structured process that uncovers the physical, human, Ch. Mohammed Gamal and latent causes of any undesirable event in the workplace. Agenda Seven-Step Problem-Solving Model DMAIC Technique TRIZ Technique SCAMPER Technique Ishikawa Diagram “fishbone diagram” Ch. Mohammed Gamal Root Cause Analysis (RCA) 2 Introduction
Failure Cause – • The physical or chemical processes, design defects, quality defects, part Failure Effect – The misapplication, or other consequence(s) a processes that are the basic failure mode has on the reason for failure or that initiate operation, function, or the physical process by which status of an item. deterioration proceeds to failure. • The circumstances during Failure – The termination design, manufacture, or of its ability to perform a operation that have led to a required function failure. Failure Mode – The effect by which a failure is observed on the failed item 3 Seven-Step Problem-Solving Model
1. Identify the problem. This step involves making sure that everyone is focused on the same issue. It may involve analysis of data to determine which problem should be worked on and writing a problem statement that clearly defines the exact problem to be addressed and where and when it occurred. A flowchart might be used to ensure that everyone understands the process in which the problem occurs.
2. List possible root causes. Before jumping to conclusions about what to do about the problem, it is useful to look at the wide range of possibilities. Brainstorming and cause-and-effect analysis are often used.
3. Search out the most likely root cause. This stage of the process requires looking for patterns in failure of the process. Check sheets might be used to record each failure and supporting information, or control charts may be used to monitor the process in order to detect trends or special causes.
4. Identify potential solutions. Once it is fairly certain that the particular root cause has been found, a list of possible actions to remedy it should be developed. This is a creative part of the problem-solving process and may rely on brainstorming as well as input from specialists who may have a more complete understanding of the technology involved. Seven-Step Problem-Solving Model
5. Select and implement a solution. After identifying several possible solutions, each should be evaluated as to its potential for success, cost and timing to implement, and other important criteria. Simple processes such as ranking or multivoting, or more scientific analysis using a matrix, are likely to be used in the selection process.
6. Follow up to evaluate the effect. All too often problem-solving efforts stop after remedial action has been taken. As with any good corrective action process, however, it is necessary that the process be monitored after the solution has been implemented. Control charts or Pareto diagrams are tools used to determine whether the problem has been solved. Possible findings might be that there was no effect (which may mean the solution wasn’t properly implemented, the solution isn’t appropriate for the root cause, or the real root cause wasn’t found), a partial effect, or full resolution of the problem. If there was no effect, then the actions taken during the previous steps of the problem-solving model need to be reviewed in order to see where an error may have occurred.
7. Standardize the process. Even if the problem has been resolved, there is one final step that needs to occur. The solution needs to be built into the process (for example, poka-yoke, training for new employees, updating procedures) so that it will continue to work once focused attention on the problem is gone. A review to see what was learned from the project is also sometimes useful. DMAIC
1. Define the customer and organizational requirements.
• Data collection tools: Define stage Interviews and brainstorming: Where to interview Who to interview Condition of people at the scene How to handle multiple witnesses How to handle after the incident How to work with teams
Documents (paper) evidence:
check sheets and flowcharts
Parts/component evidence
• Data analysis tools :
cause-and-effect diagrams, affinity diagrams, tree diagrams, root cause analysis
• Customer data collection and analysis:
QFD, surveys DMAIC
2. Measure what is critical to quality, map the process, establish measurement system, and determine what is unacceptable (defects). Measure stage • Process control tools: control charts • Process improvement tools: process mapping, Pareto charts, process benchmarking , TOC, risk assessment (FMEA), design of experiments, cost of quality, lean thinking techniques
3. Analyze to develop a baseline (process capability). Analyze stage
• Identify root causes of defects. • Pinpoint opportunities and set objectives.
4. Improve the process.
• Project planning and management. Improve stage • Training.
5. Control the system through an established process. Control stage
TRIZ
TRIZ is a Russian acronym—translated it is the theory of
the solution of inventive problems. Under development and testing for over 50 years, TRIZ has evolved into a structure for the deployment of innovative and creative problem solving.2
According to TRIZ, universal principles of creativity form
the basis of innovation. TRIZ identifies and codifies these principles, and uses them to make the creative process more predictable.
💡💡 In other words, whatever problem you're facing, somebody, somewhere, has already solved it (or one very like it). Creative problem solving involves finding that solution and adapting it to your problem TRIZ Key Points TRIZ is a system of creative problem solving, commonly used in engineering and process management. It follows four basic steps:
Define your specific problem.
Find the TRIZ generalized problem that matches it. Find the generalized solution that solves the generalized problem. Adapt the generalized solution to solve your specific problem. Most problems stem from technical or physical contradictions. Apply one of 40 of TRIZ principles and laws to eliminate these contradictions, and you can solve the problem. TRIZ
The principles are:
• Segmentation • Feedback• Convert harm into benefit
• Extraction • Mediator• Replacement of mechanical systems • Local quality • Self-service• Pneumatic or hydraulic construction • Asymmetry • Copying• Flexible membranes or thin films • Consolidation • Dispose• Porous material • Universality • Spheroidality• Changing the color • Nesting • Dynamicity• Homogeneity • Counterweight • Partial or excessive action• Rejecting or regenerating parts • Prior counteraction • Transition into a new dimension• Transformation of properties • Prior action • Mechanical vibration• Phase transition • Cushion in advance • Periodic action• Thermal expansion • Equipotentiality • Continuity of useful action• Accelerated oxidation • Do it in reverse • Rushing through• Inert environment • Composite materials SCAMPER
Using this method, seven questions are used by a team to stimulate creativity: • What can be used as a Substitute? • What can be Combined with ____________ ? • How can ____________ be Adapted? • How can ____________ be Modified? • How can ____________ be Put to other uses? • How can ____________ be Eliminated? • What if ____________ were Reversed (or Rearranged)? Ishikawa Diagram “fishbone diagram” This cause analysis tool is considered one of the seven basic quality tools. The fishbone diagram identifies many possible causes for an effect or problem. It can be used to structure a brainstorming session. It immediately sorts ideas into useful categories.
FISHBONE DIAGRAM PROCEDURE
1. Materials needed: marking pens and flipchart or whiteboard. 2. Agree on a problem statement (effect). Write it at the center right of the flipchart or whiteboard. Draw a box around it and draw a horizontal arrow running to it. 3. Brainstorm the major categories of causes of the problem. If this is difficult use generic headings: 1. Methods 2. Machines (equipment) 3. People (manpower) 4. Materials 5. Measurement 6. Environment (mother nature) 4. Write the categories of causes as branches from the main arrow. 5. Brainstorm all the possible causes of the problem. Ask "Why does this happen?" As each idea is given, the facilitator writes it as a branch from the appropriate category. Causes can be written in several places if they relate to several categories. 6. Again ask "Why does this happen?" about each cause. Write sub-causes branching off the causes. Continue to ask "Why?" and generate deeper levels of causes. Layers of branches indicate causal relationships. 7. When the group runs out of ideas, focus attention to places on the chart where ideas are few. Ishikawa Diagram “fishbone diagram” This cause analysis tool is considered one of the seven basic quality tools. The fishbone diagram identifies many possible causes for an effect or problem. It can be used to structure a brainstorming session. It immediately sorts ideas into useful categories.
FISHBONE DIAGRAM PROCEDURE
1. Materials needed: marking pens and flipchart or whiteboard. 2. Agree on a problem statement (effect). Write it at the center right of the flipchart or whiteboard. Draw a box around it and draw a horizontal arrow running to it. 3. Brainstorm the major categories of causes of the problem. If this is difficult use generic headings: 1. Methods 2. Machines (equipment) 3. People (manpower) 4. Materials 5. Measurement 6. Environment (mother nature) 4. Write the categories of causes as branches from the main arrow. 5. Brainstorm all the possible causes of the problem. Ask "Why does this happen?" As each idea is given, the facilitator writes it as a branch from the appropriate category. Causes can be written in several places if they relate to several categories. 6. Again ask "Why does this happen?" about each cause. Write sub-causes branching off the causes. Continue to ask "Why?" and generate deeper levels of causes. Layers of branches indicate causal relationships. 7. When the group runs out of ideas, focus attention to places on the chart where ideas are few. Fishbone diagram example This fishbone diagram was drawn by a manufacturing team to try to understand the source of periodic iron contamination. The team used the six generic headings to prompt ideas. Layers of branches show thorough thinking about the causes of the problem.
For example, under the heading "Machines," the idea "materials of construction" shows four kinds of equipment and then several specific machine numbers. Note that some ideas appear in two different places. "Calibration" shows up under "Methods" as a factor in the analytical procedure, and also under "Measurement" as a cause of lab error. "Iron tools" can be considered a "Methods" problem when taking samples or a "Manpower" problem with maintenance personnel. The way to get started is to quit talking and begin doing. Walt Disney
Ch. Mohammed Gamal Root Cause Analysis (RCA) 15
Summary Root cause analysis (RCA) is a tool to help identify what, how, and why an event occurred so that steps can be taken to prevent future occurrences. Additionally, RCA may be used to target opportunities for systemwide improvement. Root causes are specific underlying causes that can be reasonably identified, are within management's control to remedy, and which generate effective recommendations to prevent recurrences. The RCA process involves data collecting, causal factor charting, root cause identification, and recommendation generation and implementation.
Ch. Mohammed Gamal Root Cause Analysis (RCA) 16
Thank you If you’ve found this post helpful, make sure to like, comment or share…
