root cause analysis
DESCRIPTION
Root Cause Analysis classTRANSCRIPT
Root Cause Analysis
Solving a ProblemOBJECTIVES:
- Methods for Using Data - Cause and Effect Analysis
Drilling Down to the Cause
What is Root Cause Analysis?
DEFINEMEASUREANALYZEIMPROVECONTROL
-Structured approach-To identify and change-To prevent recurrence-To identify Lessons to be learned-To achieve better consequences
Fixing the symptomsProblem Logged by Pilot Ground Crew Action• Left, inside, main tire almost needs replacement
• Almost replaced left, inside, main tire
• Something Loose in cockpit • Something tightened in cockpit• Evidence of leak on right main landing gear
• Evidence removed• #3 Engine missing • Engine found on wing after brief search• Noise coming from under the instrument
panel. Sounds like a midget with a hammer.
• Took hammer away from midget• DME volume set to more believable level
• DME Volume is unbelievably loud
Visualizing the Problem
Pareto Principle
80%
20%Loose wire
Oversized actuator pins
New
Operator T
raining
Dam
aged motor
Softw
are Issue
0
1
2
3
4
5
6
7
8
CAUSE AND EFFECT
Problem
Methods
Material
Manpower
Machine
Environment Pareto Chart
Example
Loose Wires
Methods
Material
Manpower
Machine
EnvironmentPareto Chart
Brainstorming
Investigate the Root CauseMethod of “throwing out” any possible idea that anyone on the team thinks could be the cause.
Guidelines:
• Record all ideas
• No Judgment (there are no “bad” ideas.
• Combine like ideas
• Rank in order of likelihood
Note: Say the first thing you think of.
Rules:
One thought at a time
Don’t interrupt
Don’t criticize
Don’t discuss / analyze
Build on ideas
Record the ideas
Collect as many ideas as you can
Brainstorming
Investigate the Root CauseMethod of “throwing out” any possible idea that anyone on the team thinks could be the cause.
Guidelines:
• Record all ideas
• No Judgment (there are no “bad” ideas.
• Combine like ideas
• Rank in order of likelihood
Note: Say the first thing you think of.
Rules:
One thought at a time
Don’t interrupt
Don’t criticize
Don’t discuss / analyze
Build on ideas
Record the ideas
Collect as many ideas as you can
Review Group Findings
Example
Loose Wires
Methods
Cause
Material
Manpower
Machine
Environment
Cause
CauseCause
CAUSE AND EFFECT5 Why Analysis
The Titanic: a simple example
April 8, 2023 15
The Titanic Sinks
EFFECT
CAUSE
Why did the Titanic sink?
April 8, 2023 16
The Titanic Sinks
Bulkheads Fill w/Water, ship
loses buoyancy
EFFECT
CAUSE
Why did the bulkheads fill with water?
April 8, 2023 17
The Titanic Sinks
Bulkheads Fill
w/Water, ship loses buoyancy
Seams of the ship open up
EFFECT
CAUSE
Why did the seams open up?
April 8, 2023 18
The Titanic Sinks
Bulkheads Fill w/Water,
ship loses buoyancy
Seams of the ship open up
Rivet Heads Shear
EFFECT
CAUSE
Why did the rivets shear?
April 8, 2023 19
The Titanic Sinks
Bulkheads Fill w/Water, ship loses buoyancy
Seams of the ship open up
Side Impacts Iceberg; shear force applied along side of
ship
Rivet Heads Shear
EFFECT
CAUSE
Why did the titanic hit the
iceberg?
April 8, 2023 20
The Titanic Sinks
Bulkheads Fill w/Water, ship loses buoyancy
Seams of the ship open up
Rivet Heads Shear
Side Impacts Iceberg; shear force applied along side of
shipEFFECT
CAUSESystemic Causes
Titanic sailing too fast for conditions
Captain ignores iceberg
warningsWhite Star pushes for record crossing
time
Dark & overcast conditions reduce
visibility
Lookouts See Iceberg too late; swerve to avoid
Applying the 5 WhysA Machine is leaking coolant
Why? Because the seal has broken
Why? Because the machine is overheating
Why? Because the air filter is clogged
Why? Because there isn’t a maintenance check
Why? Because a procedure wasn’t developed
Applying the 5 Whys to the Loose Wires scenario
Group Exercise
Applying the 5 Whys to the Loose Wires scenario
Group Exercise
Applying the 5 Whys to the Loose Wires scenario
Group Exercise
Review Group Findings
The Goal of 5 Why Analysis
In conclusion
Questions?
Questions?