a tradition of excellence tr-822 rev / restricted proprietary information. marvin group proprietary...
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A tradition of excellence
TR-822 REV /Restricted Proprietary Information. Marvin Group proprietary rights are included in the information disclosed herein. Recipient by accepting this document agrees that neither this document, nor the information disclosed herein, nor any part thereof shall be reproduced or transferred to other documents or used or disclosed to others for manufacturing or for any other purpose except as specifically authorized by Marvin Engineering.
Root Cause and Corrective Action TutorialJanuary 21, 2014
TR-822 REV / - 01/21/2014© The Marvin Group 2013
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Course Overview
This presentation is an introduction to performing Root Cause and Corrective Action (RCCA).
The RCCA process includes:₋ Clearly defining and analyzing a defect₋ Identifying solutions ₋ Carrying out solutions₋ Validating the effectiveness of applied
corrections to eliminate a defect.
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Application
RCCA applies to the activities associated with correcting and preventing defects related to: ‒ all phases of production from raw material to
finished product‒ production processes‒ all aspects of your company’s business
RCCA can be beneficially applied to all departments and functions in a company.
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Goals
The Goals of this presentation are: – To provide a working understanding of the roles,
responsibilities & activities associated with RCCA;
– To assist our suppliers in performing this important function when responding to a SCAR;
– To provide tools to our suppliers that may help in identifying and addressing defects before they are delivered to Marvin Engineering.
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Hands on Experience
This afternoon we will provide an opportunity to apply the concepts provided in this presentation to:– Conduct a problem investigation (fact finding).
– Determine the Root Causes (causal analysis)
– Define actions to eliminate the problems (identify solutions)
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Root cause analysis is an approach to identify the underlying causes of why an incident occurred so that the most effective solutions can be identified and implemented
Root Cause Analysis
RCCA comes down to three basic questions:
1. What's the problem? 2. What allowed it to happen?3. What will prevent it in the
future? The word root, in root cause analysis, refers to the underlying causes, not the one cause.
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Root Cause Definition
Root Cause:A condition or action thatbegins a chain that ends in a defect
There are multiple root causes that can result in the same problem
Addressing only 1 of many causes won’t eliminate the defect.
If effective RCCA is not performed, the problem will reoccur.
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Symptom vs. Root Causes
“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.”
Symptom Approach• “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 mistake-proof it 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 ApproachOld New
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The RCCA Process Simplified
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The RCCA Process Detailed
1. Define and confirm the problem2. Capture (contain) all affected items3. Restore (rework) the discrepant items to compliance4. Find the causes of the problem5. Develop an action plan prevent a recurrence6. Implement the plan7. Evaluate the effectiveness of the solutions8. Provide Objective Evidence of the implemented
solutions
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When to initiate RCCA
Corrective Action triggers:
– Customer SCAR issued– A Supplier Notification – Recurring nonconformity– Audit finding– Sub-tier supplier defect found
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Define the Problem
A well-written problem statement answers four simple questions:
• What is the specific problem?• Where did it happen?• When did it happen?• How many or how much is involved?
Phase 1: Investigation
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Problem Statement
The statement of a documented problem (from a Marvin Engineering SCAR)
– S/B .219 +.002/-.001 Dia. Hole, B/P sheet 3, zone C-4, section A-A
– IS O/S to .228
Phase 1: Investigation
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Restate the Problem
Problem Restated:– PN 1534AS1234 has an oversized hole: S/B .219
+.002/-.001 dia.; IS O/S to .228; B/P : sheet 3, zone C-4, section A-A.
– Work orders: 216, 178 and 230– Machines: Drill Presses #2 and #9– Qty. = 121 pcs. on SCAR, 78 pcs. In work
Phase 1: Investigation
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Containment Action
Search to find all items affected by the problem. Isolate them to ensure they are not processed further, or shipped to the customer.
Investigate all areas inside and outside the company:– Work in process– Open P.O.s– At outside suppliers, e.g. plating, heat treat– Shipped to customer
Phase 1: Investigation
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Determine the Root Causes
Phase 2: Analysis
Do not sit at a desk, read the problem statement, and then “solve” the issue alone.
Instead, involve others who have knowledge to offer:
• The Purchasing Agent• The Machine Operator• The Quality Inspector
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Work Cell or Facility
Process AProcess B
Process CMarvin
Engineering
• An escape is movement ofa defect to the next work area, or to the customerEscape
Esc
ape
Escape
PLUG THE HOLE!
Something Must Change if an Escape Occurs
Escapes
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Why Perform RCCA?
Component Level
Assembly
Test or Inspection By Customer
Design
?
Defects eat your profit.The later they are found,
the more they cost
Eliminate the defect as far up the stream as possible. At the source.
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Restore affected itemsto compliance
Containment
Root CausesLong Term
Corrective Actions fix Root Causes and Prevent Recurrence
Corrective Actions
Defect orunwanted event
Short TermCorrective Actions
fix the Defect
Corrective Actions:
Fix the nonconformity and prevent its recurrence
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Corrective Action
Short Term Corrective Action(s) fix the immediate problem(s)
Long Term Corrective Action(s) fix the systemic problems at the root cause level
Generate no additional problems
Phase 3: Decision
IMPORTANT
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Not All Corrective Actions are Created Equal
Corrections that are systemic in nature, like automatic checks or gates are significantly better than just cautioning an employee to be more careful
Employee Counseled
Formal Training
Warning on/ in tools, instruction, work area
Mandatory checks & reviews
Design, tooling, kitting, shadow boxes,
automated checking
Control of process inputs,
resulting in controlled
outputs
Corrective Action Continuum
weak STRONG
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When to use Mistake Proofing: Human error can cause mistakes or defects to occur The customer can make an error which affects the output At a hand-off step in a process Consequences are expensive or dangerous
“..mistakes will not turn into defects if errors are discovered and eliminated..” Shingo
Mistake Proofing
Phase 3: Decision
Elevator
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Verification & Validation
Verification & Validation
– Verification• Did we do what we said we were going to do?
– Validation• Were the actions effective in eliminating the problem and
preventing it from recurring?• Were other problems created because of the changes?
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Objective Evidence
Each SCAR response requires that evidence of the changes made are provided to Marvin Engineering along with the SCAR
Examples: Training sign-in sheets for employee training on a new or
changed procedure A copy of the new or changed procedure The inspection data validating the First Article Inspection part
from a changed CNC program A copy of a revised inspection sheet adding a previously
skipped characteristic
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Summary
– The fundamental Root Cause & Corrective Action (RCCA) process involves• Containment, Correction, Root Cause Analysis,
Corrective Action, Verification, Validation
– Effective RCCA depends upon:• A well written problem description - define the
requirement being violated• A robust causal analysis - use quality tools• A diligent validation - with data showing
elimination of the root cause
Without these the defect cycle will repeat