crash course on rca training rev 01

8/14/2019 Crash Course on RCA Training Rev 01

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TA I K IS H A P H I L I P P IN E S , I N C O P E N C H A L L E N G E Q U I C K R E S P O N S E

QUALITY MANAGEMENT

Date: Oct 09, 2009

CA / PA BASIC TOOLS

CA/PA BASIC TOOLS Rev 01 10.08.09

ROOT CAUSE ANALYSIS


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TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E

QUALITY MANAGEMENT

Date: Oct 09, 2009

CA / PA BASIC TOOLS


ROOT CAUSE ANALYSIS

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For most of us, it's a lot easier to jumpto solutions, isn't it?


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Objectives

Module 1:

Participants will learn how to:

Create and use Pareto chart in theanalysis of a problem

Implement steps for carrying outeffective RCA

Select and apply tools that supportRCA

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Objectives

Module 2:

Participants will be able to:

Define and explain the 8D as aProblem Solving Method

Apply the 8 Disciplines and

Concepts


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HOME PAGE

INTRODUCTION

MODULE 1

MODULE 2

APPLICATION

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


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Introduction

Definition of Terms

What it is

Why use it

RCA Process

How to use it

Introduction MODULE 2MODULE 1

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Terms and Definition

Cause (causal factor) - a condition or event that resultsin an effect

Direct Cause - cause that directly resulted in theoccurrence

Contributing Cause - a cause that contributed to theoccurrence, but by itself would not have caused the

occurrenceRoot Cause - cause that, if corrected, would prevent

recurrence of a non-conformity and similaroccurrences


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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

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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


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Module 1

Digging for the Root Causes

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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
http://c/Users/user/Desktop/Reference%20for%20RCA/Coffee%20Break.pptx


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Histograms- What it is

A chart that graphically display thedistribution of a set of data.

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Pareto Chart - What it is

It reveals that asmall number ofNCNs areresponsible for thebulk of quality

issues,

a phenomenoncalled the ParetoPrinciple.

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


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Pareto Chart How to create it

1. Gather facts about the problem

2. Rank the contributions to the problem in orderof frequency.

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Pareto Chart How to create it(contn)

3. Draw the value as a bar chart.

5. Review the chart

6. Redefine classifications if necessary.

4. add a line showing the cumulativepercentage of errors


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Chart 1 : The chart gives summary information and starts the cumulative % count atthe top of the first bar:

CmptD

amage

d

Compon

entFaulty

CmptM

issing

Wrong

Comp.F

itted

Cmptn

otMeet

Elect.

Spec.

Deform

edJoin

t

Jointsn

otSolde

red

CmptT

ouching

Heatplane

Compon

entMis

fitted

Legsn

otthro

ughBo

ard

LongL

eads

LinkWireM

issfitted

Beyond

Econo

micRe

pair

Precau

tionary

Remov

al

Thiokol

Problem

Solder

Short

Faulty

Connec

tor

Contam

ination

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

DefectCount

PercentCum %

Percent

Pareto of D3 Small Engine Card Faults

Pareto Analysis Example

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

Desig

nCo

mpon

ent

Build

Other

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

CountPercentCum %

Percent

Fault by Main Cause

ConnectM

odule

Torqu

eMoto

rs

ColdS

tart

TransducerM

odule

ASIC

Calib

ration

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

CountPercent

Cum %

Percent

Design Faults

1st level Analysisgives Designas main cause offailure

2nd level Analysis givesbreakdown of Design



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Example 3: if the original Pareto is very flat, be prepared to cut the defects in adifferent way, here, it is 40:60

KDCC

788

KDCC

646

KDCC

777

KDCC

780

KDCC

782

KDCC

795

40-56

4-8116-1

0

40-66

6-7823

40-56

4-727

4-47E

Othe

rs

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

CountPercent

Cum %

Percent

Pareto Chart for Child11


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How it helps

Pareto Analysis is a useful tool to:

identify and prioritize major problem areas based on frequency ofoccurrence;

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 andEffect Analysis.

HINT !The most frequent is not

always the most important! Beaware of the impact of other

causes on Customers or goals.



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Summary

Pareto Charts provide a vi sual representation ofthe variables which contribute to problems orissues.

Pareto Charts can be used as a prioritization toolto aid in focusing on the top issues whichcontribute to specific conditions.

Pareto analysis is an approach which ranks thecontributing factors and identifies which are theones which have the most impact on a problem or

issue. Often referred to as an approach forseparating the vital few from the trivial many,sometimes referred to as the 80-20 rule

Process StepsA method for showing the distribution ofquantitative data and identifying thosewith the greatest impact.

Identify the problem and the potentialdirect or contributing causes

Develop Corrective Action orImprovement Action Plans for those

identified as the Vital Few

Identify the Vital Few (those with thehighest number of occurrences)

Construct the Pareto Chart:Causes on Horizontal Axis

Frequency of events on Vertical Axis

Collect data about each of the potentialdirect or contributing causes

Pareto

Pareto Chart and Analysis

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CAUSE AND EFFECT

Ishikawa/Fish Bone Diagram

Problem

PeopleProcedures

Equipment Materials


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Cause and Effect

Cause and Effect Analysis is a tool foridentifying all the possible causes associatedwith 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 tackledto generate a positive effect

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Cause and Effect Sources of Variation

Sources of Variation is categorized asfollows

1. People

2. Method

3. Machine

4. Material5. Environment

6. Measuring System


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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 orIssue

Method Machine

E nvi ronment M easur ement S yst em

People

Material

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How to do it (contn)

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


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Sources of Variation - People

People

The activities of the workers.

Variations caused by skill, knowledge,competency and attitude

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Sources of Variation - Method

Method

The methods used to produce theproducts.

Variations caused by inappropriatemethods or processes.


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Sources of Variation - Machine

Machine

The equipment used to produce theproducts.

Variations caused by temperature,tool wear and vibration.

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Sources of Variation - Material

Material

The "ingredients" of a process.

Variations caused by materials thatdiffer by industry, productand stage of production.


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Sources of Variation - Environment

Environment

The methods used to control theenvironment.

Variations caused by temperaturechanges, humidity etc.

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Sources of Variation Measurement System

Measurement System

The methods and instruments used toevaluate products.

Variations caused by measuring

techniques, or calibration andmaintenance of the instruments.


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Cause and Effect Analysis Example



Jumping to conclusion

Failure to define problem

Failure to find the root cause

Weak problem solving

No execution of corrective action

PROBLEM SOLVING FAILURE


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- 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 preventiveaction

- Problem did not re-occur

PROBLEM SOLVING SUCCESS

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Summary

The development of the cause and effectFishbone diagram is credited to KaoruIshikawa, who pioneered quality managementprocesses in the Kawasaki shipyards.

The cause and effect diagram is used toexplore potential causes (or inputs) thatresult in a single undesirable effect (UDE, oroutput). Causes are categorized under sixheadings, namely Machinery, Methods,

Measurement, Manpower, Materials, andEnvironment. Potential causes can bearranged according to their level ofimportance or detail, resulting in a depictionof relationships and hierarchy of events. It isthe hierarchy that creates a map that lookssomewhat like fish bones, hence the name.The Ishikawa Fishbone Diagram is intendedhelp you brainstorm and search for potentialroot causes or identify areas where there maybe problems by questioning the existence ofcauses under each of the six categories.

Ishikawa Fishbone Template

UDE

MaterialsMaterialsManpowerManpower

MachineryMachineryMethodsMethodsMeasurementMeasurement

EnvironmentEnvironment

Causes, inputs,or sources

of 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 namedfor Kaoru Ishikawa.


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$$$

Action Reflection

Wait! I think I missedsomething

It isnt that theycannot see thesolution,

Its that they cant see

the problem.

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Created by:

Sid CalayagLead Auditor forTaikisha Phils., Inc Quality ManagementSystem

Presented by: Sid Calayag


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TA I K IS H A P H IL I P P IN E S , I N C O P E N C H A L L E N G E Q U I C K R E S P O N S E


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 ofquantitative data and identifying those

with the greatest impact. Identify the problem and the potentialdirect or contributing causes

Develop Corrective Action orImprovement Action Plans for those

identified as the Vital Few

Identify the Vital Few (those with thehighest number of occurrences)

Construct the Pareto Chart:Causes on Horizontal Axis

Frequency of events on Vertical Axis

Collect data about each of the potentialdirect or contributing causes

Pareto

Pareto Chart and Analysis


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0

TA I K IS H A P H IL I P P IN E S , I N C O P E N C H A L L E N G E Q U I C K R E S P O N S E


Summary

The development of the cause and effectFishbone diagram is credited to KaoruIshikawa, who pioneered quality managementprocesses in the Kawasaki shipyards.

The cause and effect diagram is used toexplore potential causes (or inputs) thatresult in a single undesirable effect (UDE, oroutput). Causes are categorized under sixheadings, namely Machinery, Methods,Measurement, Manpower, Materials, andEnvironment. Potential causes can bearranged according to their level of

importance or detail, resulting in a depictionof relationships and hierarchy of events. It isthe hierarchy that creates a map that lookssomewhat like fish bones, hence the name.The Ishikawa Fishbone Diagram is intendedhelp you brainstorm and search for potentialroot causes or identify areas where there maybe problems by questioning the existence ofcauses 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 namedfor Kaoru Ishikawa.


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Date:

Name of Attendee: _________________________Course Title: ROOT CAUSE ANALYSIS TRAINING

Trainer: SID CALAYAG

Training Evaluation Form

My comments and suggestions in this orientation/training are:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

_______________________________ OVERALL EVALUATION: _____________Signature

TAIKISHA PHILIPPINES, INC

The trainer knew the material well enough to teach this course.

The trainer is well prepared.

The trainer keep the class discussions focused on the training orientation content.

The orientation gave me information that will help me perform my job safer.

I found the training workshop is applicable in my job assignment.

The trainer presented useful summaries and to be understood to me better..

The trainer provided enough questions and answers opportunities.

The trainer provided visuals that are very helpful in my training

The quality of the handout is ____________. (Poor, Fair, Good)

This orientation is timely for the organizations current situation

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

POOR FAIR GOOD

CRASH-COURSE

OCT 09, 2009

crash course on rca training rev 01

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