RCA Training
description
Transcript of RCA Training
“A problem well defined is a problem half solved”
-Anonymous
Root-Cause Analysis
At the end of this training, you will be able to..
• Understand the basic steps in problem-solving• Be more familiar with the term Root-Cause
Analysis • Learn to use 2 simple RCA techniques
Problem Solving Process• Define problem
• Perform RCA1.Diagnostic Phase
• Provide action plan• Implement• Determine effectiveness
2. Solution (“Fix it”)
Phase
“If I had 60 minutes to solve a problem, I’d spend 55 minutes defining it and 5 minutes solving it”.
– Albert Einstein
Root Cause Defined
• Main / root or most basic cause or problem
• Management has control to fix
• Will prevent or significantly reduce the likelihood of recurrence
Root Cause Analysis
5 Whys FMEA Pareto Charts Risk Tree Diagrams Process Maps
Tree Diagram Fish-bone Affinity Diagrams
Cause-Effect Diagram Brainstorming
Fish-Bone (Ishikawa) Analysis
• Man - people involved• Machine -equipment,
tools• Method- procedure,
requirements
Skull = Problem / Challenge
Spines = Causes (5 Ms)
• Material – raw materials, reagents
• Mother Nature / Environment – temperature, location, natural phenomenon
5 Whys Analysis Why?
Why?
Why?
Why?
Why?Why?
but…Why?
5 Whys Analysis
Keep going until the answer is “I don’t care” (management
can no longer fix it)
Why?
Why?
Why?
Why?
Why?Why?
but…Why?
NOT JUST 5x
…Why did it fell?
It fell because of gravity.
Why is there gravity?
I don’t care (doesn’t matter here)
Making the most of both..
Fish-Bone x
- Exploring causes from all possible sources
5 Whys- Drilling down to
the root-cause -(why? or so
what?)
Example: Fish-Bone x 5 Whys
Man
1st why:Analyst missed
something in the
procedure – (problem persisted
after repeat
analysis)
X
Method
1st why:Modification has been made in the
method / procedure
- NO
X
Material
1st why:<MDL
reading for Total N
2nd why:With relatively low N content as compared with majority
of samples (reflected in
NO3- and NH4+)
Machine
1st why:Total N
module is not able to
read sample below 0.3
ppm
2nd why:It’s the
current LOQ
3rd why:Suitable for majority of
samples only
Environment
1st why: N contaminati
on during NO3- and
NH4+ analysis – NO (QC
inserts are OK)
X
Initial Concern: Total N result (<MDL) is lower than combined NO3- (0.120 ppm) and NH4+ (0.170 ppm)
Example
1.Diagnostic Phase
• Define problem• Perform RCA• “Total N content of samples
is below instrument MDL”
2. Solution (“Fix it”)
Phase
• Provide corrective action plan (with due date and responsible people) “Modify instrument settings to get lower MDL and re-analyze samples, c/o MS and ACB by Jun 2012”
• Implement – Done as of Jun 2012 • Determine effectiveness – No recurrence
(Issue CLOSED)
Initial concern: Total N result (<MDL) is lower than combined NO3-N (0.120 ppm) and NH4+N (0.170 ppm)
“Don’t just stop the bleeding! Stop the bleeding first, and then address the root-cause. Do RCA”.
“If I had 60 minutes to solve a problem, I’d spend 55 minutes defining it and 5 minutes solving it”.
– Albert Einstein