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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San Jose State University
CMPE 203, Fall 2009
What is RCA?
Why do we need?
Types of RCA
- Kepner-Tregoe Method
- Fishbone Diagram
Case study of RCA
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
- Failure identification
- Failure analysis
- Failure resolution
- Complete prevention of recurrence by a single intervention is not always possible.
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.
Benefits of RCA
- Real cause of the problem can be found
- Problem recurrence will be minimized
- Investigating Accident and occupational safety and health.
- Root causes:- unidentified risks, or inadequate safety engineering, missing safety barriers.
- Quality control for industrial manufacturing.
- Root causes:- non-conformance like, malfunctioning steps in production line.
- Extension of Production-based RCA.
- Includes business processes also.
- Root causes:- Individual process failures
- Hybrid of the previous types
- New concepts includes:- change management, systems thinking, and risk management.
- Root causes:- organizational culture and strategic management
MORT: Management Oversight and Risk Tree
Human Performance Evaluation (HPE)
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.
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.
Improves the quality, reliability, and safety of products.
Increases customer satisfaction.
Stimulates open communication and collective Expertise.
Assumes cause of problem is a single event.
Examination of human error overlooked.
- Technique to graphically identify and organize many possible causes of a problem
- Helps to discover the most likely ROOT CAUSES of a problem
- Teach a team to reach a common understanding of a problem.
- 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.
Middle of the road
Ran out of Gas
Lost them in
last night’s poker
Not very good
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.
Inventory Update Every 12 hours
No Clear Understanding
Real time inventory
No Clear deadlines
Separate Systems for Sales & Supplier
No backup for Critical Resources
Lack of Standards
Time and Format of Systems different
No Communication plan
Learning for the future projects.
Encourages Team based problem solving approach.
Errors are frequent and inevitable.
Saves cost and helps in identifying solutions.