introduction to root cause analysis - frcc · pdf fileroot cause analysis proposals so if a...

Introduction to

Root Cause Analysis

As a Tool For Compliance Mitigation

Root Cause Analysis Truism #1

Bad things will happen…

The extent of the damage, or whether bad

things happen again, is a product of how

well we respond. 2

Root Cause Analysis Truism #2

“A bad system will

beat a good person

every time”

W. Edwards Deming

3

Root Cause Analysis Proposals

So if a bad system will beat a good

person every time what can you do?

• Improve the system so that success is built into

the system

• Don’t rely on individual heroic measures as a

component of your process

4

Root Cause Analysis (RCA) Objectives

• Describe RCA

• Applying RCA

– Develop mitigation activities

– Create corrective action plan

5

RCA

Description of Root Cause Analysis

• Root cause analysis is a systematic process

…for identifying “root causes” of problems or

events

• RCA serves as an effective management tool

…more than merely “putting out fires” for problems

that develop, but finding a way to prevent them

6

RCA

Benefits of Root Cause Analysis

• Prevent problems from recurring

• Reduce possible injury to personnel

• Reduce rework and scrap

• Increase competitiveness

• Ultimately, reduce cost and save money

7

RCA

Applying Root Cause Analysis

• Major accidents

• Everyday incidents

• Near-misses

• Human errors

• Maintenance problems

• Medical mistakes

• Productivity issues

• Development of corrective actions and mitigation plans

8

RCA Process

Prevention, not blame or punishment, is

the key element to having a successful RCA

9

Common Root Cause Mistakes

Initial response is usually the symptom, not the root cause of the problem.

Common “symptoms” mistaken for Root Causes:

• Equipment Failure

• Human Error

• Procedure Not Followed10

Look Beyond the Obvious

Invariably, the root cause of a problem is not

the initial reaction or response

Which leads to faulty mitigation11

Human Error

• To get to the root cause, we must look at the

systems and how they can be changed to make

the process easier on everyone

• What looks like a people problem is often a

system problem 12

Most Root Causes are System Related

• Process or program failure

• System or organization failure

• Poorly written procedures

• Lack of internal controls

• Inadequate training

13

Human Error

• To get to the root cause, we must look at the

systems and how they can be changed to make

the process easier on everyone.

• We won’t ask the question “Who?”

• This is not the place for blame.

• What looks like a people problem is often a

system problem.

14The PII Performance Pyramid TM

RCA Analysis Process

It’s Not Rocket Science…

but there is a process15

Root Cause Analysis Must-Haves

• Collaborative Effort

• Inter-disciplinary Process

• Requires participation (buy-in) by the

leadership of the organization

16

Using the RCA Process

• Investigate the incident

via Data Collection

• Attempt to understand the underlying

causes of the incident thru Analysis

• Generate effective Corrective Actions to

prevent and mitigate future incidents

17

Basic steps of the RCA process...

Step One—Data collection

Without an understanding of the event, the root

causes and causal factors cannot be identified18


Investigation

19


Step two—Analysis

• 5 Whys

•Causal factor charting

Without an understanding of the event, the causal

factors and root causes cannot be identified

20

Analysis Tool: 5 Whys

Sakichi Toyoda, one of the fathers of the Japanese

industrial revolution, developed the 5 Whys technique

in the 1930s

Toyoda has a "go and see" philosophy. This means

that its decision making is based upon an in-depth

understanding of the processes and conditions on the

production floor

21


Sakichi Toyoda:

The 5 Whys technique is most effective when the

answers come from people who have hands-on

experience of the process being examined.

22


Where do we start?

Write down the specific problem

Writing the issue helps you to formalize the problem

and describe it completely. It also helps a team focus

on the same problem

Ask "Why" the problem happens and write the answer

down below the problem

23


If the answer you just provided doesn't identify the

root cause of the problem that you wrote down in step

1, ask “Why” again and write that answer down

Keep looping back to step 3 until the team is in

agreement that the problem's root cause is identified

This may take more or less than five “Whys”

24

Analysis Tool: 5 Whys Example

Production Line Stoppage Issue

A large production company had an unusual

amount of scrap reported from the previous day’s

production on one machine.

The operator pushed the emergency stop button

by mistake during a production run.25


The Business Improvement Leader asked why?

“Operator error,” was the reply from the senior

manager

Why was it an operator error?

“Because it happens now and again,” was the

reply

26


A brief inspection of the start and stop buttons on the

machine:

Revealed both buttons were dirty to the point that the

red stop and green go buttons were not

distinguishable

And the buttons were also very close to each other

27


“Why does it happens now and again” asked the

Business Improvement Leader?

Operator pushed the stop button by mistake.

Why?

The buttons were unclear and dirty, and the stop

button was right next to the start button

28


29

Ishikawa fishbone diagram process:

Brainstorm causes

Put into pre-defined categories

Vote on which most likely to cause problems

Generate solutions

Step two —

Fishbone Cause and Effect


Step Three—

Root cause identification

After a list of Causal factors have been identified,

begin Root Cause identification30


Step Three—

Root cause identification

• Finding root cause encourages brainstorming

• There is no judgment and no wrong answers

• We are encouraged to find multiple root causes

• Pick the most appropriate root causes31


Production Stoppage Possible Root Causes:

Dirty control panels

Emergency stop button too close to the start button

32


Unacceptable Root Causes

• Human Error

• Mistake

• Distraction

33


Step 4 –

Recommendations and implementation

34

Corrective Action

Corrective Action – Mitigation Plan

• Actions to eliminate the cause of a

detected issue/problem

• Designed to prevent reoccurrence

35

Corrective Action

Unacceptable Corrective Actions

• Reminded employees

• Retraining

• Instructed to pay more attention

36


Possible Corrective Actions:

• Clean the area and control panels

• Move the emergency stop button to the other side

of the machine, away from the start button

37

Follow Up Monitoring

Monitor results to ensure that corrective

actions are effective

This is a check step to ask:

• How’s it going?

• What’s working?

• What’s not working?

• What could be improved?

• Are corrective actions effective?38

Keys to Success

Take an active approach. Having employees simply

read and sign a procedure is often not enough.

• Improve procedures and worksheets to make the

system more effective

• Communicate the new process through training

• Evaluate the new process through Internal Audits

39

McDonald’s Spilled Coffee Case

McDonald's sued over hot coffee spill

40


The Investigation

• The subject, a 79 yr. old woman was a passenger in a

car at a McDonald's drive-thru

• She received a cup of hot coffee, sealed by a lid, with an

estimated temperature of 180 degrees F

• While attempting to remove the lid and add cream and

sugar, she spilled the contents of the cup into her lap

41


The Investigation

• She was wearing sweat pants that held the hot

liquid against her skin for over 90 seconds

• Subject suffered severe, third-degree burns that

required extensive hospital treatment, including

skin grafts 42


The Investigation

• McDonald's defended its policy of serving coffee

at a temperature of 180 degrees or greater

• However, McDonald's had received over 700

complaints of coffee burns (of varying severity)

over the past 10 years 43


Why did this happen

Cause Map

44


Why did this happen

Completed Cause Map45


5 Whys Analysis

46


What caused the burn by hot coffee?

A – the person spilled the coffee on her leg (Human Error)

B – the coffee at 180F (Process)

C – the coffee cup lid is hard to open (Equipment)

D – customer adding cream and sugar at drive thru (Process)

E – A, B, C, D47


What caused the burn by hot coffee?

Answer: E – A, B, C, D

48


Describing Root Cause(s)

- The 3rd degree burns required both the coffee to

be 180F, and the person to spill the coffee on her

lap

- Controlling either causes prevents the burn

- Removing the lid to add cream and

sugar while sitting at the drive thru

are also contributors to the

incident, and should be mitigated

49


Effective Solutions: Brainstorming

Completed Cause Map

50

Summary

The ability to deal with a crisis

situation is largely dependent on the

structures that have been developed

before chaos arrives

51

Summary

An aggressive RCA Program can

improve a bad system every time

52

Questions

53

Contact Information

54

Orlando Brandon [email protected] (813) 609-4778

mailto:[email protected]

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