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  1. RCA : Root Cause Analysis


  3. What ? Where ? When ? Which ? How ?

  4. WHAT ?

  5. Introduction • When people discover problems, the most frequent response is to rush to find a solution. Finding an immediate fix for the problem is very satisfying no matter how many times this process occurs. Unfortunately, it is not the best way to solve a problem, as it leads to the need to solve the same problem over and over again. A better approach is to eliminate the root cause.

  6. Root Cause Analysis Definition • Root cause analysis (RCA) is a project management methodology used to identify the source of any issues or problems experienced in any process or product. • The core idea behind RCA is that ongoing problems are best solved by eliminating the root problem, instead of applying temporary solutions that fail to resolve recurring issues.

  7. Example:Root Cause Analysis • Customer Jane Doe receives goods from Manufacturer Smith. These goods are found to be damaged, as they were shipped in packaging trays that allowed the product to move in the cartons during transport. • Manufacturer Smith decides to add cardboard dividers between each tray to prevent the product movement in transit. While this is an adequate solution, it does not address the root problem. • Why were the goods able to move? The correct solution is to redesign the tray in a way that ensures that each item is fixed securely. • This eliminates the necessity for additional packaging material, assigning warehouse locations, adding a new item to inventory and all associated tasks.


  9. TV doesn’t turn on • What actually caused the issue or incident to occur? • As an example – let’s say you go to turn on your TV using your remote. The TV doesn’t turn on and you know the TV works if you walk over and manually turn it on. You decide the remote is broken. The fact your remote doesn’t work is a symptom of the greater problem. • You open up the battery compartment and see that the batteries are missing. The fact the batteries are missing is the root cause for the remote not working. Obviously this is an oversimplified example, but you get the idea.


  11. Mouse Example

  12. Problem Solving Requires Human Factors Root Cause Analysis

  13. WHYs: Positive Root Cause Analysis to Find Best Practices

  14. HOW ?

  15. HOW ? “Every problem is an opportunity.”

  16. How?

  17. METHODOLOGY • The Six Sigma DMAIC methodology provides an effective way to accomplish this goal:

  18. DMAIC Problem Solving • One of the most important steps in the DMAIC process is the root cause analysis. • The root cause is one that, if corrected, would prevent a recurrence of the problem. • There may be a series of causes that are identified, one leading to another, or more than one cause that combine to create the problem.

  19. DMAIC • Define and Measure the Problem • Analyze Cause-and-Effect Relationships • Implement and Control the Best Solutions

  20. Define and Measure the Problem – • What does the company want to prevent from recurring? • When and where did it occur? What is the significance of the problem? • The first step in the process is to define the problem. This is done by comparing the expectation of the customer to what he/she currently receives. Closing the gap between expectation or the voice of the customer (VOC) and reality or voice of the process (VOP) defines the problem. • Analyze Cause-and-Effect Relationships • Once the problem is defined, it is important to uncover the root causes of the problem and to understand how they interact with one another. • Collect a sample of data related to the problem and conduct a root cause analysis to identify the reasons why the problem exists. • This analysis will form the basis for determining solutions that will prevent any recurrence of the causes, and ultimately, the problem. Implement and Control the Best Solutions – • Identify solutions based on the results of the root cause analysis • Solutions are specific actions that control root causes of the problem. • Implementing the right solutions and controlling or monitoring the results


  22. Mouse Example As a simple example, picture a large block of very good Swiss cheese on a kitchen table a few feet away from an open screen door. The weather outside is warm. A man comes to the table for some wine and cheese and sees a mouse in the cheese. Problem: There is a mouse in the cheese. Solution: Throw out the cheese with the mouse and put a new block of cheese on the table. That is not the Six Sigma way. To do a root cause analysis of this situation, follow the DMAIC approach. The analysis might look like the graphic on the left. Notice that solutions such as, “Be sure to close screen door,” or “Put a note on door asking, ‘Did you latch me?’” are not good solutions. They might work but they will not prevent the problem from recurring. A spring latch is a sure solution.

  23. Root Cause-root cause analysis cycle-problem solving steps

  24. Root Cause-root cause analysis cycle-problem solving steps

  25. 5 Whys The 5 Whys technique requires that project team members do not settle for surface level explanations for problems. Rather, any time a question about why something is happening is answered, the question "Why?" is asked again. In this way deeper root causes are uncovered, so that effective long-term solutions can be implemented rather than the proverbial bandaid.

  26. Management Man Method Cause Cause Cause Cause Cause Cause Cause Cause Cause Name Effect Here Cause Cause Cause Cause Cause Cause Cause Cause Cause TOOL Measurement Machine Material

  27. TOOL

  28. TOOL

  29. TOOL

  30. “Every defect is a treasure, if the company can uncover its causeand work to prevent it across the corporation.” • - Kilchiro Toyoda, founder of Toyota

  31. KERBERKESANAN PdP Dari aspekKetuaPanitia: • PdPberkesan? • Elemen? • Bagaimanmengukur ?

  32. Pernyataan Masalah • Pernyataan masalah boleh dibahagi kepada : Bahagian 1 : Masalah semasa Bahagian 2 : Sasaran kejayaan

  33. Mendifinasikan Maslalah S.M.A.R.T Kriteria: • Specific (tepat) • Measurable (boleh diukur) • Achievable (boleh dicapai) • Realistic (realistik) • Time bond (tempoh)

  34. Define the problem:5W2H(Menyatakan masalah) • Why do we say it`s a problem? • Where is the problem located or where thus it occur? • Who is affected or concerned by the problem? • What is the nature or what happens when the problem occurs? • When does it happen? • How do we know it`s a problem? • How many; How can we quantify the size of the problem? Why Where Who What When How How many

  35. Define the problem:5W2H Begin with the initial problem statement Initial problem statement Next, complete 5W2H Reformulate original problem statement Rewritten problem statement

  36. Understand the problem: 5 why`s What is the root cause of the problem regards to teaching effectiveness.


  38. RCA in action

  39. Pernyataanmasalahawal

  40. Menyatakanmasalahsemuladenganspesifik

  41. Strategi 5W BACK

  42. DO YOU WANT TO DO IT? If it is not now, when? If it is not us, who? they want to learn, and.. Be understood MAKE THEM FEEL IMPORTANT