Mini Guide To Oot Cause Analysis-Free PDF

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MINI GUIDE TO,ROOT CAUSE ANALYSIS,1 Introduction 3. 2 Why complete Root Cause Analysis 4,3 QM T approach to RCA 5. 4 Practical guide to carrying out an RCA 6,5 RCA Tools Techniques 7. 6 Look up table for completing an RCA 13,7 Examples RCA s 14. 8 Hints and Tips 14,9 12 Pitfalls of RCA 14, Quality Management Training Limited All rights reserved 2008 2.
MINI GUIDE TO ROOT CAUSE ANALYSIS,1 Introduction, Root Cause Analysis RCA is a method that is used to address. a problem or non conformance in order to get to the root. cause of the problem It is used so we can correct or eliminate. the cause and prevent the problem from recurring, It is not rocket science anyone can do it You probably do it. on a day to day basis without thinking about it, RCA is simply the application of a series of well known. common sense techniques which can produce a systematic. quantified and documented approach to the identification. understanding and resolution of underlying causes Below are. a number of definitions which encapsulates the main points of. this technique,Identify the,Monitor the Define the. system Problem,Corrective Understand,action the problem.
Identify the,root cause, An objective thorough and disciplined methodology employed. to determine the most probable underlying causes of problems. complaints and undesired events within an organization with. the aim of formulating and agreeing corrective actions to at. least mitigate if not eliminate those causes and so produce. significant long term performance improvement Vorley. Tickle QM T 2002, A powerful tool used to identify record and visually represent. the possible causes of a problem Instead of problems and their. effects appearing vast and insoluble root cause analysis breaks. down the problem into smaller more easily handled chunks. represented by a fishbone diagram Paul Wilson RCA, The investigation and reporting the causes of occurrences to. enable the identification of corrective actions adequate to. prevent recurrence and thereby protect the health and safety of. the public the workers and the environment RCA Guidance. document DOE Guidelines Feb 92, Quality Management Training Limited All rights reserved 2008 3. MINI GUIDE TO ROOT CAUSE ANALYSIS,2 Why complete Root Cause Analysis.
Organizations often respond to problems with short term. solutions However constantly relying on quick fixes requires. staff to repeat the same tasks over and over again all while. maintaining the status quo Focusing on short term solutions is. not a recipe for increased profitability and organizational. When people spend a lot of time putting out fires in the. workplace there is an illusion of industry lots of busy people. completing lots of tasks Working harder and faster we allow. the environment s energy and rhythm to seduce us into. believing we re doing our best to increase productivity and. efficiency But the law of diminishing returns applies here. However you can improve efficiency by taking time to think. through problems from first principles and then tackling the. causes rather than the effects, To improve efficiency and profitability we need to look beneath. the surface to the root of a problem or issue By observing the. effect which is really just the symptom of a problem and. deducing what has caused it to occur you can create a. preventative solution that should put an end to the problem In. order to understand the source of a problem you will need to. undertake a root cause analysis, RCA gives the confidence that the problem can be solved by. taking a structured approach making sure that the problem. never happens again,By the way RCA is not a chore it can be fun. By eliminating the root cause you can save time and. Quality Management Training Limited All rights reserved 2008 4. MINI GUIDE TO ROOT CAUSE ANALYSIS,3 QM T approach to RCA. The first step in any RCA is to identify the problem QM T. monitor many aspects of the organisation and can spot. potential problem areas This process is known as Pareto. Analysis which we will cover later However potential RCA s. can be derived from many areas ranging from Customer. Complaints Escalations and Incidents through to recurring. EARS QA s Customer Surveys and Credit Notes, The Corrective Action Request CAR system can be used to.
document the immediate and longer term corrective action. There is no one person identified to chase and progress these. CAR This pocket guide is not intended to be a guide to the. CAR system but to provide a Road Map or approach that can. be adopted in tackling a specific RCA project The table below. may help in determining the RCA projects importance. RCA Significance,Consequences or Severity of Incident. Likelihood,of Critical High Medium Low,Occurrence,Almost Very high Very high. High Risk Low Risk,certain risk risk,Very high Moderate. Likely High Risk Low Risk,Moderate Moderate,Possible High Risk Low Risk. Moderate Very Low,Unlikely Low Risk Low Risk,Moderate Very Low Very Low.
Rare Low Risk,Risk Risk Risk, Consequences of incident Critical Health Safety issue. High Customer s Business Process CBP unavailable Medium. Customer s Business Process CBP degraded Low Non urgent. Likelihood of occurrence Almost certain Likely Possible. Unlikely Rare, Priority Very High Risk High Risk Moderate Risk Low Risk. Very Low Risk, Quality Management Training Limited All rights reserved 2008 5. MINI GUIDE TO ROOT CAUSE ANALYSIS,4 Practical guide to carrying out an RCA. To assist with the process QM T have devised a Worksheet. which can be found at on the website along with many if the. tools that can be used to complete a RCA project Once the. problem has been discovered there are 5 basic steps to. completing an RCA,the Solution 1 Define the,4 Corrective.
2 Understand,the Problem, I Define the Problem Try and use SMART principles i e. Specific Measurable Actions oriented Realistic Time. constrained Unless the problem is defined accurately the. RCA whole process maybe prone to failure This phase will. usually also define how the RCA will be run as a Project. II Understand the Problem Check the information, obtaining real data regarding the problem gaining a clear. understanding of the issues This is when the various tools. and techniques such as Cause and Effect brainstorming. etc can be used,III Immediate Action Implement temporary counter. measures at the place of the problem The further away. from the problem source the solution is determined the. less likely that the solution will be effective, IV Corrective Action Determine and prioritise the most. probable underlying causes of the problem as the, temporary counter measure may not resolve the root.
cause Taking corrective actions to at least mitigate or. preferably eliminate the causes, V Confirm the Solution After the measures have been. determined and implemented the success of the adopted. approach needs to be established Having confirmed the. success of the suggested solution then rules or control. methods need to be established that will avoid the. problem ever happening again This is probably the,most important phase in the RCA but the one most. often missed, Quality Management Training Limited All rights reserved 2008 6. MINI GUIDE TO ROOT CAUSE ANALYSIS,5 RCA Tools Techniques. 5 Why s or Gemba Gembutsu, 5 Why s can sometimes be referred to as Gemba Gembutsu.
which literally means Place and Information in Japanese from. who s car industry much of today s RCA methods are taken 5. Why s typically refers to the practice of asking five times why. the failure has occurred in order to get to the root cause causes. of the problem No special technique is required or form is. required but the results should be captured in the Worksheet. see an example of 5 Why s in Sect 6 5 Why s are best used. when tackling a simple RCA,Pareto Analysis, Pareto analysis is an easy to use technique that helps you to. choose the most effective changes to make, It uses the Pareto principle i e the idea that by doing 20 of. the work you can generate 80 of the advantage of doing the. entire job Pareto analysis is a formal technique for finding the. changes that will give the biggest benefits It is useful where. many possible courses of action are competing for your. For example you might want to establish why customers no. longer deal with us as a supplier,Study of Customer Satisfaction. Number of Customers,80 of the The graph reveals approx 20 of. 50 Quantity or Cost reasons for leaving are responsible. for 80 of the customers who left,of Customers,Reason for Leaving.
Quality Management Training Limited All rights reserved 2008 7. MINI GUIDE TO ROOT CAUSE ANALYSIS,Cause Effect diagrams. Also known as Fishbone diagrams for their appearance and. Ishikawa diagrams names after their developer Kaoru. Ishikawa this useful technique is used for more complex. RCAs This type of diagram identifies ALL the potential. processes and factors that could contribute to a problem A. basic diagram is shown below A basic Cause and Effect. template can be found in Microsoft Visio or just use. PowerPoint,Cause 1 Men,Equipment Cause 1,Cause 2 Cause 2. Cause 3 Cause 3,Cause 1 Cause 1,Cause 1 Cause 1,Measurement. Environment Process or Method, Once you have captures all the desired information try and. prioritise those areas that you have a control over and. concentrate on finding resolutions for these,Brainstorming Interviewing.
Most people are familiar with Brainstorming and Interviewing. techniques However here are a few reminders, Collect as many ideas as possible from all participants with. no criticisms or judgments made while ideas are being. All ideas are welcome no matter how silly or far out they. seem Be creative The more ideas the better because at. this point you don t know what might work, No secondary discussions should take place during the. brainstorming activity Talking about the ideas will take. place after brainstorming is complete, Do not criticize or judge Don t even groan frown or. laugh All ideas are equally valid at this point,Do build on others ideas. Do write all ideas on a flipchart or board so the whole. group can easily see them Use Cause and Effect,Diagrams and Fault Trees to help capture the.
information, Set a time limit for the brainstorming 30 minutes is often. Quality Management Training Limited All rights reserved 2008 8. MINI GUIDE TO ROOT CAUSE ANALYSIS,Process Analysis Mapping and flowcharts. Most processes we follow today are mapped out by a flowchart. Flowcharts organize information about a process in a graphical. manner thus making it clear what is impacted Whether your. problem has a documented process or not this can be a really. useful tool to understand what is going on You don t have to. be an expert to in flowcharting either Although there are. good templates in Microsoft PowerPoint and Visio you can just. as easily use a wipe board or pen and paper,Generated Process Payment. Order No Order,Problem OK,Completed Stopped,Order Check Yes Credit Invoice Shipped Invoice. Received Credit OK Prepared Order Sent,Production,Entered Stock.
Production Diskettes,Scheduled Copied,Packages Order Order. Assembled Picked Shipped, Quality Management Training Limited All rights reserved 2008 9. MINI GUIDE TO ROOT CAUSE ANALYSIS,Fault Tree, This is a graphical technique that provides a systematic. description of the combinations of possible occurrences in a. system which can result in an undesirable outcome This. method can combine system and human failures A good. example is shown below, Fault trees can either be presented left to right or top to. bottom There are many specialist software products that allow. Fault Tree analysis but both Microsoft PowerPoint and Visio can. be used to complete these diagrams, Quality Management Training Limited All rights reserved 2008 10.
MINI GUIDE TO ROOT CAUSE ANALYSIS,Check Sheets, Check Sheets or Tally Charts are simply used to gather and. record data The data is usually numerical but can also be. used for other purposes e g listing audit questions to be asked. and recording the responses You may use a Check Sheet on a. day to day basis to check for software defects or the numbers. and types of Customer incidents,Example 1 Study of projects completed late. Checked Project Number Number,1 2 3 4 5 correct Failure. 1 Correct File,Structure Contents,2 2 2 2 2 0 100,2 Specification. 3 2 2 2 2 1 80,3 Cost estimate,3 3 3 2 2 3 40,4 Customer Order.
3 3 3 2 2 3 40,Acknowledged,3 3 3 2 2 3 40,6 Contract reviewed 3 2 3 2 2 2 60. Total correct 5 3 4 0 0,Example 2 Study of customers reasons for leaving. Customer Week,Number per month,Relationship Total,No reason 11 1111 1111 1 111 17. 11 1111 1 1111 1 11 15,Competitive,1 1 1 1111 11 10. Attitude of,1111 1 1111 1 0 1111 24,Total 9 10 15 12 20 66.
Quality Management Training Limited All rights reserved 2008 11. MINI GUIDE TO ROOT CAUSE ANALYSIS,Used to collect data for the above check sheets. Control Charts, The control chart is a graph used to study how a process. through problems from first principles and then tackling the causes rather than the effects To improve efficiency and profitability we need to look beneath the surface to the root of a problem or issue By observing the effect which is really just the symptom of a problem and deducing what has caused it to occur you can create a preventative solution that should put an end to the problem

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