Incredibles_Root Cause Analysis
-
Upload
dinesh-tyagi -
Category
Documents
-
view
120 -
download
1
Transcript of Incredibles_Root Cause Analysis
![Page 1: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/1.jpg)
Root Cause Analysis
Presented By: Team: Incredibles
San Jose State University
CMPE 203, Fall 2009
![Page 2: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/2.jpg)
Agenda
• Introduction
• What is RCA?
• Why do we need?
• Types of RCA
• Techniques/Tools
- Kepner-Tregoe Method
- FMEA
- Fishbone Diagram
• Case study of RCA
![Page 3: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/3.jpg)
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.
![Page 4: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/4.jpg)
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.
![Page 5: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/5.jpg)
Why do we need it
• Benefits of RCA
- Real cause of the problem can be found
- Problem recurrence will be minimized
![Page 6: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/6.jpg)
Types of RCA
• Safety-based RCA
• Production-based RCA
• Process-based RCA
• Systems-based RCA
![Page 7: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/7.jpg)
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.
![Page 8: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/8.jpg)
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
![Page 9: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/9.jpg)
Methods of Root Cause Analysis
• Change Analysis
• Barrier Analysis
• MORT: Management Oversight and Risk Tree
• Human Performance Evaluation (HPE)
![Page 10: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/10.jpg)
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.
![Page 11: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/11.jpg)
Tools for Root Cause Analysis
![Page 12: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/12.jpg)
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.
![Page 13: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/13.jpg)
FMEA Example
![Page 14: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/14.jpg)
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.
![Page 15: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/15.jpg)
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.
![Page 16: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/16.jpg)
Fishbone Analysis
• 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.
Problem
Machine
Method
Material
Man Power
Measurement
Management
cause cause
causecause
reason
reason
![Page 17: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/17.jpg)
Fishbone Analysis
• 5 WHY’S
Ran out of GasDidn’t buy this morning
Didn’t have money
Lost them in last night’s poker
Not very good in “bluffing”
WHYWHY
WHY
WHY WHY
Car stopped Middle of the road
![Page 18: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/18.jpg)
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.
![Page 19: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/19.jpg)
Project Delay
Benchmarking
Control
Resources
Separate Systems
Inventory Update Every 12
hours
No Clear deadlines
No Clear Understanding
Scope Definition
Separate Systems for Sales & Supplier
Real time inventory
Wrong Estimates
No backup for Critical Resources
Communication
No Communication plan
Managed Systems
Different Suppliers
Case Study – Fishbone Analysis
Time and Format of Systems different
Lack of Standards
Inadequate Resources
Inventory
![Page 20: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/20.jpg)
Conclusion
• Learning for the future projects.
• Encourages Team based problem solving approach.
• Errors are frequent and inevitable.
• Saves cost and helps in identifying solutions.
![Page 21: Incredibles_Root Cause Analysis](https://reader036.fdocuments.in/reader036/viewer/2022062613/543e088cb1af9f332b8b45be/html5/thumbnails/21.jpg)
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