rca training

“A problem well defined is a problem half solved”

-Anonymous

Root-Cause Analysis

At the end of this training, you will be able to..

• Understand the basic steps in problem-solving• Be more familiar with the term Root-Cause

Analysis • Learn to use 2 simple RCA techniques

Problem Solving Process• Define problem

• Perform RCA1.Diagnostic Phase

• Provide action plan• Implement• Determine effectiveness

2. Solution (“Fix it”)

Phase

“If I had 60 minutes to solve a problem, I’d spend 55 minutes defining it and 5 minutes solving it”.

– Albert Einstein

Root Cause Defined

• Main / root or most basic cause or problem

• Management has control to fix

• Will prevent or significantly reduce the likelihood of recurrence

Root Cause Analysis

5 Whys FMEA Pareto Charts Risk Tree Diagrams Process Maps

Tree Diagram Fish-bone Affinity Diagrams

Cause-Effect Diagram Brainstorming

Fish-Bone (Ishikawa) Analysis

• Man - people involved• Machine -equipment,

tools• Method- procedure,

requirements

Skull = Problem / Challenge

Spines = Causes (5 Ms)

• Material – raw materials, reagents

• Mother Nature / Environment – temperature, location, natural phenomenon

5 Whys Analysis Why?

Why?

Why?

Why?

Why?Why?

but…Why?

5 Whys Analysis

Keep going until the answer is “I don’t care” (management

can no longer fix it)

Why?

Why?

Why?

Why?

Why?Why?

but…Why?

NOT JUST 5x

…Why did it fell?

It fell because of gravity.

Why is there gravity?

I don’t care (doesn’t matter here)

Making the most of both..

Fish-Bone x

- Exploring causes from all possible sources

5 Whys- Drilling down to

the root-cause -(why? or so

what?)

Example: Fish-Bone x 5 Whys

Man

1st why:Analyst missed

something in the

procedure – (problem persisted

after repeat

analysis)

X

Method

1st why:Modification has been made in the

method / procedure

- NO

X

Material

1st why:<MDL

reading for Total N

2nd why:With relatively low N content as compared with majority

of samples (reflected in

NO3- and NH4+)

Machine

1st why:Total N

module is not able to

read sample below 0.3

ppm

2nd why:It’s the

current LOQ

3rd why:Suitable for majority of

samples only

Environment

1st why: N contaminati

on during NO3- and

NH4+ analysis – NO (QC

inserts are OK)

X

Initial Concern: Total N result (<MDL) is lower than combined NO3- (0.120 ppm) and NH4+ (0.170 ppm)

Example

1.Diagnostic Phase

• Define problem• Perform RCA• “Total N content of samples

is below instrument MDL”

2. Solution (“Fix it”)

Phase

• Provide corrective action plan (with due date and responsible people) “Modify instrument settings to get lower MDL and re-analyze samples, c/o MS and ACB by Jun 2012”

• Implement – Done as of Jun 2012 • Determine effectiveness – No recurrence

(Issue CLOSED)

Initial concern: Total N result (<MDL) is lower than combined NO3-N (0.120 ppm) and NH4+N (0.170 ppm)

“Don’t just stop the bleeding! Stop the bleeding first, and then address the root-cause. Do RCA”.

“If I had 60 minutes to solve a problem, I’d spend 55 minutes defining it and 5 minutes solving it”.

– Albert Einstein