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Root Cause Analysis Presented By: Team: Incredibles. San Jose State University CMPE 203, Fall 2009 . Agenda. Introduction What is RCA? Why do we need? Types of RCA Techniques/Tools - Kepner-Tregoe Method - FMEA - Fishbone Diagram Case study of RCA. Root Cause Analysis.

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root cause analysis presented by team incredibles

Root Cause AnalysisPresented By: Team: Incredibles

San Jose State University

CMPE 203, Fall 2009

agenda
Agenda

Introduction

What is RCA?

Why do we need?

Types of RCA

Techniques/Tools

- Kepner-Tregoe Method

- FMEA

- Fishbone Diagram

Case study of RCA

root cause analysis
Root Cause Analysis

What is Root Cause Analysis?

- Finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms

Reactive method

Goals

- Failure identification

- Failure analysis

- Failure resolution

Iterative Process:

- Complete prevention of recurrence by a single intervention is not always possible.

steps for root cause analysis
Steps for Root Cause Analysis

Collection of data - Phase I

- A fact-finding investigation, and not a fault-finding mission

Event Investigation - Phase II

- Objective evaluation of the data collected to identify any causal factor that may have led to the failure

Resolution of occurrence - Phase III

- Realistic assessment of the viability of the corrective action that the previous phase revealed.

- The phenomenon must then be monitored periodically to verify resolution.

why do we need it
Why do we need it

Benefits of RCA

- Real cause of the problem can be found

- Problem recurrence will be minimized

types of rca
Types of RCA

Safety-based RCA

Production-based RCA

Process-based RCA

Systems-based RCA

types of rca7
Types of RCA
  • Safety-based RCA

- Investigating Accident and occupational safety and health.

- Root causes:- unidentified risks, or inadequate safety engineering, missing safety barriers.

  • Production-based RCA

- Quality control for industrial manufacturing.

- Root causes:- non-conformance like, malfunctioning steps in production line.

types of rca8
Types of RCA

Process-based RCA

- Extension of Production-based RCA.

- Includes business processes also.

- Root causes:- Individual process failures

System-based RCA

- Hybrid of the previous types

- New concepts includes:- change management, systems thinking, and risk management.

- Root causes:- organizational culture and strategic management

methods of root cause analysis
Methods of Root Cause Analysis

Change Analysis

Barrier Analysis

MORT: Management Oversight and Risk Tree

Human Performance Evaluation (HPE)

kepner tregoe method
Kepner-Tregoe Method

Developed in 1958

Fact-based approach to systematically rule out possible causes and identify the true cause.

Composed of fives Steps:

- Define the Problem

- Describe the Problem

- Establish possible causes

- Test the most probable cause

- Verify the true cause

Kepner-Tregoe is a mature process with decades of proven capabilities.

Kepner-Tregoe Problem Analysis was used by NASA to troubleshoot Apollo XIII.

failure mode effect and analysis fmea
Failure Mode effect and Analysis (FMEA)

Methodology for analyzing potential reliability problems early in the development cycle.

Failure modes are any errors or defects in a process, design, or item, especially customer related.

Effects analysis refers to studying the consequences of those failures.

slide14
FMEA

Benefits:

Improves the quality, reliability, and safety of products.

Increases customer satisfaction.

Stimulates open communication and collective Expertise.

Disadvantages:

Assumes cause of problem is a single event.

Examination of human error overlooked.

fishbone analysis
Fishbone Analysis

Definition

- Technique to graphically identify and organize many possible causes of a problem

Advantages

- Helps to discover the most likely ROOT CAUSES of a problem

- Teach a team to reach a common understanding of a problem.

fishbone analysis16
Fishbone Analysis

Machine

Material

Measurement

cause

cause

reason

Problem

cause

cause

reason

  • Components :

- Head of a Fish : Problem or Effect

- Horizontal Branches : Causes

- Sub – branches : Reason

- Non- service Categories : Machine, Manpower, Method etc.

- Service categories : People, Process, Policies, Procedures etc.

Management

Method

Man Power

fishbone analysis17
Fishbone Analysis

Car stopped

Middle of the road

Ran out of Gas

WHY

WHY

Didn’t buy

this morning

WHY

Didn’t have

money

Lost them in

last night’s poker

Not very good

in “bluffing”

WHY

WHY

5 WHY’S

case study safeway com
Case Study – Safeway.com

Safeway outsourced a module of Safeway online to HCL, India

Project Details – Add a new module for selling Patio furniture online on http://Safeway.com .

Agreed duration - 8 months, June, 07 to February, 08

Actual delivery – June ’08

After the project was finished TCS performed a Root Cause Analysis to analyze the delays and to avoid problems in future.

slide19

Case Study – Fishbone Analysis

Control

Inventory

Inventory Update Every 12 hours

No Clear Understanding

Real time inventory

Scope Definition

No Clear deadlines

Separate Systems

Separate Systems for Sales & Supplier

Wrong Estimates

Project Delay

Managed Systems

No backup for Critical Resources

Different Suppliers

Inadequate Resources

Lack of Standards

Communication

Time and Format of Systems different

No Communication plan

Benchmarking

Resources

conclusion
Conclusion

Learning for the future projects.

Encourages Team based problem solving approach.

Errors are frequent and inevitable.

Saves cost and helps in identifying solutions.

references
References
  • http://www.systems-thinking.org/rca/rootca.htm
  • http://www.workplacechallenge.co.za/pebble.asp?relid=649
  • http://www.itsmsolutions.com/newsletters/DITYvol2iss24.htm
  • http://www.envisionsoftware.com/articles/Root_Cause_Analysis.html
  • http://www.au.af.mil/au/awc/awcgate/nasa/root_cause_analysis.pdf
  • http://www.isixsigma.com/library/content/c020610a.asp
  • http://www.quality-one.com/services/fmea.php
  • http://www.npd-solutions.com/fmea.html