PowerPoint Presentation

Root Cause Analysis. (HSSC Division).

Root Cause Analysis. Problem/symptom Root Cause. Root Cause Analysis - RCA.

Definition. Root cause analysis (RCA) is a problem solving methods aimed at identifying the root causes of problems or events. RCA is based on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms..

Principles of RCA?. Aiming corrective actions at root causes is more effective than just treating the symptoms of a problem. To be effective, RCA must be performed systematically and conclusions must be backed up by evidence. There is usually more than one root cause for any given problem and therefore there may be more than one corrective action..

General process for performing root cause analysis.

Symptom Approach vs. Root Cause • If we do a poor job of identifying the root causes of our problems, we will waste time and resources putting bandaids on the symptoms of the problem. Symptom Approach "Errors are often a result of worker carelessness." "We need to train and motivate workers to be more careful." "We don't have the time or resources to really get to the bottom of this problem." Root Cause "Errors are the result of defects in the system. People are only part of the process." "We need to find out why this is happening, and implement mistake- proofs so it won't happen again." "This is critical. We need to fix it for good, or it will come back and burn us.".

Root Cause Analysis - RCA.

Cause Mapping of Root Cause Analysis. “ ROOT ” refers to the causes beneath the surface. It is the system of causes that shows all the options for solutions. Do not focus on a single cause as this can limit the solutions set resulting in missing a better solution. A Cause Map provides a simple visual look at all the elements that produced the problem..

Three Basis Steps of Cause Mapping. Define the issue by its impact to overall goals Analyze the cause in a visual map. Prevent or mitigate any negative impact of the goals by selecting the most effective solutions..

Root Cause Analysis - RCA.

[Audio] Root Cause Analysis is critical to eliminating non-conformance and non-compliance. In this portion of the training, I'll give you some tools to use. First, I'd like to give you and example of why root cause analysis is critical. I once did an audit on a plant that had a delivery dock. The delivery dock was located so that every time it rained, the dock became wet and very slippery. One of the workers fell and hurt himself while running across the slippery dock. The immediate response was to send him to training about safety precautions. In other words, "Don't run on the dock. Take your time." The dock was also coated with a non-slip material. Six months later the man fell and was very seriously injured. He sued the company. Problem: The root cause was not discovered the first time. When finally asked why he was always in such a hurry, the man explained that his boss was always "ragging" him for being slow. He had been afraid of repercussions when injured the first time. Since no one asked him the first time, he decided to take the training and keep his mouth shut. It was also discovered that the anti-slip material had worn away. No preventive-action had been taken..

Tools Used in Root Cause Analysis x BRAINSTORMING START STOP FLOWCHART PARETO CHART VALUE RUN CHART FISHBONE DIAGRAM LSL TIME USL HISTOGRAM SCATTER DIAGRAM UCL x CONTROL CHARTS TREE DIAGRAM - FACTOR DESIGN OF EXPERIMENTS.

[Audio] This is yet more detailed with 6 bones.. Root Cause Analysis - RCA.

Brain storm possible causes. Root Cause Analysis - RCA.

5 Whys. Why Why Why Why Why Basis for the 20 questions toy (Game very popular used in IA).

[Audio] How To Construct A Pareto Chart A pareto chart can be constructed by segmenting the range of the data into groups (also called segments, bins or categories). For example, if your business was investigating the escape of GM traits, you could group the data into the following categories: # Outside Providers # Site Selection # Storage # Movement The left-side vertical axis of the pareto chart is labeled Incident or Frequency (the number of counts for each category), the right-side vertical axis of the pareto chart is the cumulative percentage, and the horizontal axis of the pareto chart is labeled with the group names of your response variables. You then determine the number of data points that reside within each group and construct the pareto chart, but unlike the bar chart, the pareto chart is ordered in descending frequency magnitude. The groups are defined by the user. Questions The Pareto Chart Answers What are the largest issues facing our team or business? What 20% of sources are causing 80% of the problems ( 80/20 Rule)? Where should we focus our efforts to achieve the greatest improvements?.

Defining the problem. The tackle is the one that has the highest score. This one will give you the biggest benefit if you solve it..

Charts and Graphs. . Root Cause Analysis - RCA.

7 Best Practices to Remember. Your root cause analysis is only as good as the info you collect. Your knowledge (or lack of it) can get in the way of a good root cause analysis. You have to understand what happened before you can understand why it happened. Interviews are not about asking questions. You can’t solve all human performance problems with discipline, training, and procedures. Often people can’t see effective corrective actions even if they can find the root cause. All investigations do not need to be equal (but some steps can’t be skipped..

Summary Root Cause Analysis is a method to focus our eff01ts on the true "Root Causes" of escapes, so that we truly prevent their reoccurrence. Root Cause Analysis helps us reduce turnbacks and frustration, maintain customer satisfaction, and reduce costs significantly. Each problem is an opportunity. It contains the information needed to eliminate the problem. But to identify the root cause, we have to ask "Why?" over and over, until we reach it..

Thank You.