Root Cause Analysis - Overview

Root Cause Analysis

and
Corrective Action
(RCCA)
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RCCA - Learning Objectives

The purpose of this module is to:
Apply the 5-why technique in
problem solving analysis.
Identify and understand the direct,
contributing and root cause of a
problem.
Learn the 2 types of corrective action.
Utilize a Corrective Action Matrix form
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to track and drive action item

Root Cause Analysis - An Overview

Root Cause Analysis and Corrective
Action (RCCA) is a process for :
Finding the true cause(s) of an event
Identifying and implementing
corrective actions
Assessing the effectiveness of
corrective actions
Preventing recurrence of the events
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Why Root Cause Analysis ?

Integral part of Continuous
Improvement
If we do not take action on problems,
we will be wasting our time and all involved
will lose interest.

Our Customers expect it !

ISO 9001-2000 requirement
Makes good Business sense
Keeps us from passing on
problems to
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internal and
external

DMAIC process applied to RCCA

Quantify
Problem
Control

Form Team
Scope project

Standardize
Improvement

RCCA
Make
Improvement

Measure
Analyze
Investigate
Root Cause

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(Customer complaints,
Audit findings,
Production, Inspection Data,
Product returns, Warranty etc)

Understand and State the Problem

Understand the Problem
From the event, what is the problem to
be solved,
or
what is the customers concern?
More than one Problem?
An event could have more than one problem,
with a root cause for each problem.
If you cannot say it simply, you do not
understand the problem!

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A Cause . . .
Is a set of circumstances or conditions
that:
Allows a condition to exist or an event
to happen,
Or
Makes a condition exist or an event
happen
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The Critical Five

Direct Cause: The cause that directly resulted in
the event.
(The first cause in the chain.)
Contributing Cause: The cause(s) that
contributed to an
event but, by itself, would not have caused the
event.
(The cause after the direct cause.)
Root Cause: The fundamental reason for an
event,
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which if corrected,
would prevent recurrence.

The Critical Five

Specific Corrective Action: Action(s) taken to
correct or
improve conditions noted in the event, by changing
the
direct cause
or,
The direct cause and the effect.
Preventative Corrective Action: Action(s) taken
that
prevent recurrence of the condition noted in the
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event.

Root Cause/ Corrective Action

The process requires complete honesty
and no
predetermined assumptions.
Follow the Data! Dont try to lead it.
A common cop-out: Operator error
Why do people not comply?
Improper instructions
Worn-out tools
Improper training
Lost expectations
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Root Cause/ Corrective Action

Dont limit the search !
What role did management systems play?
Are you looking beyond your own backyard?
Remember the 80/20 rule.

Be attentive to causes that show

up frequently!
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Root Cause/ Corrective Action

Utilize 5 Whys technique for
determination of cause and effect
Ask Why? 5 times.
Most problems, even the most serious or complex,
can be handled by using the 5 Why technique when
coupled with cause chain diagrams.
So, why use the 5 Why technique?

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Root Cause/ Corrective Action

Just keep asking
Why did it happen?

Didnt get to work on time.

Why?
Car wouldnt start.

Battery was dead.

Dome light stayed on all night.

Why?
Why?
Why?

Kids played in car, left door ajar.

..
Why?

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Root Cause/ Corrective Action

The 5 Whys another example
Problem: Customers complain about waiting too long to get
connected to staff during lunch hours.
Why does the problem happen?

Backup operators take longer to connect callers.

Why does it take backup operators longer?

Backup operators dont know the job as well as the regular

operator/ receptionist do.

Why dont backup operators know the job as well?

There is no special training, no job aids to make up for the

gap in experience and on-the-job learning for back-ups.

Why dont they have special training or job aids?

In the past, the organization has not recognized this need.

Why hasnt the organization recognized the need?

The organization has no system to identify training

needs.
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Decomposition Diagram
What it is:

Involves the use of

tree structures to
break down the
area/process under
study
A tree diagram
where all items are
included
(comprehensively
exhaustive) and not
repeated (mutually
exclusive)

Poor
control of
manuf.
process

Don't know
how to
control the
process
Didn't
achieve
spec. first
time

Large volume of
rework in PCB
manufacture

Boards
difficult
to make

They're
designed
like that

The designs
have
been through
several
iterations

When to use it:

Can be used as an
analysis structure

Benefits:

Depicts a single
dimension of
hierarchy

Operations
take no
responsibility
for
their work
Operators
make
lots of
mistakes

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Operators
poorly
trained?

They rely
upon
100%
inspection

Didn't
understand
implications of
spec.

Why - Why (5 Whys) Analysis

Problem

Why?
Poor control of
manufacturing
process

Large volume of
rework in PCB
manufacture

Boards difficult to
make

Operators make
lots of mistakes

Why?

Why?

Why?

Why?

Don't know how to

control the process

They're designed
like that

The designs have

been through several
iterations

Didn't understand
Didn't achieve spec. implications of spec.
first time

Operators take no
responsibility for their
work
They rely upon
Operators poorly
100% inspection
trained?

suited to both Repetitive and Non-Repetitive Processes

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Why - Why (5 Whys) Analysis

What it is:
A combination of a decomposition diagram and cause and effect diagram in tree
diagram format that shows the linkages between an effect and its root cause

When to use it:

When a cause and effect diagram has been built and the primary causes have
been identified, the 5 whys is used to delineate the causal linkages between the
final effect and the originating root cause. ** Dont be limited to only 5 whys:
the end point is the root cause

Benefits:
Establishes the evidence chain (or the hypothesis thereof) so that confirming
facts and data can be collected to substantiate the sequence and the critical
dependencies between relationships and time sequences
Disciplines the problem solving team to critically examine assumptions and
evidence in order to support the relationships between each link. How do you
know??

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Case of a Broken
Photocopier
Why - Why Diagram
Waiting too long
Impatience

Too slow
Wrong machine

Misuse

No budget
Not trained

No plan
No trainer
No plan to replace

MACHINE
BROKEN

No budget
Age

No perceived need
No one responsible

"Old reliable"

Non-business

WHY?

Wrong type machine

Too many copies

Deadlines

Overuse
WHY?

Not obvious needed

No limits

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No one responsible
WHY?

Root Cause/ Corrective Action

Direct Cause: The cause that directly resulted in the
event.
(The first cause in the chain.)
THIS IS THE ANSWER TO YOUR FIRST QUESTION. (YOUR PROBLEM
STATEMENT)

Contributing Cause: The cause(s) that contributed to

an
event but, by itself, would not have caused the event.
(The cause after the direct cause.)
Note: For a simple problem there may not be any contributing causes.

Root Cause: The fundamental reason for an event,

which if corrected, would prevent recurrence.
(Last cause in the chain.)
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RCCA

Root
Cause

The Cause Chain

Contrib.
Cause
Direct
Cause
Contrib.
Cause
EVENT
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Root Cause Analysis

Lets expand on a problem Cause and Effect
Received ticket for safety violation
- Car exhaust too loud
- Muffler knocked loose from tailpipe
- Daughter hit pot hole
- Pot holes in road
- Winters damage roads
- Congress wont approve extra
money for better roads
- Congress doesnt have extra money
- Congress spend money on pork barrels
- Too many lawyers in Congress

Solution?
Drive in Sweden, where there are fewer Lawyers.

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Root Cause Analysis

Utilize appropriate toolset with the
team. Uncover the root cause. Test
and formulate corrective action.
Examples:
Brainstorming, Pareto analysis, Cause and Effect
analysis, X-Y matrix
Process audit, Benchmarking
Consensus, mistake proofing (poka-yoke)
Statistical analysis, quality function deployment
Opportunity for simplification - Integration and
standardization (refer to VE & VA module)

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Root Cause/ Corrective Action

Corrective Action:
A set of planned activities (actions)
implemented for the sole purpose of
permanently resolving the problem.

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Root Cause/ Corrective Action

Two types of Corrective Action:
Specific
Preventive
These two types of corrective action are
quite different in how they are applied and
what they do. Not understanding this leads
to serious mistakes in fixing problems.
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Root Cause/ Corrective Action

Specific Corrective Action:
Action(s) taken to correct the direct cause.
(Corrects, or improves the condition noted
in the
event, by changing the direct cause, or the
direct
cause and effect.)
Sometimes called containment
Only used to correct the DIRECT cause
Does not prevent
recurrence !
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Root Cause/ Corrective Action

Preventive Corrective Action:
Preventive corrective actions focus on
changing
the root cause and any contributing
cause(s).
You probably wont get a 100% effective
fix at just one point (the root cause).
You often have to consider two or more
contributing causes to ensure the chain
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is broken.

Root Cause/ Corrective Action

Preventive Corrective Action:
Action(s) taken prevent recurrence of the
condition noted in the event. (Preventive
actions must directly address the root
and contributing causes to be effective.)

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Preventive Corrective Action

Root
Cause

Contrib.
Cause

Direct
Cause

Contrib.
Cause

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EVENT

Root Cause/ Corrective Action

Test the specific solutions to
ensure they are valid:
Do the corrective actions eliminate or
control the direct cause?
Are the results desirable?

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Root Cause/ Corrective Action

Example (ask Team)

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Root Cause/ Corrective Action

Preventive Action Test:
If these preventive corrective actions
were in place, would the event have
occurred?
Are there adverse effects caused by
implementing the corrective actions that
make them undesirable?
Do the preventive corrective actions
lower the risk factor of the event to an
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level?

Root Cause/ Corrective Action

Basic elements of reporting:
Restatement of the problem/ event/
objective
Data (who, what, where, why, how, etc.)
Team (natural work group, qualified)
Causes (root, direct, contributing)
Corrective Actions (specific, preventive,
plant-wide)
Milestone dates (Analysis complete, C/A
initiated, C/A implemented, Corrective
Action Report
closed)
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Tracking Form - example

Basic tracking form
Corrective Action Matrix (CAM)
Refer to - webpage (tools)

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Tracking Form - example

NOTE: Blank form located on free lean site
Watson - Weekly Update
For w/e - FRIDAY 4/22/2005

Date Entered
into Matrix

Location

Actions

Resp

Start
Date

1/31/2005

LC

Schedule. Plan and

conduct YB training class

JW

01/15/05

Dallas

Set up
room/arrangements

JW

01/15/05

Dallas

Sent out invitations to

Dallas

JW

01/29/05

1a

Dallas

CONDUCT 1st CLASS

JW

02/10/05

1b

Dallas

CONDUCT 2nd CLASS

JW

02/24/05

16-Feb

Dallas

Assembly list, review to

existing database

JW

02/18/05

28-Feb

Dallas

Set up
room/arrangements

JW

02/28/05

28-Feb

Dallas

Sent out invitations to

Dallas

JW

02/28/05

25-Feb

Dallas

CONDUCT 3rd CLASS

JW

02/28/05

4-Mar

Dallas

Evaluate Performance

JW

02/28/05

4-Mar

Dallas

CONDUCT 4th CLASS

JW

02/28/05

Evaluate Performance

JW

02/28/05

Teach 2 Yellow Belt Training Sessions

(usually offer 3 a year for new Dallas based employees)

BEGAN assembly of YB MASTER LISTING at Corporate

1c

1d

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4-Mar

Dallas

Root Cause/ Corrective Action

Follow-up
A review must be conducted in sufficient
detail to assess whether the corrective
actions that have been implemented are
effective as implemented and are truly
preventing recurrence of the event.

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Root Cause/ Corrective Action

Effectiveness Measures
The criteria used to evaluate if the corrective
actions achieved the desired outcome.
Examples:

Scrap quantities significantly reduced

Print was not manufactured to print tolerance. After
corrective action, part meets print.
Design could not be manufactured with current technology.
After corrective action, part can be manufactured with
current technology.
Parts would not assemble properly. After corrective action,
parts would assemble properly.

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Root Cause/ Corrective Action

Did corrective actions work?
Some additional things to consider:

If corrective action implemented differs from proposed,

find out why.
If better or alternate corrective actions were implemented,
document the changes.
Periodic checks may be necessary to be sure the corrective
actions are still in place.
Document using the proper forms.

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Root Cause Analysis - Overview

Root Cause Analysis

and
Corrective Action
(RCCA)
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