Crash course rca training rev 01

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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TA I K I S H A P H I L I P P I N 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

CA/PA BASIC TOOLS Rev 01 10.08.09 CA/PA BASIC TOOLS Rev 01 10.08.09



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

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Objectives

Module 1: Participants will learn how to: • Create and use Pareto chart in the

analysis of a problem • Implement steps for carrying out

effective RCA • Select and apply tools that support

RCA

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Objectives

Module 2:

Participants will be able to:

• Define and explain the 8 – D as a Problem 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

v Definition of Terms v What it is

v Why use it

v RCA Process v How to use it

Introduction MODULE 2 MODULE 1

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Terms and Definition

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

Direct Cause - cause that directly resulted in the occurrence

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

Root Cause - cause that, if corrected, would prevent recurrence of a non-conformity and similar occurrences

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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

v Histograms and Pareto Chart

v Cause and Effect Diagram v What it is

v How to use it

v Examples

v Summary

MODULE 1 MODULE 2 APPLICATION

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Histograms- What it is

• A chart that graphically display the distribution of a set of data.

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Pareto Chart - What it is

It reveals that a small number of NCNs are responsible for the bulk of quality issues,

a phenomenon called the ‘Pareto Principle’.

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

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Pareto Chart – How to create it

1. Gather facts about the problem 2. Rank the contributions to the problem in order

of frequency.

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Pareto Chart – How to create it (cont’n)

3. Draw the value as a bar chart.

5. Review the chart

6. Redefine classifications if necessary.

4. add a line showing the cumulative percentage of errors

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

Cmpt Damaged

Component Faulty

Cmpt Missing

Wrong Comp. Fitted

Cmpt not Meet Elect. S

pec.

Deformed Joint

Joints not Soldered

Cmpt Touching Heatplane

Component Misfitte

d

Legs not through Board

Long Leads

Link Wire Missfitte

d

Beyond Economic Repair

Precautionary Removal

Thiokol Problem

Solder Short

Faulty Connector

Contamination

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 %

Perc

ent

Cou

nt

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

n

Compo

nent

Build Other

57 13 4 275.0 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 %

Percen

t

Cou

nt

Fault by Main Cause

Conn

ect M

odule

Torq

ue M

otor

s

Cold

Star

t

Tran

sduc

er M

odule

ASIC Cali

brati

on

IOP

Imon

21 10 8 8 5 3 236.8 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

DefectCount

PercentCum %

Percent

Count

Design Faults

1st level Analysis gives “Design” as main cause of failure

2nd level Analysis gives breakdown of “Design”


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

KDCC788

KDCC646

KDCC777

KDCC780

KDCC782

KDCC795

40-564-8116-10

40-666-7823

40-564-7274-47E

Others

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

CountPercentCum %

Perc

ent

Cou

nt

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 of occurrence;

• 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 and Effect Analysis.

HINT ! The most frequent is not

always the most important! Be aware of the impact of other

causes on Customers or goals.


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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 Steps A method for showing the distribution of quantitative data and identifying those with the greatest impact.

Pareto Chart and Analysis

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CAUSE AND EFFECT

Ishikawa/Fish Bone Diagram

Problem

People Procedures

Equipment Materials

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Cause and Effect

• Cause and Effect Analysis is a tool for identifying all the possible causes associated with 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 tackled

to generate a positive effect

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Cause and Effect Sources of Variation

Sources of Variation is categorized as follows 1. People

2. Method

3. Machine

4. Material

5. 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 or Issue

Method Machine

Environment Measurement System

People

Material

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How to do it (cont’n)

• 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 no one 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 the

products. • Variations caused by inappropriate

methods or processes.

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Sources of Variation - Machine

Machine • The equipment used to produce the

products. • 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 that

differ by industry, product and stage of production.

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Sources of Variation - Environment

Environment • The methods used to control the

environment. • Variations caused by temperature

changes, humidity etc.

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Sources of Variation – Measurement System

Measurement System • The methods and instruments used to

evaluate products. • Variations caused by measuring

techniques, or calibration and maintenance 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 preventive action

- Problem did not re-occur

PROBLEM SOLVING SUCCESS

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Summary The development of the cause and effect Fishbone diagram is credited to Kaoru Ishikawa, who pioneered quality management processes in the Kawasaki shipyards.

The cause and effect diagram is used to explore potential causes (or inputs) that result in a single undesirable effect (UDE, or output). Causes are categorized under six headings, namely Machinery, Methods, Measurement, Manpower, Materials, and Environment. Potential causes can be arranged according to their level of importance or detail, resulting in a depiction of relationships and hierarchy of events. It is the hierarchy that creates a map that looks somewhat like fish bones, hence the name. The Ishikawa Fishbone Diagram is intended help you brainstorm and search for potential root causes or identify areas where there may be problems by questioning the existence of causes under each of the six categories.

Ishikawa Fishbone Template

UDE

Materials Materials Manpower Manpower

Machinery Machinery Methods Methods Measurement Measurement

Environment Environment

Causes, inputs, or sources of variation

A UDE is an U n D esireable E ffect

Cause and Effect Diagram (Ishikawa)

A visual brainstorming tool used to help identify and categorize potential root causes named for Kaoru Ishikawa.

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$$$

Action Reflection

Wait! I think I missed something

It isn’t that they cannot see the solution,

It’s that they can’t see the problem.

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Created by: Sid Calayag – Lead Auditor

Quality Management System Presented by: Sid Calayag

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