root cause analysis - kepner-tregoe
Post on 29-Oct-2021
27 Views
Preview:
TRANSCRIPT
Leaders in Problem Solving
Root Cause Analysis
Michael W. Curran-Hays, Principal
John Ager, Consultant
The Critical Thinking and Tools that Support It
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
“If you can't describe what you are doing as a process, you don't know what you're doing.” ― W. Edwards Deming
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
8D What is the problem or change?What do we need to know to resolve it?
What did change to cause a change in performance?
What should change to address a change
in expectations?
What could change that would jeopardize our chosen actions or
plans?
What could change that would enhance our chosen actions
or plans?
D6
D3
YD7
D2D1D0
Deviation(s)
Defined
Describe the
Problem
Implement
Containment
Actions
Select and
Verify
Corrective
Actions
Prevent
Recurrence
Implement
Permanent
Corrective
Actions
Assemble a
Team
Process Key Situation Appraisal Problem AnalysisPotential Problem
AnalysisDecision Analysis
Identify
Opportunities
for Continuous
Improvement
Recognize
Team Efforts
Identify and
Verify Root
Causes
D5 D8
Potential Opportunity
Analysis
D4
Performance System
What is the problem or change?What do we need to know to resolve it?
What did change to cause a change in performance?
What should change to address a change
in expectations?
What could change that would jeopardize our chosen actions or
plans?
What could change that would enhance our chosen actions
or plans?
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
RCA Tools
8D StepsDescribe the
ProblemIdentify and Verify Root Cause
ROOT CAUSE ANALYSIS
PRINCIPLES
State
the
Proble
m
Describe
the
Problem
Identify Possible
Causes
Evaluate Possible
Causes
Confirm
True
Cause
INFORMATION NEEDEDFACT
SFACTS HYPOTHESES
FACTS &
ASSUMPTIONSFACTS
RCA TOOLS
Problem Statement X
5 Whys X
Cause & Effect Chart/ Fault Tree X X
IS and IS NOTs X
Distinctions & Changes X X
Cause & Effect Chart/ Fault Tree X
Fishbone/ Ishikawa X
FMEA/ PPA X
Evaluate Possible Causes X
Confirm True Cause X
8D/A3 X X X X X
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What two RCA tools do you use the most?
1. 5 Whys2. Fishbone3. KT Is/Is Not4. Fault tree5. Cause & Effect Charting6. Other (Please record in the question box from the Q&A tab)
5
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Midges were flying into
the walls of the
Jefferson Memorial
Chunks of cement falling from the
Jefferson Memorial
Soap and water mixing
with the cement and
creating a destructive
acid
Monument is washed
every day
There were an
unusually large number
of bird droppings on
the memorial
There were an
unusually large number
of sparrows
The sparrows were
feasting on a plentiful
supply of spiders
The spiders were
feasting on an
abundance of midges
Jefferson Memorial lights turned on at
dusk
What is the Problem?
The 5 Whys
Photograph from Wikipedia, the free encyclopedia
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What is the Problem?
Cause & Effect Charting
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What is the Problem?
The Performance System
Eighty-five percent of the reasons for failure are deficiencies in the systems and process rather than the employee. The role of management is to change the process rather than badgering individuals to do better.W. Edwards Deming
Put a good person in a bad system and the bad system wins, no contest.W. Edwards Deming
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What is the Problem?
The Performance System
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Which elements of the Performance System do you most frequently consider as part of your investigations?
1. Situation – Expectations (How clear and well understood?)2. Situation – Signal to Perform (How easy to recognize when to perform?)3. Situation – Inputs (What tools, information, processes support the work?)4. Situation - Priority (How are responsibilities prioritized?)5. Performer’s Capability (What skills do they have?)6. Consequences (What’s In It For Me? From the perspective of the performer)7. Feedback (How do they know how well they are doing?)8. Other ( Please record in the question box from the Q&A tab)
10
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
“What is the problem?”
"Okay, Houston, we've had a problem here" -Jack Swigert, Apollo 13
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
8D What is the problem or change?What do we need to know to resolve it?
What did change to cause a loss of oxygen and power?
What should change to restore oxygen
and power and bring the astronauts
home?
What could change on the way home that would jeopardize their safe
arrival?
What could change on the way home
that would enhance their safe arrival?
D6
D3
YD7
D2D1D0
Deviation(s)
Defined
Describe the
Problem
Implement
Containment
Actions
Select and
Verify
Corrective
Actions
Prevent
Recurrence
Implement
Permanent
Corrective
Actions
Assemble a
Team
Process Key Situation Appraisal Problem AnalysisPotential Problem
AnalysisDecision Analysis
Identify
Opportunities
for Continuous
Improvement
Recognize
Team Efforts
Identify and
Verify Root
Causes
D5 D8
Potential Opportunity
Analysis
D4
Performance System
What is the problem or change?What do we need to know to resolve it?
What did change to cause a loss of oxygen and power?
What should change to restore oxygen
and power and bring the astronauts
home?
What could change on the way home that would jeopardize their safe
arrival?
What could change on the way home
that would enhance their safe arrival?
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What is the Problem?
Cause & Effect Chart/FTA of post-Launch events
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Describe the Problem
IS and IS NOT
“Two oxygen tanks essentially identical to oxygen tank no. 2 on Apollo
13, and two hydrogen tanks of similar design, operated satisfactorily on
several unmanned Apollo flights and on the Apollo 7, 8, 9, 10, 11, and
12 manned missions. With this in mind, the Board placed particular
emphasis on each difference in the history of oxygen tank no. 2 from
the history of the earlier tanks, in addition to reviewing the design,
assembly, and test history.” – Report of Apollo 13 Review Board
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Describe Problem
IS and IS NOTIS IS NOT
WHAT
Object
Deviation
Service Module cryogenic oxygen
tank no. 2 - # 10024XTA0008
Service Module cryogenic oxygen tank
no. 1 - # 10024XTA0009
Hydrogen Tanks
Apollo 13 Apollo 7, 8, 9, 10, 11, and 12
Rapid expulsion of high-pressure
oxygen
Slow leak
WHERE In lunar orbit At Kennedy Space Center
WHEN
First
In the Life
Cycle
55:54:53.555
16 Mar 1970 – 11 Apr 1970
00:00:00:000 - 55:54:53.554
During 4th tank stir (fan)
Immediately after pressure and
temperature within oxygen tank
no. 2 rose abnormally
During Countdown Demonstration Test
During 1st – 3rd tank stirs (fan)
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What is the problem or change?What do we need to know to resolve it?
What did change to cause a loss of oxygen and power?
What should change to restore oxygen
and power and bring the astronauts
home?
What could change on the way home that would jeopardize their safe
arrival?
What could change on the way home
that would enhance their safe arrival?
D6
D3
YD7
D2D1D0
Deviation(s)
Defined
Describe the
Problem
Implement
Containment
Actions
Select and
Verify
Corrective
Actions
Prevent
Recurrence
Implement
Permanent
Corrective
Actions
Assemble a
Team
Process Key Situation Appraisal Problem AnalysisPotential Problem
AnalysisDecision Analysis
Identify
Opportunities
for Continuous
Improvement
Recognize
Team Efforts
Identify and
Verify Root
Causes
D5 D8
Potential Opportunity
Analysis
D4
Performance System
What is the problem or change?What do we need to know to resolve it?
What did change to cause a loss of oxygen and power?
What should change to restore oxygen
and power and bring the astronauts
home?
What could change on the way home that would jeopardize their safe
arrival?
What could change on the way home
that would enhance their safe arrival?
8D
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Identify Possible Causes
Ishikawa/Fishbone Diagram
Management controls not
defined in as great detail
Personnel don t know how
to install oxygen tanks
Teflon in oxygen tank
Probing with a hand tool in
manufacturing
Tank corroded Personnel don t know
how to test oxygen tanks
"shelf drop" in prime
contractor's plantFan Short Circuits
Tank released
oxygen
Assembly of equipment
essentially "blind"
Filter line ruptures
Debris strikes module
Insulation degraded
Valve fails to openTank assembled with
loose fill tube parts
Personnel not able to
install oxygen tanks
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Identify Possible CausesCause & Effect Chart/Fault Tree Analysis
“Beginning from the defined undesired event, ‘Fuel cell power not available on SM buses’, the causative factors have been shown by means of logic diagramming. Given that a specified event can occur, all possible causes for that event are arrayed under it. It is important to note that this listing includes all possible ways in which the event can occur. Next, the relationship of these causative factors to one another and to the ultimate event is evaluated and determination as to whether the defined causes are mutually independent, or are required to coexist, is made.” – Report of Apollo 13 Review Board: Appendix F –Special Tests and Analyses
Actual NASA Fault Tree Analysis
Dated June 5th, 1970
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
The Actual and Complete NASA Fault Tree Analysis
As shown on the Apollo 13 Review Board Report
Dated 1970
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Identify Possible Causes - Distinctions and Changes
IS IS NOT Distinctions Changes
WHAT
Object
Deviation
SM cryogenic oxygen tank
no. 2 - # 10024XTA0008
SM cryogenic oxygen tank
no. 1 - # 10024XTA0009
Detanked
using 65 v
heater
Temperature
inside tank
@1000⁰ F
Hydrogen Tanks
Apollo 13 Apollo 7, 8, 9, 10, 11, and 12
Rapid expulsion of high-
pressure oxygen
Slow leak
WHERE In lunar orbit At Kennedy Space Center
WHEN
First
In the
Life
Cycle
55:54:53.555
16 Mar 1970 – 11 Apr 1970
00:00:00:000 - 55:54:53.554
During 4th tank stir (fan)
Immediately after pressure
and temperature within
oxygen tank no. 2 rose
abnormally
During Countdown
Demonstration Test
During 1st – 3rd tank stirs
(fan)
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
8D
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Evaluate Possible Causes
f. Data indicate that in flight the tank heaters located in oxygen tanks no. 1 and no. 2 operated normally prior to the accident, and they were not on at the time of the accident.
g. The electrical circuit for the quantity probe would generate only about 7 millijoules in the event of a short circuit and the temperature sensor wires less than 3 millijoules per second.
h. Telemetry data immediately prior to the accident indicate electrical disturbances of a character which would be caused by short circuits accompanied by electrical arcs in the fan motor or its leads in oxygen tank no. 2.
– Report of Apollo 13 Review Board
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
8D
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Confirm True Cause
l. As shown by subsequent tests, failure of the thermostatic switches probably permitted the temperature of the heater tube assembly to reach about 1000⁰ F in spots during the continuous 8-hour period of heater operation. Such heating has been shown by tests to severely damage the Teflon insulation on the fan motor wires in the vicinity of the heater assembly. From that time on, including pad occupancy, the oxygen tank no. 2 was in a hazardous condition when filled with oxygen and electrically powered.
m. It was not until nearly 56 hours into the mission, however, that the fan motor wiring, possibly moved by the fan stirring, short circuited and ignited its insulation by means of an electric arc. The resulting combustion in the oxygen tank probably overheated and failed the wiring conduit where it enters the tank, and possibly a portion of the tank itself.
– Report of Apollo 13 Review Board
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Root Cause Analysis
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What is the problem?Cause & Effect Chart / FTA of pre-launch events
It was found that the accident was not the
result of a chance malfunction in a statistical
sense, but rather resulted from an unusual
combination of mistakes, coupled with a
somewhat deficient and unforgiving design.
- Report of Apollo 13 Review Board
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.27
What is the problem?
Cause & Effect Chart / FTA of pre-launch events
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What is the problem?
The Performance System
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What is the Problem?
The Performance System
9. The Manned Spacecraft Center should reassess all Apollo spacecraft subsystems, and
the engineering organizations responsible for them at MSC and at its prime contractors, to
insure adequate understanding and control of the engineering and manufacturing details
of these subsystems at the subcontractor and vendor level. Where necessary,
organizational elements should be strengthened and in-depth reviews conducted on
selected subsystems with emphasis on soundness of design, quality of manufacturing,
adequacy of test, and operational experience.
- Report of Apollo 13 Review Board
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
What do we need to know?
What is the problem or
change we need to
understand and resolve?
What do we need to know?
What is the problem or
change we need to
understand and resolve?
What could change that
would jeopardize
preventing the oxygen
tank to be heated to
1000⁰?
What did change to
allow the oxygen tank to
be heated to 1000⁰?
What should change to
prevent the oxygen tank
to be heated to 1000⁰?
What could change that
would jeopardize
preventing the oxygen
tank to be heated to
1000⁰?
What should change to
prevent the oxygen tank
to be heated to 1000⁰?
What could change would
enhance preventing the
oxygen tank to be
heated to 1000⁰?
What did change to
allow the oxygen tank to
be heated to 1000⁰?
What could change would
enhance preventing the
oxygen tank to be
heated to 1000⁰?
What did change to
allow the oxygen tank to
be heated to 1000⁰?
Copyright 2017 Kepner-Tregoe, Inc. All Rights Reserved..
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Understanding variation is the key to success in quality and business. - W. Edwards Deming
Confusing common causes with special causes will only make things worse. - W. Edwards Deming
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
Cause of Gap Change in Performance Change in Expectations
Response Needed Corrective and Preventive Actions Product & Process Improvements
Constructs KT 8D A3 DMAIC
What do we need to
know?
D0: Deviation Defined
D1: Assemble a TeamBackground
Define – Understand Customer
Measure – Understand Process
What did change? D2: Describe the ProblemProblem
Statement
What should change? D3: Implement Containment Actions Goal Statement
What did change?D4: Identify, and Verify Root
Causes…
Root Cause
Analysis
What should change?D5: Select and Verify Corrective
Actions
Recom-
mendations
Analyze – Identify Improvement
Opportunities
What could change?D6: Implement Corrective Actions
D7: Prevent Recurrence
Implementation
PlanImprove – Achieve Improvement
What could change?
D8: Identify Opportunities for
Continuous Improvement
D8: Congratulate Your Team
Follow Up
ActionsControl – Sustain Improvements
Kepner-Tregoe Critical Thinking Processes and Change Management
Copyright © 2019 Kepner-Tregoe, Inc. All Rights Reserved.
A3
Leaders in Problem Solving
twitter.com@kepnertregoe
facebook.com/KepnerTregoe
linkedin.com/company/kepner-tregoe
John Ager Consultant
jager@kepner-tregoe.com
Michael Curran-HaysPrincipal
mcurranhays@kepner-tregoe.com
top related