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Lecture 6 Root Cause Analysis

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Саша Дік
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6 views

Lecture 6 Root Cause Analysis

Uploaded by

Саша Дік
Copyright
© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Lecture 6: Root Cause Analysis

Jacob Bouman
2023- 2024
Overview lecture

• Why root cause analysis?

• What are requirements?

• 6 steps
– Explanation
– Practical example
RCA and why?

AD procesoptimalisatie
Who uses RCA

• Often used in bigger companies


What is root cause analysis

• Who has ever been involved in a root cause


analysis?
• Root cause behind issues/problems/challenges

The symptoms of an issue


are often clearly visible

The cause is often not visible,


there is some digging/research
needed to find it
Why root cause analysis?

Main goal RCA

Prevent an issue from reoccurring


When to do a RCA
• RCA takes quite a bit of effort and
time
– Always an RCA is not efficient
RCA

• Pyramide approach
– Most issues are easy to fix
• Cost approach
Solved by
– At standstill longer than …. operators or
• Reoccurance mechanic without
RCA
– When an issue keeps popping
up
Characteristics of an RCA

Systematic approach
Step-by-step Based on data and facts

Implement and secure RCA


solution

If the cause is found Investigate (all) possible causes


keep questioning
Who does the RCA?

• Teamwork

• RCA was widely used within infant formula


factories
– QA/QC
– Operators/ production
– Technology
– Maintenance
– Engineering
Why teamwork?

Broad commitment

Broad expertise required


More motivating

Substantial increase in success rate

Support for investigation and


Workload: division of task implementation of solution
RCA is systematic

• Many variaties of RCA


– Same systematics
– 5 or 6 Step approach
Root cause analysis: 6 steps

1. Determine what happened


2. Determine causes
3. Determine root cause
4. Find the solutions and take action
5. Verify the effectiveness of the solutions
6. Secure the solution
Problem: car does not start
Step 1: Determine what happened

• 5 W’s
– What, where, when, who and why
• Focus is important
• The more specific the better
– Focus on 1 problem, not on multiple
• Often good to describe what is not included
– Avoid confusion
• You must be working at the same issue
Step 1: Determine what happened

What The car VW Golf 5 from 2012, when the starter button
is pressed, the self-starter engages, but the
engine does not start
Where Apeldoorn Carport of Het Kasteel 410 in Apeldoorn

Who Me Jacob Bouman

When Yesterday 24 mei 2022 om 14:54


afternoon
Why I am always It seems that the self-starter cannot create
unlucky enough momentum
Step 2: Determine causes

• Brainstorm about all possibilities

• Out of the box thinking/ broad thinking


– Tunnel vision lowers your chance of finding the cause
• Example vitamin deviation

• Make use of the fish bone


Stap 2: Determine causes

(Wo)Man Machine Measurement


battery is Alternator gets
Neighbor has put
empty a wrong value
a tangerine
of battery level
in the exhaust

Problem
Warm weather car does not start
Did not use Refueled Diesel
clutch when has disrupted
instead of
starting the starter
petrol?
motor

Method Mileu/
Material
environment
Stap 2: Determine causes

• Do your investigations

• Collect evidence  cause or not casue


– Trending
– Documents
– Tests
– interviews
Step 2: Determine causes
Possible cause Likely? Why(evidence)
Neighbor has put No No mandarin orange found in the exhaust
a tangerine after checking
In the exhaust
Battery is empty Yes Battery voltage measured and was too low

Alternator gets No Mechanic has checked it  working correctly


a wrong value
of battery level
Did not use No The car will not start even when the clutch is
clutch when pressed
starting
Refueled Diesel No Analyzed the fuel  petrol
instead of
petrol?
Warm wheater No It was 25C, within spec starter motor
Solve right away!!

• Problem: car does not start


• cause
– Battery is empty
• Remedy: Replace battery

• 1 week later
• Problem: car does not start
• cause
– Battery is empty
• Remedy: Replace battery
Example: 2 times why

• Problem: car does not start


• cause
– Battery is empty
• Why
– It does not charge while driving
• Why
– Alternator does not supply power
• Remedy: replace alternator

• 1 week later
• Problem: car does not start
Step 3: Determine the root cause

• From cause to root cause


• Cause found?
– Don't fix it right away!
• 5x why
Example: 5 times why
• Problem: car does not start
• cause
– Battery is empty
• Why
– It does not charge while driving
• Why
– Alternator does not supply power
• Why
– Worn out multi belt
• Why
– Not replaced after 150000 km
• Why
– “Save” costs
Step 4: Find solutions and take action

Problem car does not start


Cause Battery is empty
1e Why It does not charge while driving
2e Why Alternator does not supply power
3e Why Worn-out multi belt
4e Why Not replaced after 150000 km
5e Why Save costs

• Will the car start if you only address the root


cause?
– No more saving costs by skipping maintenance
Step 4: Find solutions and take action

• Often 2 types of solutions are needed


• CAPA
– Corrective Action  (quick) fix current situation
Preventive Action  make sure the problem doesn't
come back

• Example car
– Corrective Action  Charge battery and replace belt
– Preventive Action  no more skipping of maintenance
Overview 4 steps

Step Mindset Tool


1. Determine what happened Be specific 5 W’s (What, where, who, when
and why)
2. Determine causes Think out of the box fishbone
3. Determine rootcause Keep asking 5 why’s
4. Find the solutions and take Often more solutions CAPA (corrective action preventive
action needed action)
Step 5: Verify the effectiveness of the solutions

• Does the solution have the desired effect?


• Search for evidence
– Comparison of the before and after situation is important

• Unbiased (Be the devil's advocate)


– Are there enough data points?
– Other factors?
• Seasonality, type of product
Step 5: verify the effectiveness of the solutions
Step 6: Secure the solutions
• Adaption of:
– Working instructions
– Maintenance plans
– Equipment
– Centerlining

• Key question: Has everything been taken and is it


really secured?
• What happens if there is….
• New staff, new project etc..
– example EPL
Overview

Step Mindset Tool


1. Determine what happened Be specific 5 W’s (What, where, who, when
and why)
2. Determine causes Think out of the box fishbone
3. Determine rootcause Keep asking 5 why’s
4. Find the solutions and take Often more solutions CAPA (corrective action preventive
action needed action)
5. Verify the effectiveness of the Be the devil's advocate Take the time for clear quantitative
solutions evidence
6. Secure the solutions Think ahead Question: What happens if…?

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