root cause analysis1279

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Successful Corrective ActionThrough Effective ProblemSolving

IT470a Six Sigma Green Belt-ISummer 2009

Reference Material #2

Ken White


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Course Objectives

Understand the basic structure of theC/PA Process

Understand how to define a problem toallow a solution

Review of basic root cause analysistools

Understand the importance of trackingand completing C/PA Steps


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#1 - Describe the Problem

#2 - Determine the RootCause

#3 Determine C/PA Steps

#4 - Verification

#5 - Conclusion

Date Issued:

KNAM Quality CPA Number: (Sector ID/Originator Initials/No. assigned)

Corrective Action Preventive Action

Sect ion A: Incident Summary

1. Title:

2. Failure of KNAM Requirements:

QPE (List reference)

QCMS (list section)

OTHER(describe)

3. Description of the nonconformity:

Date of incident:

Describe the issue:

Who identified the issue?

Where was the issue identified?

What are the consequences?

Location:

Other circumstances thatpotentially contributed to the issue

4. Root Cause (5 WHYS):

Sect ion B: Plant ident i f ied CPA or Corporate dr iven Act iv i t iesDescribe the actions to be taken, assigned responsibilities and target completion dates

1. Action Steps:

PLAN DO

What Who Target Completion Date Date completed

CHECK ACT

2. Verification: Details must include description of evidence reviewed such as type of data, observation,titles and data range of records reviewed

3. Conclusion:Effective Not Effective

If not effective, explain:

Verification Completed By: Date:


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Problem Description

If we do not define theproblem correctly, we willnever be able to solve the

problem --- PERMANENTLY


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SymptomsAny circumstance, event or condition that

accompanies something and indicates itsevidence or occurrence; a sign

Examples of symptoms:

Procedures are not followed

Operator error

Incomplete information Ensure you break through symptoms by asking

WHYS


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Problem Description Must be clearly defined

Define in terms ofWHAT, WHERE,WHEN, WHO, HOW MUCH, and theCONSEQUENCES

Example:

At 9:07 p.m., mixer operator found 2x 4metal piece in mix tank #5. The cook process

was stopped immediatelybatch #1-8 were put

on hold.


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Problem Description

Common mistakes Defining the problem and the solution at the

same time The lot tags were not found on the pallet and the

supervisor has shown the operator the correctlocation for placement.

Defining a symptom as the problem The operator was confused on how to place the

label on the pallet. Defining the problem without data to support

definition. The case operator works slowly.


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Problem Description

Avoid mistakes

State WHAT is wrong, not WHY its wrong

Define the gap between what is expectedand what is actually happening

As new information/data becomes available

review and update the problem description asnecessary.


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Step #2

Determining the Root CauseWhat is a root cause?

The single, verifiable reasonfor the problem, which if

corrected prevents itsrecurrence.


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Problem Solving Tools

Brainstorming

The act of defining a problem or

idea and coming up withanything related to the topic

no matter how remote asuggestion may sound.


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BrainstormingHow to Facilitate

Assign a scribe set a time limit

Ask each member to contribute an idea or suggestion

Allow no positive or negative comments about the

suggestions, at this point Record all possible causes or sources of a problem

Evaluate the responses as a group discussion

Look for answers that are repeated or similar

Group like-concepts together Eliminate responses that definitely do not fit

Decide which cause to attack first, by voting


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5 Whys Helps to identify the relationship between

causes

Forces you to drill down the symptomsProblem Cause

Cause

Cause

Why?Why?

Why?

Why?

Why?

Cause

ROOT


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5-WhysHow to facilitate

Write down the specific problem

Ask Whythe problem happens and write the answerdown below the problem

If the answer you just provided doesn't identify the rootcause of the problem that you wrote down in step 1, askWhy again and write that answer down

Loop back to previous step until the team is in

agreement that the problem's root cause is identified. May take fewer or more times than five Whys.

Please note that the 5 WHYs make take the groupdown multiple pathsand thats OK.


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5 Whys

Check Sheet

Pareto Chart

Time Line

Fishbone


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Check Sheets

For Collecting data and is Useful whendata is needed to determinefrequency, patterns, defects by typeor location


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Check Sheet

Operators Name(s)For week of:

How Many times did it happen Total

IIII IIII IIII IIII II

IIII IIII IIII IIIII IIII III

IIII IIII IIII IIII IIII II

IIII IIII II

IIII IIII IIIIII IIII I

IIII IIr o n g l ab e l

N o s ea lC o n t a i n e r m i s s i n gC o d e s m i ss in gC a n ' t r e a d p r i n t er

Packaging Issue

W r a p w a s lo o s eN o l a b e lsB u b b l e s


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Pareto Chart

27

22

16

13 12 1211

7

0

5

10

15

20

25

30

No Seal Loose Wrap No Labels Bubbled No container Missing Code

Dates

Unreadable

print

Wrong Label

Packaging Defects

Count

Working on top of your causes may help 2/3 ofthe problems go away!

65%


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Develop a Time Line Provides a clear picture for

understanding the incident and howit evolved

Record known changes

Must be specific with verifiable facts


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Time Line ExamplePackage Defects (rejects) have suddenly increased

Jan. 1st March 1st

Average Line Speed 500 packages per minute Average Line Speed 600 packages per minute

Feb. 1st

Reject Rate 3% Reject Rate 10%

1/2

Running 1

shift with

experienced

employees

1/4

Hired 30 new

employees

1/5

Trained new

employees

1/10

Started 2nd

shift

operation

1/20

16 hour

equipment

PM

completed

2/3

Implemented

new

packagingmaterial

2/5

Increased

line speed

2/10

10 more new

employees

more training

View CheckSheet


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Cause and Effect DiagramAlso referred to as fishbonediagram

Useful for organizing large amountsof information about a problem

Most effective when done as a

team with individuals who areknowledgeable of the overallprocess


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C & E DiagramAs a group, identify what the major

categories of causes are to the process.

Most common:

- People

- Materials

- Equipment

- Environment

- Methods

- Measurement


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C & E Diagram

Problem

Product placed on hold due touneven distribution of fruit topping.This caused uncontrollable weights

and below standard appearance offinished product


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C & E Diagram

UNEVEN FRUITAPPLICATION ON

PRODUCT

ENVIRONMENT

METHODSPEOPLE

MATERIALS

EQUIPMENT

TemporaryPosition

Excessivedowntime

Scaleerrors

Room Temperature

Temperature

Tote size

Excessivewaste

Poor Inspections

Overloading hopper

Tote size


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Prioritizing Activities

EASY DIFFICULT

HIGH

LOW

DIFFICULTY

I

M

PA

C

T

1 3

2 4


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Step #3

C/PA StepsWell defined steps

Can be the difference between a successfulresolution or one that falls short ofpreventing recurrence


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C/PA Steps

The process: Formalize and capture the activities that

need to take place Clearly identify:

WHO is going to do WHAT by WHEN

Use an Action Register to track activities


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C/PA Steps

Monitor the status of the activities

Continually update action register (addingnew tasks, completion dates)

Add as a standard agenda item indepartment meetings, management review

Maintain action register as part of the

C/PA Program


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Step #4Verification

Verification needs to be supported by evidence :

Type of data What was reviewed (charts, observation, records)

Observations Titles and data range

Records reviewed

Who was interviewed

Summary of overall findings


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Step #5Conclusion

Confirms the solution - has fixed theproblem so it doesnt come back

Confirms that the system change is

effective Process

People

May need additional long-termmonitoring Incorporate as an internal audit check point


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Questions


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Additional ResourcesReferences Correct! Prevent! Improve! ASQ (American

Society of Quality) publication The Root Cause Handbook Max Ammerman The Basics of FMEA (Failure Mode and Effect

Analysis) McDermott, Mikulak, Beauregard.Focus is on machinery and safety

Courses Problem Solving and Decision Making

Problem Solving and Decision-Making: A Course in Critical Thinking Skills
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