Download - Crash Course on RCA Training Rev 01
-
8/14/2019 Crash Course on RCA Training Rev 01
1/26
TA I K IS H A P H I L I P P IN E S , I N C O P E N C H A L L E N G E Q U I C K R E S P O N S E
QUALITY MANAGEMENT
Date: Oct 09, 2009
CA / PA BASIC TOOLS
CA/PA BASIC TOOLS Rev 01 10.08.09
ROOT CAUSE ANALYSIS
-
8/14/2019 Crash Course on RCA Training Rev 01
2/26
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
QUALITY MANAGEMENT
Date: Oct 09, 2009
CA / PA BASIC TOOLS
CA/PA BASIC TOOLS Rev 01 10.08.09
ROOT CAUSE ANALYSIS
2
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
For most of us, it's a lot easier to jumpto solutions, isn't it?
-
8/14/2019 Crash Course on RCA Training Rev 01
3/26
5
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Objectives
Module 1:
Participants will learn how to:
Create and use Pareto chart in theanalysis of a problem
Implement steps for carrying outeffective RCA
Select and apply tools that supportRCA
6
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Objectives
Module 2:
Participants will be able to:
Define and explain the 8D as aProblem Solving Method
Apply the 8 Disciplines and
Concepts
-
8/14/2019 Crash Course on RCA Training Rev 01
4/26
7
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
HOME PAGE
INTRODUCTION
MODULE 1
MODULE 2
APPLICATION
8
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
I N T R O D U C T I O N
-
8/14/2019 Crash Course on RCA Training Rev 01
5/26
9
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Introduction
Definition of Terms
What it is
Why use it
RCA Process
How to use it
Introduction MODULE 2MODULE 1
10
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Terms and Definition
Cause (causal factor) - a condition or event that resultsin an effect
Direct Cause - cause that directly resulted in theoccurrence
Contributing Cause - a cause that contributed to theoccurrence, but by itself would not have caused the
occurrenceRoot Cause - cause that, if corrected, would prevent
recurrence of a non-conformity and similaroccurrences
-
8/14/2019 Crash Course on RCA Training Rev 01
6/26
11
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
RCA Definition
Root Cause Analysis - a process
designed for use in investigating and
categorizing the root causes of
events
A process of tracing a Problem to its Origins
12
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Root Cause Analysis Process
Step One:
Define the Problem
Step Two:
Collect Data
Step Three:
Identify Possible Causal Factors
Step Four:Identify the Root Cause(s)
Step Five:
Recommend and Implement Solutions
-
8/14/2019 Crash Course on RCA Training Rev 01
7/26
13
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Module 1
Digging for the Root Causes
14
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Module 1 Table of Contents
Histograms and Pareto Chart
Cause and Effect Diagram
What it is
How to use it
Examples
Summary
MODULE 1 MODULE 2 APPLICATION
http://c/Users/user/Desktop/Reference%20for%20RCA/Coffee%20Break.pptx -
8/14/2019 Crash Course on RCA Training Rev 01
8/26
15
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Histograms- What it is
A chart that graphically display thedistribution of a set of data.
16
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Pareto Chart - What it is
It reveals that asmall number ofNCNs areresponsible for thebulk of quality
issues,
a phenomenoncalled the ParetoPrinciple.
A Pareto chart allows data to be displayed as a bar chartand enables the main contributors to a problem to behighlighted.
-
8/14/2019 Crash Course on RCA Training Rev 01
9/26
17
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Pareto Chart How to create it
1. Gather facts about the problem
2. Rank the contributions to the problem in orderof frequency.
18
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Pareto Chart How to create it(contn)
3. Draw the value as a bar chart.
5. Review the chart
6. Redefine classifications if necessary.
4. add a line showing the cumulativepercentage of errors
-
8/14/2019 Crash Course on RCA Training Rev 01
10/26
19
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Chart 1 : The chart gives summary information and starts the cumulative % count atthe top of the first bar:
CmptD
amage
d
Compon
entFaulty
CmptM
issing
Wrong
Comp.F
itted
Cmptn
otMeet
Elect.
Spec.
Deform
edJoin
t
Jointsn
otSolde
red
CmptT
ouching
Heatplane
Compon
entMis
fitted
Legsn
otthro
ughBo
ard
LongL
eads
LinkWireM
issfitted
Beyond
Econo
micRe
pair
Precau
tionary
Remov
al
Thiokol
Problem
Solder
Short
Faulty
Connec
tor
Contam
ination
Others
141 139 69 52 22 20 20 17 17 17 16 13 10 10 10 8 6 5 29
23 22 11 8 4 3 3 3 3 3 3 2 2 2 2 1 1 1 5
23 45 56 65 68 71 75 77 80 83 85 87 89 91 92 94 95 95 100
0
100
200
300
400
500
600
0
20
40
60
80
100
DefectCount
PercentCum %
Percent
Pareto of D3 Small Engine Card Faults
Pareto Analysis Example
20
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Example 2: a series of Pareto charts drill down to more detail:
Desig
nCo
mpon
ent
Build
Other
57 13 4 2
75.0 17.1 5.3 2.6
75.0 92.1 97.4 100.0
0
10
20
30
40
50
60
70
0
20
40
60
80
100
Defect
CountPercentCum %
Percent
Fault by Main Cause
ConnectM
odule
Torqu
eMoto
rs
ColdS
tart
TransducerM
odule
ASIC
Calib
ration
IOP Imon
21 10 8 8 5 3 2
36.8 17.5 14.0 14.0 8.8 5.3 3.5
36.8 54.4 68.4 82.5 91.2 96.5 100.0
0
10
20
30
40
50
0
20
40
60
80
100
Defect
CountPercent
Cum %
Percent
Design Faults
1st level Analysisgives Designas main cause offailure
2nd level Analysis givesbreakdown of Design
Pareto Analysis Example
-
8/14/2019 Crash Course on RCA Training Rev 01
11/26
21
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Example 3: if the original Pareto is very flat, be prepared to cut the defects in adifferent way, here, it is 40:60
KDCC
788
KDCC
646
KDCC
777
KDCC
780
KDCC
782
KDCC
795
40-56
4-8116-1
0
40-66
6-7823
40-56
4-727
4-47E
Othe
rs
18 13 11 11 11 10 9 9 8 138
7.6 5.5 4.6 4.6 4.6 4.2 3.8 3.8 3.4 58.0
7.6 13.0 17.6 22.3 26.9 31.1 34.9 38.7 42.0 100.0
0
100
200
0
20
40
60
80
100
Defect
CountPercent
Cum %
Percent
Pareto Chart for Child11
Pareto Analysis Example
22
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
How it helps
Pareto Analysis is a useful tool to:
identify and prioritize major problem areas based on frequency ofoccurrence;
separate the vital few from the useful many things to do;
identify major causes and effects.
The technique is often used in conjunction with Brainstorming and Cause andEffect Analysis.
HINT !The most frequent is not
always the most important! Beaware of the impact of other
causes on Customers or goals.
Pareto Analysis Example
-
8/14/2019 Crash Course on RCA Training Rev 01
12/26
23
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Summary
Pareto Charts provide a vi sual representation ofthe variables which contribute to problems orissues.
Pareto Charts can be used as a prioritization toolto aid in focusing on the top issues whichcontribute to specific conditions.
Pareto analysis is an approach which ranks thecontributing factors and identifies which are theones which have the most impact on a problem or
issue. Often referred to as an approach forseparating the vital few from the trivial many,sometimes referred to as the 80-20 rule
Process StepsA method for showing the distribution ofquantitative data and identifying thosewith the greatest impact.
Identify the problem and the potentialdirect or contributing causes
Develop Corrective Action orImprovement Action Plans for those
identified as the Vital Few
Identify the Vital Few (those with thehighest number of occurrences)
Construct the Pareto Chart:Causes on Horizontal Axis
Frequency of events on Vertical Axis
Collect data about each of the potentialdirect or contributing causes
Pareto
Pareto Chart and Analysis
24
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
CAUSE AND EFFECT
Ishikawa/Fish Bone Diagram
Problem
PeopleProcedures
Equipment Materials
-
8/14/2019 Crash Course on RCA Training Rev 01
13/26
25
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Cause and Effect
Cause and Effect Analysis is a tool foridentifying all the possible causes associatedwith a particular problem
Valuable for:
Focusing on causes not symptoms
Providing a picture of why an effect is happening
Establishing a sound basis for further data gathering
and action
Identifying all of the areas that need to be tackledto generate a positive effect
26
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Cause and Effect Sources of Variation
Sources of Variation is categorized asfollows
1. People
2. Method
3. Machine
4. Material5. Environment
6. Measuring System
-
8/14/2019 Crash Course on RCA Training Rev 01
14/26
27
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
How to do it
1. Identify the Problem/Issue
2. Brainstorm
3. Draw fishbone diagram
Place the effect at the head of the fish
Include the 6 recommended categories shown below
Problem orIssue
Method Machine
E nvi ronment M easur ement S yst em
People
Material
28
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
How to do it (contn)
4. Align Outputs with Cause Categories
5. Allocate Causes
6. Analyze for Root Causes
7. Test for Reality
Tip !The 6 categories recommended will address almost all scenarios. However, there is noone perfect set of categories. You may need to adapt to suit the issue being analyzed.
-
8/14/2019 Crash Course on RCA Training Rev 01
15/26
29
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Sources of Variation - People
People
The activities of the workers.
Variations caused by skill, knowledge,competency and attitude
30
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Sources of Variation - Method
Method
The methods used to produce theproducts.
Variations caused by inappropriatemethods or processes.
-
8/14/2019 Crash Course on RCA Training Rev 01
16/26
31
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Sources of Variation - Machine
Machine
The equipment used to produce theproducts.
Variations caused by temperature,tool wear and vibration.
32
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Sources of Variation - Material
Material
The "ingredients" of a process.
Variations caused by materials thatdiffer by industry, productand stage of production.
-
8/14/2019 Crash Course on RCA Training Rev 01
17/26
33
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Sources of Variation - Environment
Environment
The methods used to control theenvironment.
Variations caused by temperaturechanges, humidity etc.
34
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Sources of Variation Measurement System
Measurement System
The methods and instruments used toevaluate products.
Variations caused by measuring
techniques, or calibration andmaintenance of the instruments.
-
8/14/2019 Crash Course on RCA Training Rev 01
18/26
35
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Cause and Effect Analysis Example
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 0 09.01.09
Jumping to conclusion
Failure to define problem
Failure to find the root cause
Weak problem solving
No execution of corrective action
PROBLEM SOLVING FAILURE
-
8/14/2019 Crash Course on RCA Training Rev 01
19/26
37
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
- Problem is clearly defined.- Problem is accepted- As an opportunity/challenge to improve- True root cause is found- Implemented an effective and
irreversible corrective and preventiveaction
- Problem did not re-occur
PROBLEM SOLVING SUCCESS
38
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Summary
The development of the cause and effectFishbone diagram is credited to KaoruIshikawa, who pioneered quality managementprocesses in the Kawasaki shipyards.
The cause and effect diagram is used toexplore potential causes (or inputs) thatresult in a single undesirable effect (UDE, oroutput). Causes are categorized under sixheadings, namely Machinery, Methods,
Measurement, Manpower, Materials, andEnvironment. Potential causes can bearranged according to their level ofimportance or detail, resulting in a depictionof relationships and hierarchy of events. It isthe hierarchy that creates a map that lookssomewhat like fish bones, hence the name.The Ishikawa Fishbone Diagram is intendedhelp you brainstorm and search for potentialroot causes or identify areas where there maybe problems by questioning the existence ofcauses under each of the six categories.
Ishikawa Fishbone Template
UDE
MaterialsMaterialsManpowerManpower
MachineryMachineryMethodsMethodsMeasurementMeasurement
EnvironmentEnvironment
Causes, inputs,or sources
of variation
A UDE is an UnDesireable Effect
Cause and Effect Diagram (Ishikawa)
A visual brainstorming tool used to help identify and categorize potential root causes namedfor Kaoru Ishikawa.
-
8/14/2019 Crash Course on RCA Training Rev 01
20/26
39
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
$$$
Action Reflection
Wait! I think I missedsomething
It isnt that theycannot see thesolution,
Its that they cant see
the problem.
40
TAI KI SHA P HI LI PP INE S, I NC OP EN CH AL LE NGE QUI CK RE SP ONS E
CA/PA BASIC TOOLS Rev 01 10.08.09
Created by:
Sid CalayagLead Auditor forTaikisha Phils., Inc Quality ManagementSystem
Presented by: Sid Calayag
-
8/14/2019 Crash Course on RCA Training Rev 01
21/26
7
TA I K IS H A P H IL I P P IN E S , I N C O P E N C H A L L E N G E Q U I C K R E S P O N S E
CA/PA BASIC TOOLS Rev 0 09.01.09
Summary
Pareto Charts provide a visual representation of
the variables which contribute to problems or
issues.
Pareto Charts can be used as a prioritization tool
to aid in focusing on the top issues which
contribute to specific conditions.
Pareto analysis is an approach which ranks the
contributing factors and identifies which are the
ones which have the most impact on a problem or
issue. Often referred to as an approach for
separating the vital few from the trivial many,
sometimes referred to as the 80-20 rule
Process StepsA method for showing the distribution ofquantitative data and identifying those
with the greatest impact. Identify the problem and the potentialdirect or contributing causes
Develop Corrective Action orImprovement Action Plans for those
identified as the Vital Few
Identify the Vital Few (those with thehighest number of occurrences)
Construct the Pareto Chart:Causes on Horizontal Axis
Frequency of events on Vertical Axis
Collect data about each of the potentialdirect or contributing causes
Pareto
Pareto Chart and Analysis
-
8/14/2019 Crash Course on RCA Training Rev 01
22/26
0
TA I K IS H A P H IL I P P IN E S , I N C O P E N C H A L L E N G E Q U I C K R E S P O N S E
CA/PA BASIC TOOLS Rev 0 09.01.09
Summary
The development of the cause and effectFishbone diagram is credited to KaoruIshikawa, who pioneered quality managementprocesses in the Kawasaki shipyards.
The cause and effect diagram is used toexplore potential causes (or inputs) thatresult in a single undesirable effect (UDE, oroutput). Causes are categorized under sixheadings, namely Machinery, Methods,Measurement, Manpower, Materials, andEnvironment. Potential causes can bearranged according to their level of
importance or detail, resulting in a depictionof relationships and hierarchy of events. It isthe hierarchy that creates a map that lookssomewhat like fish bones, hence the name.The Ishikawa Fishbone Diagram is intendedhelp you brainstorm and search for potentialroot causes or identify areas where there maybe problems by questioning the existence ofcauses under each of the six categories.
Ishikawa Fishbone Template
UDE
MaterialsMaterialsManpowerManpower
MachineryMachineryMethodsMethodsMeasurementMeasurement
EnvironmentEnvironment
Causes, inputs,or sourcesof variation
A UDE is an UnDesireable Effect
Cause and Effect Diagram (Ishikawa)
A visual brainstorming tool used to help identify and categorize potential root causes namedfor Kaoru Ishikawa.
-
8/14/2019 Crash Course on RCA Training Rev 01
23/26
OTES
-
8/14/2019 Crash Course on RCA Training Rev 01
24/26
OTES
-
8/14/2019 Crash Course on RCA Training Rev 01
25/26
OTES
-
8/14/2019 Crash Course on RCA Training Rev 01
26/26
Date:
Name of Attendee: _________________________Course Title: ROOT CAUSE ANALYSIS TRAINING
Trainer: SID CALAYAG
Training Evaluation Form
My comments and suggestions in this orientation/training are:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_______________________________ OVERALL EVALUATION: _____________Signature
TAIKISHA PHILIPPINES, INC
The trainer knew the material well enough to teach this course.
The trainer is well prepared.
The trainer keep the class discussions focused on the training orientation content.
The orientation gave me information that will help me perform my job safer.
I found the training workshop is applicable in my job assignment.
The trainer presented useful summaries and to be understood to me better..
The trainer provided enough questions and answers opportunities.
The trainer provided visuals that are very helpful in my training
The quality of the handout is ____________. (Poor, Fair, Good)
This orientation is timely for the organizations current situation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
POOR FAIR GOOD
CRASH-COURSE
OCT 09, 2009