Project Delay

8/11/2019 Project Delay

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1Determining Root Cause 1

Determining the RootCause of a Problem

Approved for Public Release


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Why Determine Root Cause?

Prevent problems from recurring

Reduce possible injury to personnel

Reduce rework and scrap

Increase competitiveness

Promote happy customers and stockholders

Ultimately, reduce cost and save money



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Often the Stated Root Cause

is the Quick, but Incorrect Answer

For example, a normal response is:

Equipment Failure

Human Error

Initial response is usually the symptom, notthe root cause of the problem. This is whyRoot Cause Analysis is a very useful andproductive tool.



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What is Root Cause Analysis?

Root Cause Analysis is an in-depth

process or technique for identifying the

most basicfactor(s) underlying avariation in performance (problem).

Focus is on systems and processes Focus is not on individuals



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When Should Root Cause

Analysis be Performed? Significant or consequential events

Repetitive human errors are occurringduring a specific process

Repetitive equipment failures associatedwith a specific process

Performance is generally below desired

standard May be SCAR or CPAR (NGNN) driven

Repetitive VIRs



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How to Determine the Real

Root Cause? Assign the task to a person (team if necessary)

knowledgeable of the systems and processes involved

Define the problem

Collect and analyze facts and data

Develop theories and possible causes - there may bemultiple causes that are interrelated

Systematically reduce the possible theories and possiblecauses using the facts



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How to Determine the Real

Root Cause? (continued) Develop possible solutions

Define and implement an action plan (e.g., improvecommunication, revise processes or procedures or work

instructions, perform additional training, etc.)

Monitor and assess results of the action plan forappropriateness and effectiveness

Repeat analysis if problem persists- if it persists, did weget to the root cause?



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Useful Tools For

Determining Root Cause are: The 5 Whys

Pareto Analysis (Vital Few, Trivial Many)

Brainstorming

Flow Charts / Process Mapping Cause and Effect Diagram

Tree Diagram

Benchmarking (after Root Cause is found)

Some tools are more complex than others



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Example of Five Whys for Root

Cause Analysis

Problem - Flat Tire

Why? Nails on garage floor Why? Box of nails on shelf split open

Why? Box got wet

Why? Rain thru hole in garage roof Why? Roof shingles are missing



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Pareto Analysis

Count 14 14 11 9 7 7 3 3 3 3162 2 2 1 513934 20 19 19 15 15

Percent 3 3 2 2 1 1 1 1 1 132 0 0 0 127 7 4 4 4 3 3

Cum % 86 89 91 93 94 96 96 97 97 9832 98 99 991005966 70 74 78 80 83

Count

Defect

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ensio

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aging

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re

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anship

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180

160

140

120

100

80

60

40

20

0

Supplier Material Rejections May 06 to May 07

Vital Few

Trivial Many

60 % of

Material

Rejections



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Cause and Effect Diagram(Fishbone/Ishikawa Diagrams)

EFFECT

CAUSES (METHODS) EFFECT (RESULTS)

Four Ms Model

MAN/WOMAN METHODS

MATERIALS MACHINERY

OTHER



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Cause and Effect DiagramLoading My Computer

MAN/WOMAN METHODS

MATERIALS MACHINERY

OTHERCannot

Load

Softwar

e on PC

Inserted CD Wrong

Instructions are Wrong

Not Enough

Free Memory

Inadequate System

Graphics Card Incompatible

Hard Disk Crashed

Not Following

Instructions

Cannot Answer Prompt

Question

Brain Fade

CD Missing

Wrong Type CDBad CD

Power Interruption



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Tree Diagram

Result Cause/Result Cause/Result Cause

Result Primary

Causes

Secondary

CausesTertiary

Causes



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Tree Diagram

Poor SafetyPerformance

Stale/TiredApproaches

InappropriateBehaviors

Lack ofEmployeeAttention

Lack of Models/Benchmarks

No Outside Input

Research Not

Funded

No Money for ReferenceMaterials

No Funds forClasses

No Consequences

InfrequentInspections

InadequateTraining

No Publicity

Lack of Sr.Management Attention

No PerformanceReviews

No Special SubjectClasses

Lack of RegularSafety Meetings

Zero Written SafetyMessages

No Injury CostTracking

Result Cause/Result Cause/Result Cause



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Bench Marking

Benchmarking: What is it?

"... benchmarking ...[is] ...'the process of identifying, understanding, andadapting outstanding practices and processes from organizationsanywhere in the world to help your organization improve itsperformance.'"American Productivity & Quality Center

"... benchmarking ...[is]... an on-going outreach activity; the goal of theoutreach is identification of best operating practices that, whenimplemented, produce superior performance."Bogan and English, Benchmarking for Best Practices

Benchmark refers to a measure of best practice performance.Benchmarkingrefers to the search for the best practices that yields thebenchmark performance, with emphasis on how you can apply theprocessto achieve super ior resul ts.



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Bench Marking

All process improvement efforts require a soundmethodology and implementation, and benchmarkingis no different. You need to:

Identify benchmarking partners Select a benchmarking approach

Gather information (research, surveys, benchmarkingvisits)

Distill the learning Select ideas to implement

Pilot

Implement



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Common Errors of Root Cause

Looking for a single cause- often 2 or 3

which contribute and may be interacting

Ending analysis at a symptomatic cause Assigning as the cause of the problem the

why event that preceded the real cause



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Successful application of the

analysis and determination of

the Root Cause should result

in elimination of the problem

and create Happy Campers!



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Summary:

Why determine Root Cause? What Is Root Cause Analysis?

When Should Root Cause Analysis beperformed?

How to determine Root Cause Useful Tools to Determine Root Cause1. Five Whys

2. Pareto Analysis

3. Cause and Effect Diagram

4. Tree Diagram5. Brainstorming

Common Errors of Root Cause

Where can I learn more?



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Where Can I Learn More?

Solving a Problem & Getting Along: Toward the Effective Root CauseAnalysis, Khaimovich,1998.

The Quality Freeway, Goodman, 1990

Potential Failure Modes & Effects Analysis: A Business Perspective, Hatty

& Owens, 1994

In Search of Root Cause, Dew, 1991

Solving Chronic Quality Problems, Meyer, 1990

The Tools of Quality, Part II: Cause and Effect Diagrams, Sarazen, 1990

Root Cause Analysis: A Tool for Total Quality Management, Wilson, Dell &Anderson, 1993


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