QUALITY MANAGEMENT

ROOT CAUSE ANALYSIS

By: Sid Calayag

Date: September 11, 2009
 Training Description

Root Cause Analysis training is consist of

lectures and practices (application) that
provide participants with a practical
understanding of how to do an analysis in
identifying the root cause of a problem.
This presentation has two modules. The
second module is deleted from this
presentation.
The hands-on training exercises and
samples were also excluded in this
presentation.
 Presentation set-up

Module 1 will guide participants in the creation

and use of histograms, Pareto chart and
Fishbone diagram.

Module 2 will guide participants in the process of

creating a good 8 – D Report

Application Section is part of both modules,

however, it will require knowledge gained in
Module 2 to apply advance application such
as the 8 – D Report.
 Objectives

Module 1:
Participants will learn how to:
• Create and use Pareto chart in the
analysis of a problem
• Implement steps for carrying out
effective RCA
• Select and apply tools that support
RCA
Objectives

Module 2:
Participants will be able to:
• Define and explain the 8 – D as a
Problem Solving Method
• Apply the 8 Disciplines and
Concepts
 HOME PAGE

• INTRODUCTION

• MODULE 1

• MODULE 2

• APPLICATION
 INTRODUCTION
To
ROOT CAUSE ANALYSIS
 Introduction

Introduction MODULE 1 MODULE 2

 Definition of Terms
 What it is
 Why use it
 RCA Process
 How to use it
 Terms and Definition

Cause (causal factor) - a condition or event that results

in an effect
Direct Cause - cause that directly resulted in the
occurrence
Contributing Cause - a cause that contributed to the
occurrence, but by itself would not have caused the
occurrence
Root Cause - cause that, if corrected, would prevent
recurrence of a non-conformity and similar
occurrences
 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

 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
 Module 1
Digging for the Root Causes
 Module 1 Table of Contents

MODULE 1 MODULE 2 APPLICATION

 Histograms and Pareto Chart

 Cause and Effect Diagram
 What it is
 How to use it
 Examples
 Summary
 Histograms- What it is

• A chart that graphically display the

distribution of a set of data.
 Pareto Chart - What it is

A Pareto chart allows data to be displayed as a bar chart

and enables the main contributors to a problem to be
highlighted.

It reveals that a
small number of
NCNs are
responsible for the
bulk of quality
issues,

a phenomenon
called the „Pareto
Principle‟.
 Pareto Chart – How to create it

1. Gather facts about the problem

2. Rank the contributions to the problem in order
of frequency.
 Pareto Chart – How to create it
(cont’n)

3. Draw the value as a bar chart.

4. add a line showing the cumulative
percentage of errors

5. Review the chart

6. Redefine classifications if necessary.
 Pareto Analysis Example

• Chart 1 : The chart gives summary information and starts the cumulative % count at
the top of the first bar:

Pareto of D3 Small Engine Card Faults

600 100

500 80

400

Percent
60
Count

300
40
200
20
100
ec . ne ir
t. Sp pla ar d epa v al
y Etlteecd H
r eedat ittegdh Bo m
te d R Remo
ic r
lt t i ge f oit
0 d a u ee. F t
nhoinld isr o u on
s f r y em c to 0
angeent
F mgp
toiM
n t ciS
Juo not tMth Mscis tiona
E obl rnt ne ion
am t niso
Cs e
ptst
d
T
n o
o
peogsn en n
ir d
e
a d u Pr h
Coo inat
t oDmpo
pC C m
r
p optnM g
fCo
o rinm
m o mL iB
ne
k
ngyWoLe ec a
P r iokol lda
S
eurlty ntam er s
m CWm D J e C h SoF o
C L
Lo T C Oth
Defect
Count 141 139 69 52 22 20 20 17 17 17 16 13 10 10 10 8 6 5 29
Percent 23 22 11 8 4 3 3 3 3 3 3 2 2 2 2 1 1 1 5
Cum % 23 45 56 65 68 71 75 77 80 83 85 87 89 91 92 94 95 95 100

* This is a sample output from Minitab Statistical Software

 Pareto Analysis Example

• Example 2 : a series of Pareto charts drill down to more detail:

Fault by Main Cause

100
70 1st level Analysis
gives “Design”
60 80

50

Percent
60
Count

40 as main cause of
30 40

20 failure
20
10

0
ign pon
ent
er
0
2nd level Analysis gives
Des Com Buil
d

breakdown of “Design”
Oth
Defect
Count 57 13 4 2
Percent 75.0 17.1 5.3 2.6
Cum % 75.0 92.1 97.4 100.0

Design Faults

100
50
80
40

Percent
60
Count

30
40
20

10 20

le
0 dule rs odu on 0
rM r ati
t Mo Moto rt uc e alib
nec que Sta r ans d IC C n
Con Tor Cold T AS IOP Imo
Defect
Count 21 10 8 8 5 3 2
Percent 36.8 17.5 14.0 14.0 8.8 5.3 3.5
Cum % 36.8 54.4 68.4 82.5 91.2 96.5 100.0

* This is a sample output from Minitab Statistical Software

 Pareto Analysis Example

• Example 3 : if the original Pareto is very flat, be prepared to cut the defects in a
different way, here, it is 40:60

Pareto Chart for Child11

100

200
80

Percent
60
Count

100 40

20

0 6- 1
0 47E 0
3 74-
- 811 - 782 64- 72
788 646 777 780 782 795 64 6
66 40- 5 er s
CC CC CC CC CC CC 40- 5 40-
KD KD KD KD KD KD Oth
Defect
Count 18 13 11 11 11 10 9 9 8 138
Percent 7.6 5.5 4.6 4.6 4.6 4.2 3.8 3.8 3.4 58.0
Cum % 7.6 13.0 17.6 22.3 26.9 31.1 34.9 38.7 42.0 100.0

* This is a sample output from Minitab Statistical Software

 Pareto Analysis Example

How it helps
Pareto Analysis is a useful tool to:

• identify and prioritize major problem areas based on frequency of

occurrence;

• 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 and
Effect Analysis.

HINT !
The most frequent is not
always the most important! Be
aware of the impact of other
causes on Customers or goals.
 Pareto Chart and Analysis

A method for showing the distribution of Process Steps

quantitative data and identifying those Pareto

with the greatest impact.

Identify the problem and the potential

Summary
direct or contributing causes

Pareto Charts provide a visual representation of

the variables which contribute to problems or Collect data about each of the potential
direct or contributing causes
issues.

Pareto Charts can be used as a prioritization tool

to aid in focusing on the top issues which
Construct the Pareto Chart:
Causes on Horizontal Axis

contribute to specific conditions.

Frequency of events on Vertical Axis

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”
Identify the Vital Few (those with the
highest number of occurrences)
Develop Corrective Action or
Improvement Action Plans for those
identified as the Vital Few
 Coffee Break

15 Minutes Break Only


 CAUSE AND EFFECT
Ishikawa/Fish Bone Diagram
Procedures People

Problem

Equipment Materials
 Cause and Effect

• Cause and Effect Analysis is a tool for

identifying all the possible causes associated
with 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 tackled
to generate a positive effect
Cause and Effect Sources of Variation

Sources of Variation is categorized as

follows
1. People
2. Method
3. Machine
4. Material
5. Environment
6. Measuring System
 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

People Method Machine

Problem or
Issue

Material Environment Measurement System

 How to do it (cont’n)

• 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 no
one perfect set of categories. You may need to adapt to suit the issue being analyzed.
 Sources of Variation - People

People
• The activities of the workers.
• Variations caused by skill, knowledge,
competency and attitude
 Sources of Variation - Method

Method
• The methods used to produce the
products.
• Variations caused by inappropriate
methods or processes.
 Sources of Variation - Machine

Machine
• The equipment used to produce the
products.
• Variations caused by temperature,
tool wear and vibration.
 Sources of Variation - Material

Material
• The "ingredients" of a process.
• Variations caused by materials that
differ by industry, product
and stage of production.
 Sources of Variation - Environment

Environment
• The methods used to control the
environment.
• Variations caused by temperature
changes, humidity etc.
 Sources of Variation – Measurement System

Measurement System
• The methods and instruments used to
evaluate products.
• Variations caused by measuring
techniques, or calibration and
maintenance of the instruments.
Cause and Effect Analysis Example
 Cause and Effect Diagram (Ishikawa)

A visual brainstorming tool used to help identify and categorize potential root causes named
for Kaoru Ishikawa.

Ishikawa Fishbone Template

Summary
The development of the cause and effect
Fishbone diagram is credited to Kaoru
Ishikawa, who pioneered quality management
processes in the Kawasaki shipyards. Measurement
Measurement Methods
Methods Machinery
Machinery

The cause and effect diagram is used to

explore potential causes (or inputs) that
result in a single undesirable effect (UDE, or
output). Causes are categorized under six UDE
headings, namely Machinery, Methods, Causes, inputs,
or sources
Measurement, Manpower, Materials, and of variation
Environment. Potential causes can be
arranged according to their level of
importance or detail, resulting in a depiction
of relationships and hierarchy of events. It is Manpower
Manpower Materials
Materials Environment
Environment
the hierarchy that creates a map that looks
somewhat like fish bones, hence the name.
The Ishikawa Fishbone Diagram is intended
help you brainstorm and search for potential
root causes or identify areas where there may A UDE is an UnDesireable Effect
be problems by questioning the existence of
causes under each of the six categories.
Module 2
APPLICATION
 Application Table of Contents

MODULE 1 MODULE 2 APPLICATION

 ISO 9001:2000 CA/PA & IQA Report

 Eight Discipline
 What it is
 How to use it
 Examples
 Summary
 Different Action to Improve Performance

Corrective - the action taken to eliminate the

cause of a detected non-conformity
(and prevent its recurrence.)
Preventive – the action taken to eliminate the
cause of a potential non-
conformity and to prevent its
occurrence.

After
Before
Action 2

Action 1
Time
 Different Action to Improve Performance

Continual Improvement

Breakthrough
P
e Continual
r
f
o
r
m
a Continuous
n
c
e

TIME
Corrective Action

Steps to Complete
Document plan for implementing C/A

Implement Containment Action

Implement the Corrective Actions

Remove the Containment Actions

Verify the Corrective Actions Overtime

 V- Verify Corrective Actions

Your Guide in verification

1. Are SOLUTIONS and not PATCHES
2. Are Doable and Time-bounded
3. Will not introduce a new problem or effect

Verify Effectiveness
 3 Steps in Verifying Effectiveness

1. The “after” condition eliminates the

problem.
2. There is a difference between the
“before” and “after” condition.
3. The “after” condition does not create
another effect
 PROBLEM SOLVING FAILURE

• Jumping to conclusion
• Failure to define problem
• Failure to find the root cause
• Weak problem solving
• No execution of corrective action
 PROBLEM SOLVING SUCCESS

- 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 preventive
action
- - Problem did not re-occur
Action Reflection
PROBLEM SOLVING SUCCESS

- Which principle or
technique will I apply
$$$when I get
right away
back to work?
 Your Guide to Conformance

• Say what you do

– Document the system
• Do what you say
– Implement the system
• Prove it
– Demonstrate implementation

Use our Standard Form

PREVENTIVE ACTION
 PA INITIATIVES
The PA initiative may be derived from sources such
as:

• Lessons learned USING BENCHMARKING

• Lessons learned from any other performance

issues.

• Review of preventive/predictive maintenance

data records.

• Analysis of defect trends and outlier fallouts.

• Lessons learned from actual field failures and

customer COMPLAINTS
 Preventive Action Process Flow

1. Identify an Opportunity/Initiative based on gathered

information,
-define the success criteria
Defects Day1 Day2 Day3 Day4 Day5 Day6

Bent Lead 3 0 2 2 9 4

Control Chart Damaged

Leads
2

0
0 4

9
2

0
5

2
1

Joggled 0 7
Leads
Wrong 4 3 15 0 1 2
symbol
Mixed device 5 5 5 8 7 0
15

Chipped 0 5 0 9 1 1
package

Scrap Rework Illegible

symbol
2 0 3 2 0 1

10

Check Sheets
5

0
21

1 3 5 7 9 11 13 15 17
19 23 25 27 29 31 33 35 37 39 41 43 45

Histogram

Pareto Diagram
Scatter Diagrams
 Preventive Action Process Flow
2. Identify an Opportunity based on gathered information
- Root cause Analysis considers the potential problem and its
future risk
- Use error-proofing actions whenever possible
- Consider resource needs and costs

3. Identify and Implement Preventive Actions

- Verify effectiveness of PA
- Document actions into specs, Engineering designs etc.
- Confirm that the success criteria was met
- did the performance metric improve?
- plan to fan-out- create the implementation timeline/roadmap
chart
 SUMMARY
Symptom Problem (Is & Is Not) Containment

What ?
Where ?
When ?
How Big ?
X
Preventive Actions Corrective Actions Root Cause
What about ... Occur Cause Escape Cause

Occur Cause Escape Cause

Created by:
Sid Calayag – Lead Auditor for
Taikisha Phils., Inc Quality Management
System
Presented by: Sid Calayag

“Sorry I don’t accept donation”

“I only did it for the love of my company”

But CASH is still acceptable if you will

not tell anybody about it …”

By: Anonymous
End of Presentation