ROOT CAUSE ANALYSIS

By : Magnifico Training and Consultancy Services

Magnifying Performance Through Innovative Mentoring

 Let ‘s check your understanding first….
Please Identify Symptom and Problem( Cause)

• Customer getting burned due to coffee is too hot

• Carpet got wet because of leaking roof

• I have headache because I could not rest enough

Magnifying Performance Through Innovative Mentoring

We should work on
Symptoms or Problem(Cause)

That’s why we should have

root cause approach to solve
the problem

Magnifying Performance Through Innovative Mentoring

SYMPTOM APPROACH Vs RCA
• Symptom Approach
• Errors are often results of
operators carelessness
• We need to train and
motivate operators to be
more careful
• We do not have time or
resources to go to bottom
of problem
Magnifying Performance Through Innovative Mentoring
• Root Cause Approach
• Errors are the result of
defects in the system.
People are only part of
process
• We need to find out why
this is happening and
implement mistake
proofing so that it won’t
happen again
• This is critical and we
need to fix it once for all
When should Root cause analysis be performed…….
When PROBLEM occurs….!!!!

Magnifying Performance Through Innovative Mentoring

 What we do now…….
Firefighting Problem
Problem Immediate Containment reoccurs
Identified Action Implemented elsewhere

PREFERRED
CURRENT APPROACH
Solutions are
Immediate Defined Solution applied
Problem Containment Root cause Validated across
Identified Action Analysis with Data company and
Implemented Process
never return

Magnifying Performance Through Innovative Mentoring

How to change the approach form…
current to preferred
• State the problem in terms of money !!!
• Determine how much each occurrence of the
problem costs the company
• speaks the language of management
• Justify any spending on root cause analysis
and corrective actions
• Prioritize financial impact of problem

Magnifying Performance Through Innovative Mentoring

Root Cause Analysis – Typical ?
Morning Meeting : Motor tripped out overnight cause production loss.
WHO

Maintenance Operation

Mechanical E/I

Electrical Instrumentation

Magnifying Performance Through Innovative Mentoring

 Opinion /
“The Solution”
With Little Then we look for more
Information information to
We create an opinion support our decision
or a solution

We lock our thoughts….because Defend our opinion !!!

we told others our opinion

Magnifying Performance Through Innovative Mentoring

OnlyThis
ThisArea
Area Contains
ContainsRoot Cause
problem
PREVENT THE PROBLEM

Magnifying Performance Through Innovative Mentoring

 What THINKING PROCESS should look like
1. Collect Information
2. Develop and consider possible causes
3. Select most likely causes
4. Develop and consider possible solution
5. Select solution

1. More 2. Possible 3. Most likely 4. Possible 5. Pick Solution

Information Causes causes solution

Magnifying Performance Through Innovative Mentoring

 Root Cause is a Thinking Process
Problem

Problem

Problem Possible Select most Possible Select Eliminate

Problem Trigger
Statement Causes Likely Cause Solution Solution Problem

Problem
• All Root cause methods uses • Various software are just
Problem
similar work process documentation system
• Problem • Proact
• Collect data • KT
• Possible Causes • Fishbone
• Pick /Verify Causes • 5 Why
• Implement Solution • Logic Tree
• Etc.

Magnifying Performance Through Innovative Mentoring

A Special Note about tools

• Fault Tree, Cause-Effect Diagram,5-Why is the same thing if you use

them right, they all should have CAUSE–AND-EFFECT Relationship

• A fishbone diagram is not a problem solving tool it’s a

brainstorming or categorization tool

• Most software used for problem solving is restrictive, slows

the process down and kills creative and critical thinking

• RCA is a THINKING PROCESS!!!

Magnifying Performance Through Innovative Mentoring

Emotional Decision making

• No logic
• Squeaky wheel Syndrome
• Personality Driven
• Paradigm Driven
• We have always done that way

Magnifying Performance Through Innovative Mentoring

Which car belongs to whom ?

Magnifying Performance Through Innovative Mentoring

How do we break the patterns?

…………….Thinking Tools
• We need a process
• We need a tool to help us de-emotionalize the decision

Magnifying Performance Through Innovative Mentoring

 Basic Belief on RCA
• A process that will handle 80 – 90% of all problems is
possible to implement on the frontline if it is simple
enough.
• In best in class organization that means up to 30% of all
hours are used for RCA in one form or another
• Forming large (4+) teams for problem solving are not
always necessary or effective
• RCA is mostly a matter of creative and critical thinking
• Documentation methods are tool , but not the core of RCA.

Magnifying Performance Through Innovative Mentoring

Thoughts about Thinking

Critical and Creative Thinking :

• Creative thinking is generally considered to be involved

with the creation or generation of Ideas, Processes,
Experiences or objects

• Critical thinking is considered with the Evaluation of

Ideas, Processes, Experiences or objects

• Both are used at Various stages in RCA

Magnifying Performance Through Innovative Mentoring

Creative Thinking
• Is used in several thinking steps of RCA
- How more information can be found
- Come up with possible causes
- Come up with possible solutions
• Creative Thinking can be practiced
- The workouts, consist of getting out of our pre programmed
patterns

Magnifying Performance Through Innovative Mentoring

Critical Thinking – The Basics
• Thinking Endurance
- Work through complexity & frustration
• Believe in Reason
- Explain each cause and effect relationship
• Distinguish Between Facts and Perception
• Process of Elimination
- How often have said to you that when you have eliminated
the impossible, whatever remains must be the truth?

Magnifying Performance Through Innovative Mentoring

What is the problem – Exactly ?

“ I never had problem with drugs. I have had problems

with the police”
- Keith Richards
Magnifying Performance Through Innovative Mentoring
The Problem Statement
• Best if there is ONE object and ONE Problem
• Has to be a Fact
• Must relate to the trigger to answer the “ So what question”
• Keep it sample
• Example
- Hydraulic system not working Vs Hydraulic Cylinder not
extending fast enough

Magnifying Performance Through Innovative Mentoring

What is the Problem ?
Make sure you Solve the Right One!
• I have lost my key
or
• I can’t get into the house
• We don’t have enough resources to manage our materials
or
• There is no bill of materials in CMMS
• We are not trained in alignment
or
• Too many breakdowns of bearings
Magnifying Performance Through Innovative Mentoring
What is the Problem Statement ?

• The pump is not delivering enough flow, it

sounds as if it is cavitating and the bearings
are hot.
 Make sure we are at right level
 Hot bearings……Problem or symptom
 Vibration…..Problem or Symptom
 Noisy machine………Problem or Symptom

Magnifying Performance Through Innovative Mentoring

Collect Evidence
Base Questions to ask ….Just the FACTS
• What
– Exactly what happened
– Surrounding, pictures, Environment, data
• Where
– Is the object exactly
– Exactly on the object is the problem?
• When
– Was it first noticed?
– Timeline
– Pattern
• Changes in time
– Events, Modification, Changes, Updates
• Other Similar Objects
– Similar item to study and to compare with
– Similar situation to compare with

Magnifying Performance Through Innovative Mentoring

How to collect Evidences

Magnifying Performance Through Innovative Mentoring

Facts Vs Information
• Consider any data collected to be information until it is proven
to be fact

IUMRING TO GQNGIUSIQNS
JUMPING TO CONCLUSIONS

Magnifying Performance Through Innovative Mentoring

5W2H Approach
• Who? Individuals / Customers associated with problem
• What? The problem statement or definition
• When? Date and time problem was identified
• Where? Location of complaints ( area, Facilities,
Customer)
• Why? Any Previous known explanations
• How? How did the problem happen( root cause) and
how will the problem be corrected
• How many? Size and frequency of the problem

Magnifying Performance Through Innovative Mentoring

 5 Why Example
Statue of Unity is deteriorating
1.WHY?
Use of Harsh chemical for cleaning
2. WHY?
Cleaning up after Pigeons leftovers
3. WHY?
Pigeons hanging around to eat the spiders
4. WHY?
Spiders finding lots of insects near statue
5. WHY?
Insects are attracted to the light dusk
6. WHY?
Timing of Light doesn’t changes with seasons
Magnifying Performance Through Innovative Mentoring
“Creative Thinking” Hat
• Possible Causes
• How can Vs Why
• Use initial evidences to determine
• Must have cause and effect relationship between each level
• Item should contain an object and a verb
• Need Diverse group for this
• Guiding Principles
– Sensible and Defensible
– Happened Before?
– Likely to happen again?
• Document with “How can” Diagram
• Sticky Notes!!!
Magnifying Performance Through Innovative Mentoring
“Thinking Tool”….The How can Diagram

• Simple approach
• Can be applied by anyone anytime
• Easy to change and edit
• Low cost
• Does not distract from the thinking process
• White board
• Glass Board
• Etc…..

Magnifying Performance Through Innovative Mentoring

 HOW CAN Diagram…..

Design of
Hull
Inadequate

Opening in
Hull
Safety Water Filled
Titanic Outer forces
1500 the whole
Sank Exceed strength
died Hull
of Hull

Bulk heads
not Sealed

Magnifying Performance Through Innovative Mentoring

Process of Elimination
• Critical Thinking Hat
• Logic
• Deduction
• Reasoning Skill
• Use evidence not to prove what is, but to prove what is not,
• Gather more evidence as needed

Magnifying Performance Through Innovative Mentoring

Total 115 causes of Titanic Sank

Magnifying Performance Through Innovative Mentoring

Another Example

Magnifying Performance Through Innovative Mentoring

Look for 3 Root Causes

Impact with Iceberg at speed holed

Technical hull AND bulkhead not sealed

Look out failed to provide warning of

Human Factor Iceberg
Captain going fast for conditions

Work Process Pressure from company to

achieve fast crossing

Magnifying Performance Through Innovative Mentoring

When a solution is selected
• Focus an effort on some CREATIVE thinking
• Don’t just pick the first solution that comes in
mind
• Try to look at several options then selected by
– Which is most effective
– Which is most efficient
– Which is technically feasible and worth doing
– Cost to solve Vs cost to fail

Magnifying Performance Through Innovative Mentoring

 3 Types of Corrective actions:
• Immediate Action
– The action taken to quickly fix the impact of the problem so the
“Customer” is not further impacted

• Permanent Root Cause Corrective Action

– The action taken to eliminate the error on the affected process or pr
product

• Preventive (Systematic) Root cause Corrective Action

– The action taken to prevent the error from recurring on any process
or product

Magnifying Performance Through Innovative Mentoring

Example of Corrective Actions

• Immediate Action
– All current batches are re-inspected by another inspector for
same type of problem

• Permanent Root Cause Corrective Action

– Correction or changes done in the existing process and tools

• Preventive (Systematic) Root cause Corrective Action

– The action is implemented in all Similar product / Process / tools
with same features in company

Magnifying Performance Through Innovative Mentoring

Permanent Vs Preventive Actions
• Permanent
• Train employee on proper use of
machine
• Change product design to make
parts easier to assemble
manually
• Specific customer document
critical to project is identified
with red folder
• Fallen patient given full-time
assistance to provide help moving
around hospital
• Employee fired for ethical
violation
Magnifying Performance Through Innovative Mentoring
• Preventive
• Made training a requirement to
new employees working in that
area
• Change design guideline to allow
design part most suitable for
assembly
• All documents that are critical to
project are identified with red
folders
• Process developed to identify “at
risk” patients for fails who require
assistance
• Ethics training developed and
provided to all employees
 RCA – Problem Elimination
• First a few questions to ask
– Is this “one time” fix to eliminate the problem?
– Does the problem elimination require the re-design of existing system?
– Is engineering required to assist with the problem elimination?
– Is the elimination of the problem addressed in the addition of or
modification to some preventive / Condition based Maintenance task?
• Does the elimination of problem require a combination of
solutions?
• Guiding principles
– Sensible Defensible
– Technically feasible and worth doing
– What is the cost to prevent the failure Vs the consequences of the failure?
• WIIFM( Show me some money)

Magnifying Performance Through Innovative Mentoring

The Forensics of RCA
• Combination of work processes and skills to
achieve better reliability and lower cost

Magnifying Performance Through Innovative Mentoring

Bearing failure Evidences Preservation…..a few
tips
• Disassemble and inspect bearing in a well lit area, preferably
with natural light
• Take photograph of each disassembly process
• Using a paint marker or metal marker. Mark relative location
of housing, inner and outer races, and any grease / oil ways
• Note orientation of bearings in machines, including:
– Whether inboard or outboard
– Direction of bearing faces and orientation of side by side bearing
• Use a cutting torch as last resort. Always attempt to remove
stubborn part with a disk grinder / Chisel first.
• Inspect all part thoroughly before cleaning

Magnifying Performance Through Innovative Mentoring

Inspection

• Visual
– Unaided eye or low magnification first ( 10x)
– Grangers law

Magnifying Performance Through Innovative Mentoring

Photography
• Resolution
– Highest possible
• Macro
– Use Tripod
– Turntable
• Focus
• Lighting
– Oblique for fracture faces
• Software adjustments
• Resize images for distribution

Magnifying Performance Through Innovative Mentoring

Review of failure Terms
• Spalling • Scoring
• Normal load • Peeling
• Abnormal Load • De-lamination
– Axial wear crack • Damage
– Wide Track
• Corrosion
• Fracture
• Chipping off

Magnifying Performance Through Innovative Mentoring

Fasteners – Common Failure Causes

• Combination of work processes and skills to

achieve better reliability and lower cost

Magnifying Performance Through Innovative Mentoring

Common Failure Problems
• Incorrect tension
– Too loose
– Too tight
• Wrong Selection
• What tightening method used?
– Feel
– Stretch
– Turn of nut
• Torque applied Vs required
• Lubrication

Magnifying Performance Through Innovative Mentoring

Who should Do Root cause analysis…
A suggestion…
Plant team
Third Level of
Problem

Area Team

Second level Problem

Individual /
Informal Team
First “ Crack”
at problem

Magnifying Performance Through Innovative Mentoring

 Cost Impact of doing RCA at stages
Defect Own Next Later Before Found by
Found at: Process Process Process reaching customer
step Step Step Customer

Cost:

Significant
Very Minor Warranty Cost
Impact: Rework rework
minor delay
Delay in Admin cost
Reschedule
of work Delivery Reputation
Additional Loss of
Inspection market share
Magnifying Performance Through Innovative Mentoring
 Summary – Key Points
• RCA is a structured approach to eliminate the problem
• RCA is a thinking process to identify and eliminate root
cause
• SIMPLE documentation tools are used to organize our
thinking process
• Simple RCA principles should be applied by frontline
employees
• One problem may have more than one root cause
• One root cause may have contributed to many problems

Magnifying Performance Through Innovative Mentoring

 Summary – Key Points
• Preserve failed part for inspection
• Simple inspection with 10 x Magnification reveals a lot
• There are significant savings from implementing and
effective RCA process
• RCA should be integrated into everyone’s work function
• When the root cause is not addressed then expect the
problem to reoccur
• Prevention is the KEY.

Magnifying Performance Through Innovative Mentoring

 THANKS

From : Magnifico Training and Consulting

Magnifying Performance Through Innovative Mentoring