AWARENESS TRAINING PROGRAM ON PROBLEM SOLVING BY

ROOT CAUSE ANALYSIS

Name: AJIT D BHOSALE
Designation: SR.GENERAL MANAGER – QUALITY AND SYSTEMS
Date: 31.10.2014

Rev 00
INTRODUCTION TO ROOT CAUSE ANALYSIS
INTRODUCTION

SUB HEADING
In any organization numerous problems exist in all facets of its
activities. The efficiency and survival of the organization depends
on how promptly these problems are recognized and their root
causes are isolated and eliminated.

A systematic analysis of each potential problem area to recognize

the root causes which are responsible for creating the problem.
is called as Root Cause Analysis.
INTRODUCTION

SUB HEADING
A root cause is a cause that once removed from the problem
prevents the final undesirable event from occurring or recurring.

Why Determine Root Cause?

• Prevent problems from occurring / recurring

• Reduce possible injury to personnel

• Reduce rework and scrap

• Increase competitiveness

• Promote happy customers and stockholders

• Ultimately, reduce cost and save money

ROOT CAUSE ANALYSIS STEPS

SUB HEADING
Follows a specific set of steps:
• Define the problem
• Collect data
• Identify possible factors
• Identify root cause(s)
• Identify & Implement solutions
• Verify the effectiveness of the
implemented solutions
STEP 1

SUB HEADING
DEFINE THE PROBLEM:
• What happened?
• When did it happen?
• Where did it happen?
• What was the impact?
STEP 2

SUB HEADING
COLLECT DATA:
•What proof do you have that the problem
exists?
•How long has the problem existed?

•What is the impact of the problem?

Analysis of Data

SUB HEADING
EMHS Data for Analysis:
• Customer Feedbacks (CSI)
• Customer Complaints
• Crane Stoppages (Lean)
• Design Concession Requests
• NC’s raised during internal inspection of Cranes
• Customer NC’s during inspection at our works
• NC’s raised during ISO 9K Internal Audits
• NC’s raised during Site Audits
• Supplier Rejections
• Customer Order Loss
• Plant Machinery Breakdowns
• Accidents, Near Miss Accidents,
• Sale Meet Minutes, Service Meet Minutes, KRA/KPI Review Meet Minutes,
etc
STEP 3&4: IDENTIFY THE POSSIBLE FACTORS & ROOT CAUSE

SUB HEADING
(TECHNIQUE NO.- 1)

Cause and effect diagram (also known as

Ishikawa diagram or fishbone diagram) is an
analysis tool to analyze many potential or
actual causes of a problem in a systematic way.
It is a very effective way of improving the
quality of the product or service.
ISHIKAWA DIAGRAM / FISH BONE DIAGRAM

SUB HEADING
Major and Subsidiary Causes
Material Environment

Procedures Noise level

Assemblies
Temperature
Consumables Humidity
Components Accounting
Suppliers Lighting
Policies
Quality
Variability
Instruments
Training
Experience Tests
Technology
Tooling
Attitude Gauging

Skill Fixtures Counting

Men Machine Measurement
EXAMPLES:

SUB HEADING
Machine factors
• Inadequate process capability
• Incorrectly designed
• Worn components
• Poor maintenance
• Equipment effected by environmental factors such as
heat, humidity etc.

Material factors
• Use of untested materials or wrong selection of material
• Substandard material accepted on concession
because of non-availability of correct material
• Inconsistency in specifications on the part of vendors
EXAMPLES:

SUB HEADING
Men factors
• Incorrect knowledge of doing settings, assembly, etc
• Careless operator and inadequate supervision
• Undue rush by the operator to achieve quality targets
• Lack of understanding of drawing instructions relating
to a process
• Operator does not posses requisite skill for handling
the equipment

Method factors
• Inadequate process controls
• Non availability of proper test equipments
• Test equipment out of calibration
• Vague inspection/ testing instructions
• Inspectors do not possess the necessary skill
• Methods / Work Instructions not defined
STEP 3&4: IDENTIFY THE POSSIBLE FACTORS & ROOT CAUSE

SUB HEADING
(TECHNIQUE NO.- 2)

ASK WHY 5 TIMES:

5 whys – Ask “why” until you get to the root of the problem

Very often, the answer to the first "why" will prompt

another "why" and the answer to the second "why" will
prompt another and so on; hence the name the 5 Whys
strategy.

Benefits of the 5 Whys include:

• It helps to quickly determine the root cause of a
problem
• It is easy to learn and apply
IDENTIFY THE SOLUTIONS:

SUB HEADING
• For better effectiveness
• Ease of Implementation
• Return on Investment
(not always applicable especially with Safety
Incidents)
• Prevent Potential Negative Effects –
solution shall not cause other problems

Evaluate Solutions before you implement them

TYPES OF SOLUTIONS

SUB HEADING
5
What can be done to prevent the problems?

Two types of solutions (actions):

1. Corrective – reactive, the problem has already occurred
and actions are taken to prevent reoccurrence
2. Preventative – proactive, problem has not happened yet
and the actions are taken to prevent occurrence.

Tools for Preventive Action are like –

DFMEA (Design Failure Modes & Effect Analysis),
PFMEA (Process Failure Modes & Effect Analysis),
Horizontal Deployment, etc

Note: All the solutions shall be recorded.

IMPLEMENTATION OF SOLUTIONS

SUB HEADING
This is essentially the action plan -
• How will the solution be implemented?
• Who is responsible for the solution?
• Target dates for completion

Action plan to reviewed periodically for timely

implementation of solutions.
VERIFICATION OF EFFECTIVENESS

SUB HEADING
• It is not verification of implementation.
• It is the verification of the effectiveness of
the actions taken.
• Poor results found in effectiveness
verification often indicate - wrong Root
Cause or wrong Corrective / Preventive
Action(s).
• Consider performing audits as a
verification tool.
CLOSURE OF SOLUTIONS IMPLEMENTED

SUB HEADING
• Closure can only happen after successful
verification of Corrective / Preventive
Actions
• By nature, effective Corrective / Preventive
Actions will prevent recurrence / occurrence
• If Corrective / Preventive Actions are found
to be not effective, then Root Cause
Analysis should be repeated.
• Record the date of closure.
DEMING - PDCA CYCLE

SUB HEADING
PLAN
ACT

Customer

Satisfaction

CHECK DO
THANK YOU FOR YOUR TIME.