manufacturing, just a few contributors to a process control the vast majority of that processs results.
20 percent of the customers generate 80 percent of total sales. 80 percent of your stock comes from 20 percent of your suppliers. 20 percent of the defects cause 80 percent of the problems. 80 percent of your warehouse is taken up by 20 percent of stock.

Pareto's Law can be a terrific tool to help you manage effectively, separating the vital few from the trivial many, allowing you to focus on what is truly important to control.

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 Weve defined a specific problem (i.e., a process) and determined it is important to solve. Our team is on it! Weve outlined and described (mapped) the steps in that process, to give everyone better understanding, and created a preliminary Cause-and-Effect Diagram. Weve brainstormed ideas on measurements we wished to gather, to better understand the process, its inputs, and its outputs.

Determination of the root cause analysis

Weve diligently executed a detailed data collection plan.

We now seek to analyze the collected data, first visually (through charts and graphs) and then critically (through challenges, questions and experience).
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Tools for Root Cause Analysis

Tools for Prioritizing Root Causes and Making Decisions

Cause-and-Effect Diagram 5 Whys Multi-Voting Pareto Analysis

Pareto Chart
A Pareto chart is a graphical tool to detect and prioritize multiple quality problems in a process.

Pareto Chart

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Pareto Chart (cont)

The Pareto principle (80/20 Rule) states that 80% of our problem can be explained by just 20% of the causes.
We just have to figure out which 20% are the critical ones!

The Pareto chart makes clear which vital few problems (causes) should be addressed first:
Manufacturing
A quality engineer wants to know which defects occur most frequently.

Transactional
A human resources manager wants to know which day of the week the majority of resumes are received. A salesperson wants to review last quarters sales figures by product line.
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Pareto Chart (cont)

Pareto charts help you identify which of your problems are most significant, so you can focus your improvement efforts on areas where the largest gains can be made. Pareto charts are a special type of bar chart in which the horizontal axis represents categories of interest (e.g., material types, sizes, scrap codes, process centers), rather than a continuous scale (e.g., 0-100). The categories are often defects, sources of defects, or inputs into a process. The vertical axis represents some type of count or frequency (e.g., occurrences, incidents, parts, time).
By ordering the bars from left-to-right, largest to smallest, a Pareto chart can help you visually determine which of the defects comprise the vital few, and which represent the trivial many.

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Sample Chart Freight Billing Errors

Freight Billing Errors
40 100 80 30

Count

60 20 40 10 20 0
Non-core Carrier Missing Code Incorrect Destination Zip Codes Incorrect Codes Incorrect Freight Classification Others

Defect
Count Percent Cum %

The Pareto chart bars are divided into causes of freight billing errors. The vertical axis shows a count of each error type. The red line is a cumulative percentage. Non-core carrier is the most frequent problem, representing 42.9% of the total errors. Next-largest contributor: Missing code

18 42.9 42.9

15 35.7 78.6

4 9.5 88.1

2 4.8 92.9

1 2.4 95.2

2 4.8 100.0

We should consider focusing our improvement efforts on non-core carriers and missing codes.
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Percent

Sample Chart Order Processing Delays

The top 3 processes will get the most attention for improvement efforts here.

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How to Create a Pareto Chart

Collect data on different types or categories of problems.
Use check sheets, daily scrap reports, production reports, etc.

Tabulate the scores. Determine the total number of problems and/or the total impact (time to fix, cost, etc.). Also, determine the counts or impact for each category.
If there are a lot of small or infrequent problems, consider adding them together into an other category.

Sort the problems by frequency or by level of impact. Draw bars for each category, starting with the largest and working down.
The other category goes last, even if it is not the smallest bar.

Add in the cumulative percentage contribution line (sum of each categorys contribution / totals).
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Interpreting a Pareto Chart

Clear Pareto Effect? No Clear Pareto Effect?
Any ideas?

Defects
40 35 30 25 20 15 10 5 0 Factor Factor Factor Factor Factor Factor Factor Factor Factor Other A B C D E F G H I 20% 0% 80% 60% 40% 120% 100%

Count

Cum %

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Interpreting a Pareto Chart (cont)

Clear Pareto Effect: Just a few categories account for about 80% of the count or impact.
Great! Focus improvement efforts on those specific categories.

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Interpreting a Pareto Chart (cont)

No Clear Pareto Effect: Though some bars are taller than others, it takes a lot of categories to account for about 80% of the count or impact. No cause (or category) youve identified is much more important than any other.

Re-do any Pareto charts using counts by focusing on the impact of the categories (time/delay, quality/rework, cost, etc.), to see if the change in focus creates a clear Pareto effect. Revisit your cause-and-effect (fishbone) diagram or list of potential causes, then:
Ask which factors could be contributing to all potential causes; Think about other stratification factors you may not have considered, and then re-do the Pareto analysis with them in mind.
40 35 30 80.00% 25 20 15 40.00% 10 20.00% 5 0 60.00% Count Cum % 120.00% 100.00%

Factor Factor Factor Factor Factor Factor Factor Factor Factor I Other A B C D E F G H

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0.00%

Takeaways
We often see the 80/20 Rule in action where the majority of the impacts come from only a small fraction of the sources. A Pareto chart is a visual tool used to help identify which problems are most significant, so that improvement efforts can be focused where they will have the greatest impact. We can use the Pareto chart to manage effectively, by focusing on the area of pain where we can have the greatest financial impact in the least amount of time or with the fewest required resources.
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Ishikawa diagrams (also called fishbone diagrams, or herringbone diagrams , cause-and-effect diagrams, or Fishikawa) are causal diagrams that show the causes of a specific event -- created by Kaoru Ishikawa (1968). Common uses of the Ishikawa diagram are product design and quality defect prevention, to identify potential factors causing an overall effect. Each cause or reason for imperfection is a source of variation. Causes are usually grouped into major categories to identify these sources of variation. The categories typically include: People: Anyone involved with the process Methods: How the process is performed and the specific requirements for doing it, such as policies, procedures, rules, regulations and laws Machines: Any equipment, computers, tools etc. required to accomplish the job Materials: Raw materials, parts, pens, paper, etc. used to produce the final product Measurements: Data generated from the process that are used to evaluate its quality Environment: The conditions, such as location, time, temperature, and culture in which the process operates

Typical causes categories are:

The 6 Ms (used in manufacturing) Machine (technology) Method (process) Material (Includes Raw Material, Consumables and Information.) Man Power (physical work)/Mind Power (brain work): Kaizens, Suggestions Measurement (Inspection) Milieu/Mother Nature (Environment) The original 6Ms used by the Toyota Production System have been expanded by some to included the following and are referred to as the 8Ms. However, this is not globally recognized. It has been suggested to return to the roots of the tools and to keep the teaching simple while recognizing the original intent, most programs do not address the 8Ms. Management/Money Power Maintenance

The 8 Ps (used in service industry) Product=Service Price Place Promotion/Entertainment People(key person) Process Physical Evidence Productivity & Quality The 5 Ss (used in service industry) Surroundings Suppliers Systems Skills Safety

Man/Operator Was the document properly interpreted? Was the information properly circulated to all the functions? Did the recipient understand the information? Was the proper training to perform the task administered to the person? Was too much judgment required to perform the task? Were guidelines for judgment available? Did the environment influence the actions of the individual? Are there distractions in the workplace? Is fatigue a mitigating factor? - Is his work efficiency acceptable? - Is he responsible/accountable? - Is he qualified? - Is he experienced? - Is he medically fit and healthy? How much experience does the individual have in performing this task? - can he carry out the operation without error? Machines Was the correct tool/tooling used? - Does it meet production requirements? - Does it meet process capabilities? Are files saved with the correct extension to the correct location? Is the equipment affected by the environment? Is the equipment being properly maintained (i.e., daily/weekly/monthly preventative maintenance schedule) Does the software or hardware need to be updated? Does the equipment or software have the features to support our needs/usage? - Was the machine properly maintained? Was the machine properly programmed? Is the tooling/fixturing adequate for the job? Does the machine have an adequate guard? Was the equipment used within its capabilities and limitations? Are all controls including emergency stop button clearly labeled and/or color coded or size differentiated? Is the equipment the right application for the given job?

Measurement Does the gauge have a valid calibration date? Was the proper gauge used to measure the part, process, chemical, compound, etc.? Was a gauge capability study ever performed? - Do measurements vary significantly from operator to operator? - Do operators have a tough time using the prescribed gauge? - Is the gauge fixturing adequate? Does the gauge have proper measurement resolution? Did the environment influence the measurements taken? Material (Includes Raw Material, Consumables and Information ) Is all needed information available and accurate? Can information be verified or crosschecked? Has any information changed recently / do we have a way of keeping the information up to date? What happens if we don't have all of the information we need? Is a Material Safety Data Sheet (MSDS) readily available? Was the material properly tested? Was the material substituted? Is the suppliers process defined and controlled? - Was the raw material defective? - was the raw material the wrong type for the job? Were quality requirements adequate for the part's function? Was the material contaminated? Was the material handled properly (stored, dispensed, used & disposed)?

Method Was the canister, barrel, etc. labeled properly? Were the workers trained properly in the procedure? Was the testing performed statistically significant? Was data tested for true root cause? How many if necessary and approximately phrases are found in this process? Was this a process generated by an Integrated Product Development (IPD) Team? Did the IPD Team employ Design for Environmental (DFE) principles? Has a capability study ever been performed for this process? Is the process under Statistical Process Control (SPC)? Are the work instructions clearly written? Are mistake-proofing devices/techniques employed? Are the work instructions complete? - Is the work standard upgraded and to current revision? Is the tooling adequately designed and controlled? Is handling/packaging adequately specified? Was the process changed? Was the design changed? - Are the lighting and ventilation adequate? Was a process Failure Modes Effects Analysis (FMEA) ever performed? Was adequate sampling done? Are features of the process critical to safety clearly spelled out to the Operator? Environment Is the process affected by temperature changes over the course of a day? Is the process affected by humidity, vibration, noise, lighting, etc.? Does the process run in a controlled environment? Are associates distracted by noise, uncomfortable temperatures, fluorescent lighting, etc.?

Cause-and-Effect Diagram
Represents the relationship between an effect (problem) and its potential causes. Pushes teams beyond symptoms to uncover potential root causes and avoid the theme effect. Provides structure in cause identification (6Ms, 4Ps, etc.). Repeat the process on each specific root cause to drill-down to identify Key Process Input Variables and controllable factors.
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 Ask "why" each major cause happens at least 5 times. Follow up each answer with a question about that answer. Only stop when the team reaches a potential cause that the team can act upon. Pushes people to think about root causes. Prevents a team from being satisfied with superficial solutions that wont be sustainable or wont fix the problem in the long run.
________________ 1. Why? 2. Why? 3. Why? 4. Why? 5. Why?

5 Whys (review)

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Fishbone Analysis
Components : - Head of a Fish : Problem or Effect - Horizontal Branches : Causes - Sub branches : Reason - Non- service Categories : Machine, Manpower, Method etc. - Service categories : People, Process, Policies, Procedures etc.

Measurement

Material

Machine

cause

cause reason

cause

cause reason
Man Power

Problem

Management

Method

Fishbone Analysis
5 WHYS
Didnt buy this morning

WHY

Ran out of Gas

WHY

Car stopped Middle of the road

WHY

Didnt have money

WHY

Lost them in last nights poker

WHY

Not very good in bluffing

Case Study Safeway.com

Safeway outsourced a module of Safeway online to HCL, India Project Details Add a new module for selling Patio furniture online on http://Safeway.com . Agreed duration - 8 months, June, 07 to February, 08 Actual delivery June 08 After the project was finished TCS performed a Root Cause Analysis to analyze the delays and to avoid problems in future.

Case Study Fishbone Analysis

Control
No Clear Understanding Inventory Update Every 12 hours

Inventory

Scope Definition No Clear deadlines

Real time inventory Separate Systems

Wrong Estimates

Separate Systems for Sales & Supplier Managed Systems

Project Delay

No backup for Critical Resources

Inadequate Resources

Different Suppliers

Communication
No Communication plan

Lack of Standards
Time and Format of Systems different

Resources

Benchmarking

Example Fishbone Diagram

Fishbone Diagram Example

Machines New valve access requires ladder

No Mgt of Change analysis

Methods Written checklist did not include warnings re safe ladder use

Ladder legs uneven

Lack of Maintenance

No hazard analysis of procedure

No Trng Mgt System

Operator not trained Steps wet and slippery Operator did not heed ladder warning label
No discipline for previous safety violations Lack of Housekeeping

Operator broke wrist on fall from ladder

People

Material

35

Multi-Voting (review)

IIII III IIII II

Issue / Idea A Issue / Idea B Issue / Idea C Issue / Idea D

A method for selecting or narrowing a set of alternatives. Improves the teams ability or allows each member to express strength of opinion through voting. List all alternatives and count them (N=# of alternatives). Give each member N / 3 votes (or whatever # seems reasonable given the number of alternatives).
Cast all, some, or none of your votes for any alternative. When all votes (the sum) are cast, the member is done voting.

Rank order the alternatives based on total votes received. Repeat the process until clear prioritization can be viewed.

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Determining Root Cause

What is the underlying cause(s) of symptoms, that if resolved, would eliminate or reduce the symptom? The Five Whys. A process to seek root cause by asking why five times in succession. System Planning Process. Problem solving approach asks 4 questions: Where are we now? Where are we going? How will we get there? What is holding us back?
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problems are best solved by attempting to address, correct or eliminate root causes,

as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is more probable that problem recurrence will be prevented. However, it is recognized that complete prevention of recurrence by one corrective action is not always possible. Nevertheless, in the U.S. nuclear power industry the NRC requires that "In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to prevent repetition." [10CFR50, Appendix B, Criterion XVI, Sentence 2)] In practice more than one "cause" is allowed and more than one corrective action is not forbidden. Conversely, there may be several effective measures (methods) that address the root causes of a problem. Thus, RCA is often considered to be an iterative process, and is frequently viewed as a tool of continuous improvement. RCA is typically used as a reactive method of identifying event(s) causes, revealing problems and solving them. Analysis is done after an event has occurred. Insights in RCA may make it useful as a pro-active method. In that