Crash Course On RCA Training Rev 01

TA I K I S H A P H I L I P P I N E S , I N C OPEN CHALLENGE QUICK RESPONSE
QUALITY MANAGEMENT
ROOT CAUSE ANALYSIS
CA / PA BASIC TOOLS
Date: Oct 09, 2009

CA/PA BASIC TOOLS Rev 01 10.08.09
TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE
QUALITY MANAGEMENT
ROOT CAUSE ANALYSIS
CA / PA BASIC TOOLS
Date: Oct 09, 2009

For most of us, it's a lot easier to jump

to solutions, isn't it?
2
1
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
5
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
6
2
HOME PAGE
• INTRODUCTION
• MODULE 1
• MODULE 2
• APPLICATION
7
INTRODUCTION
8
3
Introduction
Introduction MODULE 1 MODULE 2
 Definition of Terms
 What it is
 Why use it
 RCA Process
 How to use it
9
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
10
4
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
11
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
12
5
Module 1
Digging for the Root Causes
13
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
14
6
Histograms- What it is
• A chart that graphically display the

distribution of a set of data.
15
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‟.
16
7
Pareto Chart – How to create it
1. Gather facts about the problem

2. Rank the contributions to the problem in order
of frequency.
17
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.
18
8
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 . e ir
Sp lan oar
d epa v al
c t. atp tedh B d R Remo
lty E ted
itle rHeed teic
0 dt Fau epe. tF ldge
tin is f itug osnfo
itm ry c to
r
0
e M g Juo Sho
t cin t Mthr o Mscis tiona ble
m
t ne n
g
moanen
t m
Csoin
niso dTnoo nsennot eadE
ired
n u Pr o hoorn atio
D ap pntMg m
rinpe
t
ts p
m g
o W
y o
L c a k ol r yS C ntamin
pt m
Cm Co
mot
mrp
C fC
DeJo
om Co Le
e
k
oBng Pr e Thio ldeult er s
CW Lin
L SoFa Co 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
19
• 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
gn pone
nt
0
2nd level Analysis gives
Desi Com Build
er
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
ule
0 ule or s Mod tion 0
Mod Mot t uc er libra
ec t ue Star ansd C Ca
Conn Torq Cold Tr A SI IOP Imon
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
20
9
• 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
E
0 10 - 47 0
16- 23 - 7274
- 81 - 78
788 646 777 780 782 795 64 666 40- 56
4
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
21
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.
22
10
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
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 Identify the Vital Few (those with the
highest number of occurrences)
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”, Develop Corrective Action or
sometimes referred to as the “80-20 rule” Improvement Action Plans for those
identified as the Vital Few
23
CAUSE AND EFFECT

Ishikawa/Fish Bone Diagram
Procedures People
Problem
Equipment Materials
24
11
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
25
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
26
12
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
27
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.
28
13
Sources of Variation - People
People
• The activities of the workers.
• Variations caused by skill, knowledge,
competency and attitude
29
Sources of Variation - Method
Method
• The methods used to produce the
products.
• Variations caused by inappropriate
methods or processes.
30
14
Sources of Variation - Machine
Machine
• The equipment used to produce the
products.
• Variations caused by temperature,
tool wear and vibration.
31
Sources of Variation - Material
Material
• The "ingredients" of a process.
• Variations caused by materials that
differ by industry, product
and stage of production.
32
15
Sources of Variation - Environment
Environment
• The methods used to control the
environment.
• Variations caused by temperature
changes, humidity etc.
33
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.
34
16
Cause and Effect Analysis Example
35
PROBLEM SOLVING FAILURE
• Jumping to conclusion
• Failure to define problem
• Failure to find the root cause
• Weak problem solving
• No execution of corrective action
17
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
37
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.
38
18
Action Reflection
Wait! I think I missed

$$$
something
It isn’t that they

cannot see the
solution,
It’s that they can’t see

the problem.
39
Created by:
Sid Calayag – Lead Auditor for
Taikisha Phils., Inc Quality Management
System
Presented by: Sid Calayag
40
19
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
Pareto Charts provide a visual representation of

the variables which contribute to problems or Collect data about each of the potential
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 Identify the Vital Few (those with the
highest number of occurrences)
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”, Develop Corrective Action or
sometimes referred to as the “80-20 rule” Improvement Action Plans for those
identified as the Vital Few
17

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.
30

NOTES
NOTES
NOTES
TAIKISHA PHILIPPINES, INC
Training Evaluation Form

Date: OCT 09, 2009
Name of Attendee: _________________________
Course Title: ROOT CAUSE ANALYSIS TRAINING CRASH-COURSE
Trainer: SID CALAYAG
POOR FAIR GOOD
1. The trainer knew the material well enough to teach this course.
2. The trainer is well prepared.
3. The trainer keep the class discussions focused on the training orientation content.
4. The orientation gave me information that will help me perform my job safer.
5. I found the training workshop is applicable in my job assignment.
6. The trainer presented useful summaries and to be understood to me better..
7. The trainer provided enough questions and answers opportunities.
8.
The trainer provided visuals that are very helpful in my training
9.
The quality of the handout is ____________. (Poor, Fair, Good)
10. This orientation is timely for the organization’s current situation
My comments and suggestions in this orientation/training are:

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_______________________________ OVERALL EVALUATION: _____________

Signature
Individual Rating: Overall Rating:
Poor : 1 – 3, Fair: 4 – 7, Good: 8 – 10 Poor : 10 – 30 Fair: 40 – 70 Good: 80 - 100

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TA I K I S H A P H I L I P P I N E S , I N C OPEN CHALLENGE QUICK RESPONSE

ROOT CAUSE ANALYSIS

Date: Oct 09, 2009

ROOT CAUSE ANALYSIS

Date: Oct 09, 2009

For most of us, it's a lot easier to jump

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Introduction MODULE 1 MODULE 2

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Terms and Definition

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

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Root Cause Analysis - a process

A process of tracing a Problem to its Origins

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Root Cause Analysis Process

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Module 1 Table of Contents

MODULE 1 MODULE 2 APPLICATION

 Histograms and Pareto Chart

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

• A chart that graphically display the

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Pareto Chart - What it is

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

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

1. Gather facts about the problem

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Pareto Chart – How to create it

3. Draw the value as a bar chart.

5. Review the chart

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Pareto of D3 Small Engine Card Faults

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Pareto Analysis Example

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

Fault by Main Cause

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Pareto Chart for Child11

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Pareto Analysis Example

• identify and prioritize major problem areas based on frequency of

• identify major causes and effects.

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

A method for showing the distribution of Process Steps

with the greatest impact.

Pareto Charts provide a visual representation of

Pareto Charts can be used as a prioritization tool

contribute to specific conditions.

Pareto analysis is an approach which ranks the

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

CAUSE AND EFFECT

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

• Cause and Effect Analysis is a tool for

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

Cause and Effect Sources of Variation

Sources of Variation is categorized as

TA I K I S H A P H I L I P P I N E S , I N C OP E N C H ALLE N GE QUICK RESPONSE

___________________ OVERALL EVALUATION: _