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Root Cause AnalysisOverview

Performance & Productivity Improvement

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AgendaAgenda

• Root Cause Analysis Definition• The Root Cause Analysis Method & Tools • How Do We Perform Root Cause Analysis?• Other Quality Improvement Process Tools• When do we perform RCA?• References

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Definition of Root Cause AnalysisDefinition of Root Cause Analysis

• The objective of this process is to determine the true cause of a problem. It is one of the most vital functions we can perform to improve service excellence for our clients because it helps to prevent problems from occurring again.

• Everyone in the Organization needs to understand the purpose of root cause analysis and should be able to perform the related procedures.

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The Root Cause Analysis Method & Tools

The Method is based on determine what has happened during an occurrence/ incident, how it did happen, and why it did happen. The method includes:

1. Problem/ Incident Detection and Data Collection.

2. Root Cause Determination.

3. Development of corrective actions and follow up

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• Information collected consists of conditions before, during, and after the occurrence.

• Personnel involvement (including actions taken).

• Environmental factors.• All information relevant to the condition or problem.

Problem/ Incident Detection and Data Collection

Root Cause Determination

Develop corrective actions and follow up

The Root Cause Analysis Method & Tools

• In the root cause determination phase consider analyzing data so as to identify the causal factors using a specific technique and summarizing the findings.

• The major cause areas could be assigned to Equipment/Material Problem, Procedure Problem, Personnel Error, Design Problem, Training Deficiency, Management Problem, External Problem.

• Root cause analysis enables the improvement of reliability and safety by selecting and implementing effective corrective actions.

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How Do We Perform Root Cause Analysis?

After you have asked WHY five times, you should have reached

the root cause of the problem.

Have you heard of the Rule of Five?

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How Do We Perform Root Cause Analysis?

Continue asking the WHY question until you can’t

find any further underlying problems.

Ask WHY a problem occurred.

A client experienced a Severity 1 outage. Why? Because the server powered off. Why? Because the server became unplugged. Why? Because someone tripped over the power cord. Why? Because the power cord was draped over a table. Why? Because it was not the appropriate length. Why? Because the vendor sent the wrong length power cord. Why?

Because human error occurred during the vendor manual

ordering process.

This is the root

cause.

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Other Quality improvement process tools

Brainstorming Cause & Effect Diagram Decision Matrix Nine-Block Worksheet &

Grid Pareto Analysis Planning Worksheet Process Model Worksheet Quality Audits Threads of Similarity

Check Sheet

Control Chart

Flowchart

Histogram

Opportunities for Error

Run Chart Team Meeting Review Structure Tree

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When Do We Perform Root Cause Analysis?

• Identify Root Cause Analysis will be performed based on, but not limited to: History of common set of symptoms (threads

of similarity.) Problem escalated to Senior Management

and/or Customer Management. Root causes compared to existing requests

to determine if association is possible. Identification of preventive actions that could

be useful to implement ongoing preventive maintenance (i.e. equipment maintenance) or to propagate corrective action solution to other environments.

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When chronic problems occur, the organization will work with all related parties to identify causes and possible resolutions.

If not resolved in a timely fashion, the project will escalate the issue until the problem is resolved.

If the chronic problem cannot be resolved, the project will work with CLIENT to determine appropriate steps.

Root cause analysis is required for severity 1, 2 and 3 problems and for nonconformance records (CARs), which must be

evaluated every month.

Severity 3 and 4 problems should be considered and evaluated every 6 months.

When Do We Perform Root Cause Analysis?

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References

– http://www.dcmc.hq.dla.mil/teaminfo/aqbd/99plan/METRICS/root.htm

– http://www.philipcrosby.com/qualitystore/cdrom.details/cd.problemsolving.htm

– http://tis.eh.doe.gov/techstds/standard/nst1004/nst1004.pdf