QUALITY MANAGEMENT

By: Sid Calayag

Date: September 11, 2009

ROOT CAUSE ANALYSIS

Training Description

Root Cause Analysis training is consist of

lectures and practices (application) that provide participants with a practical understanding of how to do an analysis in identifying the root cause of a problem.

This presentation has two modules. The second module is deleted from this presentation.

The hands-on training exercises and samples were also excluded in this presentation.

Presentation set-up

Module 1 will guide participants in the creation

and use of histograms, Pareto chart and

Fishbone diagram.

Module 2 will guide participants in the process of

creating a good 8 – D Report

Application Section is part of both modules,

however, it will require knowledge gained in

Module 2 to apply advance application such

as the 8 – D Report.

Objectives

Module 1:

Participants will learn how to:

• Create and use Pareto chart in the

analysis of a problem

• Implement steps for carrying out

effective RCA

• Select and apply tools that support

RCA

Objectives

Module 2:

Participants will be able to:

• Define and explain the 8 – D as a

Problem Solving Method

• Apply the 8 Disciplines and

Concepts

HOME PAGE

• INTRODUCTION

• MODULE 1

• MODULE 2

• APPLICATION

I N T R O D U C T I O N

T o

R O O T C A U S E A N A L Y S I S

Introduction

Definition of Terms

What it is

Why use it

RCA Process

How to use it

Introduction MODULE 2MODULE 1

Terms and Definition

Cause (causal factor) - a condition or event that results

in an effect

Direct Cause - cause that directly resulted in the

occurrence

Contributing Cause - a cause that contributed to the

occurrence, but by itself would not have caused the

occurrence

Root Cause - cause that, if corrected, would prevent

recurrence of a non-conformity and similar

occurrences

RCA Definition

Root Cause Analysis - a process

designed for use in investigating and

categorizing the root causes of

events

A process of tracing a Problem to its Origins

Root Cause Analysis Process

Step One:

Define the Problem

Step Two:

Collect Data

Step Three:

Identify Possible Causal Factors

Step Four:

Identify the Root Cause(s)

Step Five:

Recommend and Implement Solutions

Module 1

Digging for the Root Causes

Module 1 Table of Contents

Histograms and Pareto Chart

Cause and Effect Diagram

What it is

How to use it

Examples

Summary

MODULE 1 MODULE 2 APPLICATION

Histograms- What it is

• A chart that graphically display the

distribution of a set of data.

Pareto Chart - What it is

It reveals that a

small number of

NCNs are

responsible for the

bulk of quality

issues,

a phenomenon

called the „Pareto

Principle‟.

A Pareto chart allows data to be displayed as a bar chart and enables the main contributors to a problem to be highlighted.

Pareto Chart – How to create it

1. Gather facts about the problem

2. Rank the contributions to the problem in order of frequency.

Pareto Chart – How to create it (cont’n)

3. Draw the value as a bar chart.

5. Review the chart

6. Redefine classifications if necessary.

4. add a line showing the cumulative percentage of errors

• Chart 1 : The chart gives summary information and starts the cumulative % count at

the top of the first bar:

Cmpt Damaged

Component Faulty

Cmpt Missing

Wrong Comp. Fitte

d

Cmpt not M

eet Elect. S

pec.

Deformed Jo

int

Joints not Soldered

Cmpt Touching Heatplane

Component Misfitt

ed

Legs not through Board

Long Leads

Link Wire

Missfitted

Beyond Economic Repair

Precautionary Removal

Thiokol Problem

Solder Short

Faulty Connector

Contamination

Others

141 139 69 52 22 20 20 17 17 17 16 13 10 10 10 8 6 5 29

23 22 11 8 4 3 3 3 3 3 3 2 2 2 2 1 1 1 5

23 45 56 65 68 71 75 77 80 83 85 87 89 91 92 94 95 95 100

0

100

200

300

400

500

600

0

20

40

60

80

100

Defect

Count

Percent

Cum %

Per

cent

Cou

nt

Pareto of D3 Small Engine Card Faults

Pareto Analysis Example

* This is a sample output from Minitab Statistical Software

• Example 2 : a series of Pareto charts drill down to more detail:

DesignComponent

BuildOther

57 13 4 2

75.0 17.1 5.3 2.6

75.0 92.1 97.4 100.0

0

10

20

30

40

50

60

70

0

20

40

60

80

100

Defect

Count

Percent

Cum %

Perc

ent

Coun

t

Fault by Main Cause

Connect Module

Torque Motors

Cold Start

Transducer Module

ASIC Calibration

IOP Imon

21 10 8 8 5 3 2

36.8 17.5 14.0 14.0 8.8 5.3 3.5

36.8 54.4 68.4 82.5 91.2 96.5 100.0

0

10

20

30

40

50

0

20

40

60

80

100

Defect

Count

Percent

Cum %

Perce

nt

Coun

t

Design Faults

1st level Analysis

gives “Design”

as main cause of

failure

2nd level Analysis gives

breakdown of “Design”

Pareto Analysis Example

* This is a sample output from Minitab Statistical Software

• Example 3 : if the original Pareto is very flat, be prepared to cut the defects in a

different way, here, it is 40:60

KDCC788

KDCC646

KDCC777

KDCC780

KDCC782

KDCC795

40-564-8116-10

40-666-7823

40-564-7274-47E

Others

18 13 11 11 11 10 9 9 8 138

7.6 5.5 4.6 4.6 4.6 4.2 3.8 3.8 3.4 58.0

7.6 13.0 17.6 22.3 26.9 31.1 34.9 38.7 42.0 100.0

0

100

200

0

20

40

60

80

100

Defect

Count

Percent

Cum %

Perc

ent

Coun

t

Pareto Chart for Child11

Pareto Analysis Example

* This is a sample output from Minitab Statistical Software

How it helps

Pareto Analysis is a useful tool to:

• identify and prioritize major problem areas based on frequency of

occurrence;

• separate the „vital few‟ from the „useful many‟ things to do;

• identify major causes and effects.

The technique is often used in conjunction with Brainstorming and Cause and

Effect Analysis.

HINT !

The most frequent is not

always the most important! Be

aware of the impact of other

causes on Customers or goals.

Pareto Analysis Example

Summary

Pareto Charts provide a visual representation of

the variables which contribute to problems or

issues.

Pareto Charts can be used as a prioritization tool

to aid in focusing on the top issues which

contribute to specific conditions.

Pareto analysis is an approach which ranks the

contributing factors and identifies which are the

ones which have the most impact on a problem or

issue. Often referred to as an approach for

“separating the vital few from the trivial many”,

sometimes referred to as the “80-20 rule”

Process StepsA method for showing the distribution of quantitative data and identifying those with the greatest impact.

Identify the problem and the potential

direct or contributing causes

Develop Corrective Action or

Improvement Action Plans for those

identified as the Vital Few

Identify the Vital Few (those with the

highest number of occurrences)

Construct the Pareto Chart:

Causes on Horizontal Axis

Frequency of events on Vertical Axis

Collect data about each of the potential

direct or contributing causes

Pareto

Pareto Chart and Analysis

Coffee Break

15 Minutes Break Only

CAUSE AND EFFECT

Ishikawa/Fish Bone Diagram

Problem

PeopleProcedures

Equipment Materials

Cause and Effect

• Cause and Effect Analysis is a tool for

identifying all the possible causes associated

with a particular problem

Valuable for:

• Focusing on causes not symptoms

• Providing a picture of why an effect is happening

• Establishing a sound basis for further data gathering

and action

• Identifying all of the areas that need to be tackled

to generate a positive effect

Cause and Effect Sources of Variation

Sources of Variation is categorized as

follows

1. People

2. Method

3. Machine

4. Material

5. Environment

6. Measuring System

How to do it

• 1. Identify the Problem/Issue

• 2. Brainstorm

3. Draw fishbone diagram

Place the effect at the head of the “fish”

Include the 6 recommended categories shown below

Problem or

Issue

Method Machine

Environment Measurement System

People

Material

How to do it (cont’n)

• 4. Align Outputs with Cause Categories

• 5. Allocate Causes

• 6. Analyze for Root Causes

• 7. Test for Reality

Tip !

The 6 categories recommended will address almost all scenarios. However, there is no

one perfect set of categories. You may need to adapt to suit the issue being analyzed.

Sources of Variation - People

People

• The activities of the workers.

• Variations caused by skill, knowledge,

competency and attitude

Sources of Variation - Method

Method

• The methods used to produce the

products.

• Variations caused by inappropriate

methods or processes.

Sources of Variation - Machine

Machine

• The equipment used to produce the

products.

• Variations caused by temperature,

tool wear and vibration.

Sources of Variation - Material

Material

• The "ingredients" of a process.

• Variations caused by materials that

differ by industry, product

and stage of production.

Sources of Variation - Environment

Environment

• The methods used to control the

environment.

• Variations caused by temperature

changes, humidity etc.

Sources of Variation – Measurement System

Measurement System

• The methods and instruments used to

evaluate products.

• Variations caused by measuring

techniques, or calibration and

maintenance of the instruments.

Cause and Effect Analysis Example

Summary

The development of the cause and effect Fishbone diagram is credited to Kaoru Ishikawa, who pioneered quality management processes in the Kawasaki shipyards.

The cause and effect diagram is used to explore potential causes (or inputs) that result in a single undesirable effect (UDE, or output). Causes are categorized under six headings, namely Machinery, Methods, Measurement, Manpower, Materials, and Environment. Potential causes can be arranged according to their level of importance or detail, resulting in a depiction of relationships and hierarchy of events. It is the hierarchy that creates a map that looks somewhat like fish bones, hence the name. The Ishikawa Fishbone Diagram is intended help you brainstorm and search for potential root causes or identify areas where there may be problems by questioning the existence of causes under each of the six categories.

Ishikawa Fishbone Template

UDE

MaterialsMaterialsManpowerManpower

MachineryMachineryMethodsMethodsMeasurementMeasurement

EnvironmentEnvironment

Causes, inputs,or sourcesof variation

A UDE is an UnDesireable Effect

Cause and Effect Diagram (Ishikawa)

A visual brainstorming tool used to help identify and categorize potential root causes named

for Kaoru Ishikawa.

Module 2

APPLICATION

ISO 9001:2000 CA/PA & IQA Report

Eight Discipline

What it is

How to use it

Examples

Summary

Application Table of Contents

MODULE 1 MODULE 2 APPLICATION

Different Action to Improve Performance

Corrective

BeforeAfter

Action 1

Action 2

Time

BeforeAfter

Action 1

Action 2

Time

BeforeAfter

Action 1

Action 2

Time

- the action taken to eliminate the cause of a detected non-conformity (and prevent its recurrence.)

Preventive – the action taken to eliminate the cause of a potential non-conformity and to prevent its occurrence.

Continual

Continuous

TIME

Performance

Breakthrough

Continual Improvement

Different Action to Improve Performance

Document plan for implementing C/A

Implement Containment Action

Implement the Corrective Actions

Remove the Containment Actions

Verify the Corrective Actions Overtime

Steps to Complete

Corrective Action

V- Verify Corrective Actions

Your Guide in verification

1. Are SOLUTIONS and not PATCHES

2. Are Doable and Time-bounded

3. Will not introduce a new problem or effect

Verify Effectiveness

3 Steps in Verifying Effectiveness

1. The “after” condition eliminates the

problem.

2. There is a difference between the

“before” and “after” condition.

3. The “after” condition does not create

another effect

• Jumping to conclusion

• Failure to define problem

• Failure to find the root cause

• Weak problem solving

• No execution of corrective action

PROBLEM SOLVING FAILURE

- Problem is clearly defined.

- Problem is accepted

- As an opportunity/challenge to improve

- - True root cause is found

- - Implemented an effective and

irreversible corrective and preventive

action

- - Problem did not re-occur

PROBLEM SOLVING SUCCESS

PROBLEM SOLVING SUCCESS

$$$

Action Reflection

- Which principle or technique will I apply right away when I get back to work?

Your Guide to Conformance

• Say what you do

– Document the system

• Do what you say

– Implement the system

• Prove it

– Demonstrate implementation

Use our Standard Form

PREVENTIVE ACTION

PA INITIATIVES

The PA initiative may be derived from sources such

as:

• Lessons learned USING BENCHMARKING

• Lessons learned from any other performance

issues.

• Review of preventive/predictive maintenance

data records.

• Analysis of defect trends and outlier fallouts.

• Lessons learned from actual field failures and

customer COMPLAINTS

Preventive Action Process Flow

Pareto DiagramScatter Diagrams

Check Sheets

Defects

Bent Lead

Damaged

Leads

Joggled

Leads

Wrong

symbol

Mixed device

Chipped

package

Illegible

symbol

Day1 Day2 Day3 Day4 Day5 Day6

3

3

3

2

2

15

7

1

4

5

8

9

0 2

2

2

2

2

0

0

0

0

0

0

0

0

9

9

4

4

5

5 5 5

00

2

1

1

7

1

1

Scrap

Histogram

Rework

Control Chart

1 3 5 7 9 11 13 15 1719

21

23 25 27 29 31 33 35 37 39 41 43 45

0

5

10

15

1. Identify an Opportunity/Initiative based on gathered

information,

-define the success criteria

Preventive Action Process Flow

2. Identify an Opportunity based on gathered information

- Root cause Analysis considers the potential problem and its

future risk

- Use error-proofing actions whenever possible

- Consider resource needs and costs

3. Identify and Implement Preventive Actions

- Verify effectiveness of PA

- Document actions into specs, Engineering designs etc.

- Confirm that the success criteria was met

- did the performance metric improve?

- plan to fan-out- create the implementation timeline/roadmap

chart

SUMMARY

Symptom Problem (Is & Is Not)

What ?

Where ?

When ?

How Big ?

Containment

X

Root Cause

Occur Cause Escape Cause

Corrective Actions

Occur Cause Escape Cause

Preventive Actions

What about ...

Created by:

Sid Calayag – Lead Auditor for

Taikisha Phils., Inc Quality Management

System

Presented by: Sid Calayag

“Sorry I don’t accept donation”

But CASH is still acceptable if you will not tell anybody about it …”

By: Anonymous

“I only did it for the love of my company”

End of Presentation