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Root Cause Analysis – Digging Deep!. Tom Land. Who is the best manager?. A) “I ask ‘ why ’ five times.”. B) “I ask ‘ why ’ seven times.”. C) “I ask ‘ why ’ nine times.”. Two possible root causes. BANG!. Who is the best manager?. A) “I ask ‘ why ’ five times.”.

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Root Cause Analysis – Digging Deep!

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Root cause analysis digging deep

Root Cause Analysis – Digging Deep!

Tom Land


Who is the best manager

Who is the best manager?

A) “I ask ‘why’ five times.”

B) “I ask ‘why’ seven times.”

C) “I ask ‘why’ nine times.”


Root cause analysis digging deep

Two possible root causes

BANG!


Who is the best manager1

Who is the best manager?

A) “I ask ‘why’ five times.”

B) “I ask ‘why’ seven times.”

C) “I ask ‘why’ nine times.”

D) “I ask ‘why’ thirty times.”


Root cause how deep is enough

Root cause, how deep is enough?

  • Symptom

    • Why? – Cause

    • Why?- Deeper Cause

    • Why? – Deeper Cause

    • Why? – Deeper Cause

    • Why? – Deeper Cause

    • Why? – Deeper Cause

    • Why? – Deeper Cause

    • Why? – Deeper Cause

    • Why? -Big Bang/ Forbidden Fruit


Root cause analysis short on a circuit board

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits


Root cause analysis short on a circuit board1

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching


Root cause analysis short on a circuit board2

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned


Root cause analysis short on a circuit board3

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned

    • Deeper Cause – operator failed to follow instructions “looked clean”


Root cause analysis short on a circuit board4

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned

    • Deeper Cause – operator failed to follow instructions “looked clean”

    • Deeper Cause – insufficient training


Root cause analysis short on a circuit board5

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned

    • Deeper Cause – operator failed to follow instructions “looked clean”

    • Deeper Cause – insufficient training

    • Deeper Cause – 1st day on job


Root cause analysis short on a circuit board6

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned

    • Deeper Cause – operator failed to follow instructions “looked clean”

    • Deeper Cause – insufficient training

    • Deeper Cause – 1st day on job

    • Deeper Cause – supervisor desperate for help


Root cause analysis short on a circuit board7

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned

    • Deeper Cause – operator failed to follow instructions “looked clean”

    • Deeper Cause – insufficient training

    • Deeper Cause – 1st day on job

    • Deeper Cause – supervisor desperate for help

    • Deeper Cause – too much product/too few employees


Root cause analysis short on a circuit board8

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned

    • Deeper Cause – operator failed to follow instructions “looked clean”

    • Deeper Cause – insufficient training

    • Deeper Cause – 1st day on job

    • Deeper Cause – supervisor desperate for help

    • Deeper Cause – too much product/too few employees

    • Deeper Cause – management trying to run “lean”


Root cause analysis short on a circuit board9

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned

    • Deeper Cause – operator failed to follow instructions “looked clean”

    • Deeper Cause – insufficient training

    • Deeper Cause – 1st day on job

    • Deeper Cause – supervisor desperate for help

    • Deeper Cause – too much product/too few employees

    • Deeper Cause – management trying to run “lean”

    • Deeper Cause – profitability pressure


Root cause analysis short on a circuit board10

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned

    • Deeper Cause – operator failed to follow instructions “looked clean”

    • Deeper Cause – insufficient training

    • Deeper Cause – 1st day on job

    • Deeper Cause – supervisor desperate for help

    • Deeper Cause – too much product/too few employees

    • Deeper Cause – management trying to run “lean”

    • Deeper Cause – profitability pressure

    • Deeper Cause – investors want larger return


Root cause analysis short on a circuit board11

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits

    • Cause – insufficient rinsing of resist residue before etching

    • Deeper Cause – machine not sufficiently cleaned

    • Deeper Cause – operator failed to follow instructions “looked clean”

    • Deeper Cause – insufficient training

    • Deeper Cause – 1st day on job

    • Deeper Cause – supervisor desperate for help

    • Deeper Cause – too much product/too few employees

    • Deeper Cause – management trying to run “lean”

    • Deeper Cause – profitability pressure

    • Deeper Cause – investors want larger return

    • Root Cause – Big Bang/Forbidden Fruit


Root cause vs actionable cause

Root Cause vs. Actionable Cause

  • Can I turn the problem on/off or up/down? – YES

  • Is the solution less expensive than the problem? – YES

  • Is this the deepest actionable cause? - YES


Root cause analysis short on a circuit board12

Root Cause Analysis - Short on a Circuit Board

  • Symptom – extraneous copper between circuits – No, No, No

    • Cause – insufficient rinsing of resist residue before etching – Yes, No, No

    • Deeper Cause – resist remover not sufficiently cleaned - Yes, Yes, No

    • Deeper Cause – operator failed to follow instructions - Yes, Yes, No

    • Deeper Cause – insufficient training – Yes, Yes, Yes

    • Deeper Cause – 1st day on job – NOT ACTIONABLE!

    • Deeper Cause – supervisor desperate for help

    • Deeper Cause – too much product/too few employees

    • Deeper Cause – management trying to run “lean”

    • Deeper Cause – profitability pressure

    • Deeper Cause – investors want larger return

    • …. Root Cause: Big Bang/Forbidden Fruit

    • a) On/Off or Up/Down -YES b) Cost OK – YES c) Deepest Actionable - YES


Difficulty entering road from my house to highway

Difficulty entering road from my house to highway

  • 1) Why?: Increased traffic on that road

  • 2) Why?: Several new subdivisions that funnel onto the road

  • 3) Why?: Many people want to buy houses there

  • 4) Why?: Better house for money than elsewhere

  • 5) Why?: Market driven economy

  • 6) Why? Capitalist economy

  • 7) Why? Communism doesn’t work

  • 8) Why? Goes against human nature

  • 9) Why? Big Bang/Forbidden Fruit


Dmaic process

DMAIC Process

  • Define

  • Measure symptoms

  • Analyze

    • Create Theories of “root” cause

    • Test Theories of “root” cause

  • Improve – Remedy the “root” cause

  • Control – Standardize the remedy


Dmaic process1

DMAIC Process

  • Define – Extraneous copper causing shorts

  • Measure symptoms – was 1.0% now is 5.0%

  • Analyze – insufficient cleaning by new operator

  • Improve – thoroughly clean machine

  • Control – change training instructions for new & experienced operators


Sporadic vs chronic problems

Chronic Problems

Too many shorts on circuit boards

It takes too long to get to work

Fiber breaks too much

Shipping performance too low

Sporadic Problems

More shorts than there used to be

Takes longer to get to work than before

Increase in fiber break rate

Shipping performance getting worse

Sporadic vs. Chronic Problems


Root cause analysis digging deep

Define

Current commute requires more than

50 minutes ~50% of the time. This is

longer than the goal of less than 50

minutes 97% of the time.


Root cause analysis digging deep

Pareto Chart


Root cause analysis digging deep

Measure


Analysis theory creation symptom it takes too long to get to work

Analysis – Theory CreationSymptom: It takes too long to get to work

  • Why? – too much traffic

  • Why? – too many others going at same time

  • Why? – most businesses on similar schedule

  • Why? – use traditional stop/start times

  • Why? – daylight requirement before electricity

  • Why? – planet rotates every 24 hrs


Symptom it takes too long to get to work

Symptom: It takes too long to get to work

  • Why? – too much traffic NOT ACTIONABLE

  • Why? – too many others going at same timeACTIONABLE

  • Why? – most businesses on similar scheduleACTIONABLE

  • Why? – use traditional stop/start timesACTIONABLE

  • Why? – daylight requirement before electricity NOT ACTIONABLE

  • Why? – planet rotates every 24 hrs NOT ACTIONABLE


Symptom it takes too long to get to work1

Symptom: It takes too long to get to work

  • Why? – too much traffic – NOT ACTIONABLE

  • Why? – bottleneck at key intersection –ACTIONABLE

  • Why? – design error 20 years ago – NOT ACTIONABLE

  • Why? – forecast of population growth too low – NOT ACTIONABLE

  • Why? – forecaster failed to predict future – NOT ACTIONABLE

  • Why? – forecaster not omnipotent – NOT ACTIONABLE

  • Why? – forecaster is human – NOT ACTIONABLE

  • Why? – no plant/animal/divinity available – NOT ACTIONABLE

  • Why? -


Symptom it takes too long to get to work2

Symptom: It takes too long to get to work

  • Why? – live too far away -ACTIONABLE

  • Why? – better schools near home- NOT ACTIONABLE

  • Why? – better funding – NOT ACTIONABLE

  • Why? – parents in that area wealthier – NOT ACTIONABLE

  • Why? – capitalist economy – NOT ACTIONABLE

  • Why? – communism yet to work anywhere – NOT ACTIONABLE

  • Why? – goes against human nature – NOT ACTIONABLE

  • Why?


Root cause analysis digging deep

Drill Down on multiple causes

Commute too long

Too much traffic

No alternative means

Others at same time

bottlenecks

Live too far

No public means

Many Businesses-

similar schedules

Design error

Better schools

Most people

Going another way

Wrong forecast

Traditional times

More funding

Fail to predict future

Daylight

Requirement

(historical)

Live near me

Work elsewhere

Work near me

Live elsewhere

Wealthier parents

Not omnipotent

Capitalist economy

More jobs

downtown

Less expensive

housing

Human error

Planet’s

rotation

Failures of

communism

Divinity not available

More difficult

To get downtown

City began

there

Human nature

Fewer roads

Railroad yard

location

Less clout in

legislature


Root cause analysis digging deep

What are the odds of striking it rich?


Root cause analysis digging deep

Brainstormed Theories

people

material

environment

cost

schools

Wrong turn

Too far away

Cell phone

CD/radio

pedestrians

Synthetic oil

bottlenecks

scenery

Time of day

wrecks

School buses

87 octane gas

distractions

Too much traffic

Too long

to work

Not using alternatives

Clock too slow

Slow car

Inaccurate start time

breakdowns

bicycle

helicopter

Inaccurate finish time

Bus/train

walk

battery

Flat tire

danger

Too far

methods

measures

machines


Root cause analysis digging deep

After collective judgment process

environment

cost

schools

Too far away

bottlenecks

Time of day

wrecks

Too much traffic

Too long

to work

Not using alternatives

bicycle

helicopter

Bus/train

walk

danger

Too far

methods


Theory testing proposal what s wrong with this

Theory Testing Proposal – What’s Wrong with This?

  • Too far – Move, measure time from new house

    • Schools

    • Cost

  • Too much traffic – Purchase M1 tank, plow through traffic, measure time

    • Time of Day

    • Bottlenecks

    • Wrecks

  • Not using alternatives

    • Walk – start off on foot (18 miles), measure time

    • Bike – hop on bike, ride 18 miles in metro Atlanta, measure time

    • Bus/Train – hop on train..see if goes near office, measure time

    • Helicopter – purchase helicopter and fly to office, measure time


Theory testing

Theory Testing

  • Too far – leave early, drive there, wait a while, drive to work

    • Schools - research

    • Cost - research

  • Too much traffic –

    • Time of Day – leave early

    • Bottlenecks – try another route

    • Wrecks – record elapsed time each day and wreck/no wreck

  • No alternatives

    • Walk – 18 miles, divide by 4 miles/hr – 4.5 hours

    • Bike – no bike lanes, big hills, out of shape

    • Bus/Train – Office inconvenient to train, research schedules

    • Helicopter – no place to land it near office, no license


Root cause analysis digging deep

Use of Locational Data

<$300k

2

$300k-$400k

$400k-$500k

house

$500k+

work

1

3


Root cause analysis digging deep

Time-To-Time Analysis


Root cause analysis digging deep

Use of Flowcharting

Route “A”

Leave

Neigh-

borhood

(2 min)

Stop

light

(2 min)

Wait to

Merge

(7 min)

Drive to

US78

(3 min)

Drive to

I-285

(5 min)

Drive to

I-85

(6 min)

Stop

light

(4 min)

Grind way

across

Peachtree

(6 min)

Park

(1 min)

Wait to

Merge

(5 min)

Drive to

I-75

Merge

(2 min)

Wait to

Merge

(5 min)

Wait to

Merge

(8 min)

Drive to

10th St

(5 min)

Drive to

400

Merge

(10 min)


Stream to stream analysis time to work

Stream-to-Stream Analysis-Time to Work


Root cause analysis digging deep

Use of Flowcharting

Leave

Neigh-

borhood

(2 min)

Stop

light

(2 min)

Wait to

Merge

(7 min)

Drive to

US78

(3 min)

Drive to

I-285

(5 min)

Drive to

I-85

(6 min)

Route “D”

N. Druid (20 min)

Route “B”

Ponce

(30 min)

Stop

light

(4 min)

Grind way

Across

Peachtree

(6 min)

Park

(1 min)

Route “C”

Claremont Rd

(25 min)

Wait to

Merge

(5 min)

Drive to

I-75

Merge

(2 min)

Wait to

Merge

(5 min)

Wait to

Merge

(8 min)

Drive to

10th St

(5 min)

Drive to

400

Merge

(10 min)


Theory testing1

Theory Testing

  • Too far – leave early, drive there, wait a while, drive to work

    • 3 areas where schools OK & can afford house

    • area 1: 40 min, area 2: 45 min, area 3: 85 min

  • Too much traffic –

    • Time of Day (Route A) – 5:00-6:00 takes 30 min, 6:30 takes 40 min, 7:00-8:30 50 min, 9:00+ 30 min

    • Bottlenecks – (at 7:30) route B: 40 min, route C: 60 min, route D: 55 min

    • Wrecks – Days with wrecks (route A): 85 min, 65 min, no wrecks other days

  • No alternatives

    • Bus/Train – MARTA estimates 75 min via train&bus after 30 min drive to rail station


Root cause analysis digging deep

42

3.5

0

53

5.8

0

42

3.5

1

48

4.5

0

39

4.0

1

38

3.0

0

40

3.4

0

39

3.3

0

mean

St dev

wrecks

Route B

Route A

7:00

6:45

7:15

6:30


Can we answer yes to the three questions

Can We Answer Yes to the Three Questions?

  • Can I turn the problem on/off or up/down? - Yes

    • Yes mean = 53 min with standard route and time

    • Mean = ~40 min by moving or by adjusting time or route

  • Is this the solution less expensive than the problem?

  • Is this the deepest actionable cause? - Yes

    • Live too far – better schools, better funding, capitalist economy, human nature

    • Time of Day – traditional hours, daylight (before electricity), rotation of the planet

    • Bottlenecks – design error, wrong forecast, human error (in the distant past)


Save 11 min day @ 25 hr 1100 yr

Save 11 min/day @ $25/hr = $1100/yr


Summary of tested theories

Summary of Tested Theories


Root cause analysis digging deep

Remeasure Symptoms


Dmaic process2

DMAIC Process

  • Define – Takes too long to get to work

  • Measure symptoms – longer than 50 min half the time

  • Analyze – bottlenecks on primary route 7:00 and 8:30

  • Improve – travel on alternate route during that timeslot

  • Control – leave a reminder on steering wheel

    I don’t need to know why there are bottlenecks.

    I just need to avoid them!


Have i dug down far enough

Have I dug down far enough?

  • Do I know root cause? – NO

  • Can I turn the problem on/off or up/down? – YES

  • Is the solution less expensive than the problem? – YES

  • Is this the deepest actionable cause? - YES


Theory testing techniques ref juran s quality handbook

Theory Testing Techniques- ref: Juran’s Quality Handbook

  • Pareto

  • Flowcharting

  • Process Capability Analysis

  • Design of Experiment (DOE)

  • Math/Science/Logic/Research

  • Locational analysis

  • Multi-vari charts – Is variation

    • Within piece?

    • Piece to piece?

    • Time to time within shift?

    • Between shifts?

  • Process Dissection

    • Test at intermediate steps

    • Stream-to-stream analysis (look for immunities-full or partial)

    • Time-to-time analysis

  • Cutting New Windows


Root cause analysis digging deep

1st shift

8:00

10:00

12:00

2:00

Multi-Vari Charts-Problem on 2nd Shift

2nd shift

3rd shift

4:00

6:00

8:00

2:00

4:00

6:00

10:00

12:00


Root cause analysis digging deep

Multi-Vari Charts-Other Sources of Variation

4:00

8:00

6:00

8:00

2:00

4:00

6:00

10:00

10:00

12:00

12:00

2:00

Excessive

Piece-to-Piece

Variation

Excessive

Within Piece

Variation

Excessive

Within Shift

Variation


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