copyright © 2012 thinking dimensions global - singapore. all rights reserved. root cause analysis...

Copyright © 2012 Thinking Dimensions Global - Singapore. All Rights Reserved.

ROOT CAUSE ANALYSISFebruary 2014

Think .… Investigate ResolveThink .… Investigate Resolve


Today’s Agenda

Page 1

1. Introduction to Thinking Dimensions LLC

2. Overview of the KEPNERandFOURIE™ Critical Thinking Skills

3. Demonstration of our Root Cause Analysis process via a case study

4. Reference/Close


About Thinking Dimensions

Solutions• Corporate Strategy• Operational Improvement• Learning & Development

Approach• Bring proven thinking methodologies to

assist clients battling growth, cost, productivity and innovation challenges

• Our collaborative strategy, process improvement and KEPNERandFOURIE™ Thinking Technologies guide the development of effective corporate strategies, operational improvements, innovation and L&D solutions

Used by some of the most well-known companies world-wide

–Norfolk Naval Shipyard- Stihl Inc.- BASF- Church & Dwight Co.


Intellectual Foundation

Developed by Dr. Chuck Kepner and Dr. Matthys Fourie

Recognized experts in design and consulting Integration of rational, creative and intuitive

dimensions of thinking Application of divergent - convergent

thinking skills Scalable approaches to deal with different

tiers of problems and complexity levels Action Plan Oriented Results Based

Dr. Chuck Kepner

Dr. Matthys Fourie


Thinking about Thinking as a Process

InformationData

KnowledgeExperience

Facts

Gather Gather SortSort

Organize Organize AnalyzeAnalyzeConfirmConfirm

Inputs Process Output

Rational

Creative

Intuitive

Root CauseSolution


Knowing which Questions to ask….

QuestioningQuestioning is key

Makes your Thinking VisibleThinking Visible

Provides a Consistent Common Language Consistent Common Language

Copyright 2011 © KEPNERandFOURIE™ All rights reserved www.thinkingdimensionsglobal.com

Think ..… Investigate Resolve

Thinking Process

DivergentThinking

ConvergentThinking

Procedure for addressing an Incident

1.State the problem

2.Gather incident/problem detail

3.Evaluate for causes

4.Confirm true cause1. Testing2. Verifying root cause



DivergentThinking

ConvergentThinking


1.State the problem




Factual

information

gathering

Thinking Process



DivergentThinking

ConvergentThinking


1.State the problem




Factual

information

gathering

Intuitive analysis of own suggestions

Thinking Process



“Minimalistic principle”..

• Only need to analyze the information that would be relevant to the incident

• Worked questions within a customized “factor analysis” framework

• Get a quick factual “snapshot” of the characteristics of the incident and then use SME experience and gut feel to explain the snapshot

• Test SME inputs against logic of snapshot

“Too much informationcan cause confusion.

The key is to get all therelevant information

onlyand that is

substantially less thangathering all the

Information.”Innovation – the FreeZone

thinking experience.

by Kepner & Fourie



ThinkingWisePURPOSE: To determine the correct focus ofcomplex/vague problems

CauseWisePURPOSE: To find the truecause(s) of a deviation

PriorityWisePURPOSE:

To prioritize

problems SolutionWise

PURPOSE: To find the best solution for a given situation

RiskWisePURPOSE: To avoid future problems


Levels of Problem Solving

Tier 1: Typical problem with typical causes- “TOYF” Approach /Check List

Tier 2: Atypical problem with expert guesses…but no proof that expert guess is the true cause

- Intuitive Approach to verify true cause

Tier 3: Atypical problem: No idea- Investigative Approach (deep dive with metrics)


PITFALLS in ROOT CAUSE ANALYSIS

Pitfall is looking for the people reason first

First look for the technical reason – True Cause

Once verified, then look for the people reason – Root Cause

DeviationTrue

CauseRoot Cause

EVENT TECHNICAL The P’s


True Cause vs. Root Cause

TRUE CAUSE: technical reason for failure

ROOT CAUSE: reason(s) for the technical failure–People–Processes–Procedures/Policies_______________________________________________

SOLUTIONWISE: agreement about what to do

Steps in CauseWiseSteps in CauseWise

1. Determine Problem Statement

2. Clarify Problem Detail

Is But Not Why (Not)

3. Generate Causes

4. Confirm True Cause

Testing Verification

Please read the Case Study: Fine Metals Company

Corner Unit Rejects

April 18, 2023 www.thinkingdimensions.com 17

PROBLEM STATEMENTPROBLEM STATEMENT

Object

• Painted units

• Corner Units

• Bus Window Corner

Units

Fault

• Rejected

• Paint Problems

• Rough spots

• Fish eyes


CauseWise: Step 1

Problem Statement

Object Fault

Bus Window Corner Units

Rough Spots

CLARIFY PROBLEM DETAIL

1 “IS” “BUT NOT” “WHY NOT”

2

3

4

5

6

7


“IS” “BUT NOT” “WHY NOT”

1. Bus Window Corner Units

Window Long Units

CauseWise: Clarify Problem Detail

Case: Bus Window Corner Units




Window Long Units

Window Short Units






Window Long Units

Window Short UnitsNew Operators

Higher Rate

Own Line






Window Long Units

Window Short UnitsNew Operators

Higher Rate

Own Line

2. Rough Spots






Window Long Units

Window Short Units

New Operators

Higher Rate

Own Line

2. Rough Spots Flaking

Running

Orange Peel






Window Long Units

Window Short Units

New Operators

Higher Rate

Own Line


Running

Orange Peel

Function of dirt






Window Long Units

Window Short Units

New Operators

Higher Rate

Own Line


Running

Orange Peel

Function of dirt

3. Line 2






Window Long Units

Window Short Units

New Operators

Higher Rate

Own Line


Running

Orange Peel

Function of dirt

3. Line 2

Paint Booth Exit






Window Long Units

Window Short Units

New Operators

Higher Rate

Own Line


Running

Orange Peel

Function of dirt

3. Line 2

Paint Booth Exit

Packaging






Window Long Units

Window Short Units

New Operators

Higher Rate

Own Line


Running

Orange Peel

Function of dirt

3. Line 2

Paint Booth Exit

Packaging 1st inspection point




4 Random on painted surface





Isolated





Isolated

Specific place





Isolated

Specific place

Pattern





Isolated

Specific place

Pattern

DNK

DNK





Isolated

Specific place

Patterned

DNK

DNK

5 Monday, 2 Oct





Isolated

Specific place

Pattern

DNK

DNK

5 Monday, 2 Oct Before

After





Isolated

Specific place

Pattern

DNK

DNK


After

Peak Period started



PatternPattern

PERIODIC

SPORADIC

CONTINUOUS



Isolated

Specific place

Pattern

DNK

DNK


After

Peak Period started

6 Periodic





Isolated

Specific place

Pattern

DNK

DNK


After

Peak period started

6 Periodic

Every hour





Isolated

Specific place

Pattern

DNK

DNK


After

Peak period started

6 Periodic

Every hour

Continuous

Sporadic

Wash tank changeover



Sequence of Events

• What was happening to the object in its sequence of events when the fault was first noticed?

• When in the life cycle of the object was the fault first noticed?



Isolated

Specific place

Pattern

DNK

DNK


After

Peak period started

6 Periodic

Every hour

Continuous

Sporadic


7 During initial visual inspection





Isolated

Specific place

Pattern

DNK

DNK


After

Peak period started

6 Periodic

Every hour

Continuous

Sporadic



During final visual inspection





Isolated

Specific place

Pattern

DNK

DNK


After

Peak period started

6 Periodic

Every hour

Continuous

Sporadic



During final visual inspection

First time units are inspected



CLARIFY PROBLEM DETAIL

1 Window Corner Units Long & Short Unit •New Employees

•More produced per hour

•Own Production Line

2 Rough Spots Running, Flaking and Peeling

Function of Dirt

3 Paint Booth Exit Packaging First inspection place

4 Random spots on the painted surfaces

Isolated, or at a specific place every time

Do not know

5 Monday, October 2nd Before or After Peak period in the last few days

6 Periodic, every hour Continuous, sporadic Wash tank changes after cleaning every hour

7 During initial inspection Final visual inspection Do not know

Steps in CauseWiseSteps in CauseWise

Determine Problem Statement

Clarify Problem Detail

Is But Not Why (Not)

Generate Causes

Confirm True Cause

Testing Verification

Generate Possible Causes

• New employees

Generate Possible Causes

• New employees do not have the experience to do the job properly.

Generate Possible Causes• New employees cannot handle the higher

production volume and therefore do not do the paint spraying properly.



• Washing tanks on Line 2 not cleaned properly, leaving dirt behind on the corner unit surfaces.



• Washing tanks on Line 2 not cleaned properly, leaving dirt behind on the corner unit surfaces.

• Washing liquid getting contaminated towards the end of the wash cycle, not cleaning the surfaces properly.

Test for True Cause

New employees cannot handle the higher production volume and therefore do not do the paint spraying properly.

Washing tanks on Line 2 not cleaned properly, leaving dirt behind on the corner unit surfaces.

Washing liquid getting contaminated towards the end of the wash cycle not cleaning the surfaces properly.

Testing Question

If “New employees cannot handle the higher production volume and therefore do not do the paint spraying properly” is the true cause, how does it substantiate that we have a problem with “Window Corner Units” and not the “Long and Short Corner Units”?

Testing for True Cause




Yes

Testing Question

If “New employees cannot handle the higher production volume and therefore do not do the paint spraying properly” is the true cause, how does it substantiate that we have a problem with “Rough Spots” and not with “Flaking, running or peeling”?





Yes No

Recording Assumptions• No: It rather explains the “running” fault.





Yes No

Yes





Yes No

Yes Yes

Test for True Cause




Yes No

Yes Yes Yes

Test for True Cause




Yes No

Yes Yes Yes Yes

Test for True Cause




Yes No

Yes Yes Yes Yes A1


• A1: Only if the higher production volumes influenced the abilities of the operators in cleaning the tanks.

Test for True Cause




Yes No

Yes Yes Yes Yes A1 No


• A1: Only if the higher production volumes influenced the abilities of the operators in cleaning the tanks.

• No: Rejects as a result of dirt will occur throughout the cycle.

Test for True Cause




Yes No


Yes

Test for True Cause




Yes No


Yes Yes

Test for True Cause




Yes No


Yes Yes Yes

Test for True Cause




Yes No


Yes Yes Yes Yes

Test for True Cause




Yes No


Yes Yes Yes Yes Yes A2

Recording Assumptions• No: It rather explains the “running” fault. • A1: Only if the higher production volumes

influenced the abilities of the operators in cleaning the tanks.

• No: Rejects as a result of dirt will occur throughout the cycle.

• A2: Only if the rejects are the last number of units being rejected at the end of each cycle.

Test for True Cause




Yes No


Yes Yes Yes Yes Yes A2 Yes

Verify for True Cause• Verify assumptions.

• Verify information in the analysis.

• Verify whether the cause went away.

• Verify “A2: Only if the rejects are the last number of units being rejected at the end of each cycle.”

• (Check the strength of the solution at the end of the washing cycle)

TestimonialTestimonial

“Prior to our use of Kepner and Fourie CauseWise and SolutionWise, it took us from 2 weeks to several months to “turn around” a plan of action to improve our processes and prevent re-occurence. That time has been reduced to less than one week on complex issues. On non-complex issues, the turn around time for “return to work” with the solution buy-in has been reduced from >12 hours to 1.5 hours.”

Quality Manager Naval Shipyard


April 18, 2023 www.thinkingdimensions.com FJC presentation 23 July 2008 77

April 18, 2023 www.thinkingdimensions.com ASQ February 2014 78

THINKING DIMENSIONS LLCTHINKING DIMENSIONS LLC

4234 Upper Park Drive4234 Upper Park DriveFairfax, Va. 22030Fairfax, Va. 22030

[email protected]

www.thinkingdimensions.comwww.thinkingdimensions.com

copyright © 2012 thinking dimensions global - singapore. all rights reserved. root cause analysis...

Documents

thinking process slide

key thinking visible

proven thinking methodologies

rights reserved

root cause slide

resolve slide

root cause analysis

true cause