RCCA Process 11-3-11 (3)

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    Root Cause and Corrective

     Action Process

    PROPRIETARY INFORMATION The information contained herein is proprietary to Alliant Techsystems and shall not be reproduced or disclosed in whole

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    severe criminal penalties.

    Michael Gardiner

    Continuous Improvement Manager

    11-3-11

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    SS&C Lane RCCA Standardization

    Develop a single process to be used by all si tes within the SS&C

    Lane:

    • Single tool for all discrepancies and problems

    • Process is not only limited to Quality problems/discrepancies

    • Establish common language

    • Facilitate sharing of lessons learned

    • Common metrics

    • Creation of Standard Work

    • Helps identify where/when process breaks down

    • Becomes the training document

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    RCCA Process

    Suggested Standard process:

    • Simple

    • Cost effective

    • Can be formal or informal

    • Can be performed by an individual or by a team

    Determineproblem

    statement

    CreateFishboneDiagram

    (identify symptoms

    and causes)

    Perform 5 Why'sanalysis

    (determine root

    cause(s))

    Implementimmediate

    corrective action

    Implement longterm corrective

    action

    Verify outcomeof corrective

    action

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    Defining the problem

    “ Go See” the problem at the point of occurrence to

    truly understand the current condition.

    Observe the condition, collect data and facts.

    Using the observations, data, and facts state what

    the current condition is.

    The current condition should include

    • The point of cause

    • The time and place at which the abnormality is occurring

    The current condit ion should not imply any causes or solutions

    State what the desired condit ion is.

    • What is the standard

    • Objective

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    Problem Statement

    Once the Current Condit ion and Desired condition are understood

    the problem statement can be generated.

    The Problem Statement should be:

    • Short

    • Simple

    • Concise

    • Focused on one problem

    “ If you cannot say it simply, you do not understand

    the problem.”

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    Fishbone Diagram

     A Fishbone Diagram attempts to identify al l potential causes and

    symptoms of a non-conformance by following a standardprocess

    • Start with a defined problem statement

    • Identify all potential causes and symptoms by top level categories

    Benefits of Fishbone Diagrams include:

    • Prevents jumping to conclusions as to a problem’s true root cause

    • Identi fying that a problem may have more than one root cause

    • Helps determine the difference between causes and symptoms

    • Understanding interactions between multiple issues

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    Fishbone Diagram

    The potential causes identified by a Fishbone Diagram are visually

    grouped into six distinct top-level categories:

    • Man (People) – Anyone involved with the process

    • Method – How the process is performed and the documentation to define the

    process; including drawings, work instructions, specifications, etc

    • Machine – Any equipment, tools, computers etc required to perform a task

    • Material – Raw materials used to produce the final product

    • Measurement – Data generated from the process that is used to define quality

    • Mother Nature (Environment) – The conditions, such as time, temperature,

    humidity, etc in which the process is performed

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    Fishbone Diagram (Blank)

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    Fishbone Diagram (Sample)

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    Creating a Fishbone Diagram

    Fishbone diagrams can be done on a blank piece of paper or created

    electronically.

    Microsoft Visio has a bui lt-in template to easily create Fishbone diagrams

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    Symptoms and Causes

    Once a Fishbone Diagram has been created it is important to

    distinguish between symptoms and causes

    • Symptoms are things that indicate the presence of a problem

    • Machine is down

    • Scrap rate has increased from X to Y

    • FOD in parts

    • Failure to meet requirements

    • Causes are reasons for the problem

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    5 Why Analysis

    The 5 Why’s is a questions-asking method used to explore the

    cause/effect relationships underlying a particular problem and/or cause.

    The goal of applying the 5 Why’s method is to determine the root

    cause of a defect or problem.

    • Identify the possible causes of the problem (from fishbone) and ask why it

    happened

    • Make assumptions as to why the cause occurred

    • Obtain facts to affirm or reject each assumption to enable asking why again

    • Test for Cause and Effect

    • Repeat the process as many times as needed to achieve true root cause

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    5 Why Analysis

    Make Assumptions

    Prove / DisproveEach Assumption

     Ask WhyStart with

    causeidentified

    byfishbone

    Identify RootCause

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    Simplified 5 Why Form (Blank)

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    Simplified 5 Why Form (Sample)

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    5 Why Flowchart

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     Additional Root Cause Tools

    For more complex problems where the root cause is not/cannot be

    determined using 5 why’s the are additional problem solvingmethods available:

    • K-T Analysis (Kepner-Tregoe)

    • Decision Focus®

    • Design of Experiments

    • 6 Sigma - DMAIC

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    Immediate Corrective Actions

    Immediate corrective actions are:

    • “Band-aids” that provide temporary relief until a more effective or

    extensive solution can be implemented.

    • Rework to fix the problems found (short-term fix).

    • Short-term protection goals

    • Best when applied at the point of occurrence of the problem.

    Example:

    The immediate corrective action can become long term if a more

    effective solution can not be found.

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    Long Term Corrective Actions

    Factors to consider when creating long term corrective actions:

    • Feasibility - Must be within company resources and schedule

    • Budget - Cost to implement must be within budget and appropriate forextent of the problem

    • Employee Involvement - Departments and personnel affected need to be

    involved in the actions

    • Focus on Systems - Focused on systemic issues, not on individuals.

    Long Term Corrective Actions incorporate:

    • Preventive action to prevent problems recurring (long-term fix)

    • Mistake Proofing

    • Methods of verification

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    Verification Questions

    In order to verify results of a corrective action there needs to be

    answers to the following questions:

    1. What are the expected results of the corrective action?

    2. What metrics are in place to measure the results of the corrective

    action?

    3. How often should the corrective action be monitored to assure

    sustainability?

    4. Who is responsible to monitor the results?

    5. What needs to be done to continue to improve the process?

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    Verification Process

    Questions to ask if “ No” occurs

    1. What is the point of cause, the time and place at which the abnormality

    is occurring? Is it different from what was identified in the original

    problem statement?

    2. What is the root cause?

    3. Have you tested for cause and effect?

    4. What are your temporary and permanent corrective actions?

    5. How will you confirm your corrective actions?

    • Adjust hypothesis

    • Solve Problems

    • Standardize

    • Look forimprovement

    Results

    MeetsExpectations

    ?

    Yes

    No

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    RCCA Worksheet

    Problem Investigation -

    Description: Current Standard: Date:

    Department/Zone

    First observed (date/time):

    Problem Investigated By: Repeat Item: YES NO

    Causes: [Use fishbone diagram on back if necessary]

    Root Causes: [Use 5 Why’s]

    Cause and Effect Confirmed: YES NO How:

    Countermeasures:

    Temporary/

    Immediate

    Permanent

    What:

    What:

    Who:

    Who:

    When:

    When:

    Review Standard Work:

    Exists Does not exist Followed Not followed Adequate Not adequate

    Follow up Action:

    [Confirm

    Countermeasures]

    What: Who: When: