ROOT CAUSE ANALYSIS

TEL:+233 (0) 246 595 313

EMAIL: info@assuredreliability.com
WEB: assuredreliability.com
 RCA TRAINING

OBJECTIVES:
 To understand the definition of RCA (Why – Why/Apollo
Analysis)
 To clarify the procedure for developing RCA (Why –
Why/Apollo) Analysis.
 To stress the importance of each step in the RCA process
(Why – Why/Apollo Analysis)
.
ROOT CAUSE ANALYSIS

 What is Root Cause Analysis?

It is a tool to identify root cause(s)
of a problem so that
countermeasures can be applied
to prevent reoccurrence.
 RCA
There are different types problem solving techniques
5Why or Why Why Analysis
RCA Apollo/RCFA
Failure Mode and Effect Analysis (FMEA)
Fault Tree Analysis (FTA)
Event Tree Analysis (ETA)
Barrier Analysis
Change Analysis
Six Sigma-DMAIC
Others
 We don’t Do well with Solving Problems

We assume we know exactly what caused the failure to occur

 Because it has happened before and we know what caused
it
 We don't take holistic view
 We take linear approach to solving problems
Therefore the same problem, different analyst would
conclude on different causes
Tendency to look for Who and not Why
 We don’t Do well with Solving Problems
• Tendency for investigators to stop at symptoms rather than going
on to lower-level root causes.
• Inability to go beyond the investigator's current knowledge -
cannot find causes that they do not already know.
• Lack of support to help the investigator ask the right "why"
questions.
• Results are not repeatable - different people using 5 Whys come
up with different causes for the same problem.
• Tendency to isolate a single root cause, whereas each question
could elicit many different root causes
CAUSES
Obvious Cause(s)- are what we see on the surface or what we think as the
cause to our failure.
 Corrective measure
 Failure is most likely to occur again
Latent Cause (s)- are the hidden causes that we normally don’t see and
ignore
 Preventive measures
 Prevents re-occurrence
Most of our failures are symptoms of latent (hidden) causes
 Recommended
RCA Approach

Go On the Floor, at the point of the problem

See the problem

Listen to the people who live the problem

Reveview failure History, PID, PEF, PM/CM, Process Logs, and other relevant data

GATHER INITIAL INFORMATION

 LET’S BREAK THE ANALYSIS INTO THE FOLLOWING
STEPS

Understanding the Problem

1.

2. Defining the Phenomenon to be analyzed.

3. Conduct Cause Analysis (cause/effect relationship)
4. Identify Effective solution
5. Implement Solutions
6. Monitor and Evaluate
 UNDERSTANDING THE PROBLEM
Set up RCA Team
Team Charter
Multi disciplinary
OEM representative if possible
Reliability Engineer or trained facilitator
Subject matter experts (SME)
UNDERSTANDING THE PROBLEM
• Gemba- Go to the source of the problem-see the
problem
• Take pictures
• Interview people. Listen to the people who lived the
problem
• Review operational data
• Review failure history
• Other
 PROBLEM VS PHENOMENON EXAMPLE

Problem: The room is too dark

Better: The light bulb “doesn’t go on”

Best: There is no flow of electric current through

the filament
 SCOTOMA TRAINING

Definition

 Scotoma literally means “limited vision within our field of vision.” It is

used to explain the fact that we sometimes see what we expect to
see.

How it links to this training

 Scotomas can keep us from recognizing the causes to some
problems. We might not even recognize the problem. (Like the way
we overlook defects if we have gotten to the point where we consider
them as normal.)
Our conditioning of reading black letters may have
caused us to not see the white letters F L Y.
WHAT’S THE PROBLEM?
Where you focus your attention, affect
your problem statement.
If you focus on the people, you
may see the problem as “they are
about to fall” or maybe that “they
are fighting with each other.”
WHAT’S THE PROBLEM?

If you focus on the rope, the problem may

be “the rope is too weak.”
WHAT’S THE PROBLEM?

If you focus below, the problem might be “there are

crocodiles in the water.” or “there are
crocodiles swimming with sharks” or “there
is water”
 DEFINING THE PROBLEM

A problem well stated is a problem half-solved.” — Charles

Kettering
Problem definition needs to be short and concise. It should
have impact. It should avoid the use of generic or
ambiguous language.
Defining the problem a very important step in the problem-
solving process and there should be sufficient time devoted
to this activity
It provides a clear purpose, a clear starting point and a clear
direction
DEFINING THE PROBLEM
Example . Think about a generic problem title: “person injured”.

 A more precise definition would be “second degree burns to left

forearm”.

This more specific title immediately conveys how serious the

problem is, and also generates far more specific questions in the
analysis of the incident. In turn, this leads to more precise
responses and a better understanding of the issue.
 DEFINING THE PROBLEM
A Complete Problem Definition includes answers to these 4 questions:
 What is the problem (Primary Effect)
 When did it happen?
 Where did it happen?
 What is the significance of the problem?

What the Problem Definition Does Not Contain

 WHO - There is no need to ask “Who” unless you are asking who knows the
answer to a question. This is important to mention because of the strong
tendency to place blame, which detracts from the focus on prevention.
 WHY - Asking “Why” at this stage detracts from defining the problem and is part
of the analysis step that will be addressed soon after defining the problem.
PROBLEM PERSPECTIVE
People will look at the same set of information and form
a different understanding of the problem. To be
effective problem solvers, we must understand that no
two people share the same reality and every person
brings a different perspective to the table
Every event can have many different perspectives of
what the problem is and each stakeholder's
perspectives provide causes for cause and effect
chart
 EXAMPLE

On Monday December 14, 2009 at 10 PM, 10 million gallons

of raw sewage was released into Teshies waterfront after a
switch at a treatment plant malfunctioned. Ten waterfront
resident died as a result of drinking the water.
 What is the problem? –(primary effect)
 When did it happen?
 Where did it happen?
 What is the significance of the problem?
THE WHAT (PRIMARY EFFECT)

-Switch failed (Primary Effect)

Water release ( Secondary
effect)
- 10 people died (Tertiary effect)
PROBLEM PERSPECTIVE
Remember: You are never wrong when choosing a
starting point as all causes are related. They are
simply at different points in the timeline. Your choice
may reflect your role or responsibility within the
company
HOW WOULD DEFINE THESE PROBLEMS

2
Phenomena Statements
What is the problem?

Normal:
• The faucet is leaking or
• The handle is not tight

Actual Phenomena: Drops of liquid

are coming out of the faucet at a rate
of 54 drips/minute.
Phenomena Statements
What is the phenomena?

Normal: The bolt is loose

Normal: Too much vibration

Actual Phenomena: A grade 8 bolt has

two threads exposed from the gear head.
The bolt cannot be turned by hand.
3. CAUSE ANALYSIS

5 WHY/WHY-WHY Analysis
Apollo/Reality Charting
 5WHY
 Why-Why Process:
Basically the process is to keep asking why for all possible causes
until you can find the root cause for each effect and, therefore,
find a countermeasure for each root cause.
The answer to the first why is always the first layer or symptom, or obvious
cause that we see. Its not the true cause
Ask 2nd, 3rd 4th and 5th why to peel off the layers to the root cause
See this as an onion with many layers

 5 Why is not always a single point or linear analysis-i.e A cause by B cause by C

…..
Brainstorm all potential causes as you ask “WHY” the effect
occurred”
Validate each with evidence
 ASKING WHY

Sketch the phenomena

Explain theory of operation and failure modes
Brainstorm and write down all causes the team comes out with and DON’T shut or
ignore any contribution
Look for the WHY and not the WHO
Validate with evidence all listed causes (validate at source)
 Observation
 Testing
 Checking
 Inspecting
 interviewing
 BRAIN STORMING-AVOID TEAM CONFLICT

Conflict arises from differences between views

 viewpoints, experiences, skills, and opinions
Healthy and constructive conflict is a component of high-
functioning teams
We need to …….
Appreciate different view points
Understand where the other person is coming from through:
 active listening
 Clarification eg. paraphrasing
BRAIN STORMING-AVOID TEAM CONFLICT
Separate facts from assumption and reach agreement
Be open minded and discard emotions, beliefs
Encourage different views
Demonstrate respect
 I respect your point view but I humbly disagree because IOG# xyz
says that…..
Don’t look for blame
Agree to disagree- know when to let go and move on
HOW DO TOOLS FIT?
HuMan Machine

Effect

Material Methods EnvironMent Cause and Effect Worksheet

Cause Effect

Type of Check Check Details

1. Direct Observation Thesis

2. Evidence from collected data
3. Expert’s experience
4. Theory
5. Others
Already existing reference standard Check method to be
used

Verify existence of cause and effect for

this situation
Already existing Control Method Results of the check

Problem Why Why Why Why Why

 ASKING WHY
•Clear your mind of any “prejudices”
•I have been here for a long time. I know exactly
what caused the equipment to fail
• What you’re saying doesn’t hold any water. You
don’t know what you are talking about
•Consider the 5M’s (Man, Machine, Method,
Environment, Material)
•Man
•Operator skills, knowledge
•Supervision
•Administration
ASKING WHY

Machine
 Equipment condition
 Maintenance failure history
Methods
 Procedure
 SOP
I
Material
 Quality
 Strength
Environment
 Sabotage
 Internal and external
EXAMPLE
SINGLE POINT 5WHY ANALYSIS
The vehicle will not start. (the problem)
Why? - The battery is dead. (first why)
Why? - The alternator is not functioning. (second why)
Why? - The alternator belt has broken. (third why)
Why? - The alternator belt was well beyond its useful
service life and not replaced. (fourth why)
Why? - The vehicle was not maintained according to the
recommended service schedule. (fifth why)

This will end in different conclusion for different teams

 5 WHY EXAMPLE

1st Why did your car stop?

1. Because it ran out of fuel (check)-true
2. Car hit an electric pole (observation)-Not true
3. Engine failed (inspection)- not true
4. Car crashed (observation)-not true
5. Heavy traffic (observation)-true
2nd a) Why did it run out of fuel?
1. Because I didn't buy any fuel on my way to work. (interview/record
review)-true
2. There were no filling station on the way (observation)-not true
 b) Why is there heavy traffic
 Rush hour (time assessment) true (leave early)
 Accident ahead-(observation)n-ot true
 5 WHY EXAMPLE

3rd Why didn't you buy any fuel this morning?

 Because I did not have any money
 There is no feeling station (not true)
4th Why did you have no money?
 Because I forgot my cash card (check) true
 No savings (check) not true
5th Why did you forget your cash card?
 Because I don’t make a last minute check on essentials before leaving
home
3. Cause Analysis
First “Why” about the Phenomenon
 This question needs to be answered from a physical
and/or logical point of view.
 The question needs to be answered for each element
involved in the description made in the previous step.
 At this point, focus on the evidence of the flaws, that is:
 a) Verify the evidence of the causes of the problem in the field
(whether it exists or not, stopping the analysis for that branch when
the cause doesn’t exist).
 b) If it is possible to put a direct countermeasure to the cause into
place, do it and stop the analysis ensure that procedures or
standards are in place to maintain condition achieved..
 NOTES AND ADVICE:
The analysis should be done at the problem area, not in
another location that is isolated from the case.
The analysis is a team effort, not by just one person.
The most important thing is the physical and/or logical
description of the phenomenon to be studied. (Step 1)
The Analysis ends when countermeasures TO AVOID
RECURRENCE of the phenomenon are found.
 Notes and Advice:
ALWAYS make a sketch or drawing of the
phenomenon.
The 4-M’s don’t always apply to every cause to be
analyzed, but we should always consider them so as
not to forget possible “causes of causes.”
The more simplicity and objectivity in steps 1 and 2,
the easier it is to ensure that all possible causes are
covered.
Practice develops skill.
This tool makes us more objective in our way of
looking at things.
STEP 2 USING APOLLO(REALITY CHART)

A causal process whereby one asks why of a defined problem and

answers with at least two causes in a form of an action and
condition. (An event is cause by an action and at least one
condition)
Cause action

Opponent
scored more

observed
Lost game
cause Condition
More point
The What (primary effect) wins

rules
 Action

Heat (match stroke)

observed

Condition

Fire Presence of Fuel

observed

Primary effect
Condition
“the WHAT”

Presence of Air
observed
PRIMARY EFFECT
It is a singular effect of consequence that we wish to eliminate or mitigate
It is the problem name; The “What” in the problem definition
It is the starting point from the present to the past in the chain of causes
It is the point at which we begin to ask “why”
It is a noun-verb or verb noun statement
 Impeller failed or failed impeller
STOPPING A CAUSE PATH
Don’t Know; will get more information
Desired condition
 Procedure followed
Don’t have control
 Force Gravity
New primary effect
 If the cause is a beginning of another problem
Other cause path more productive
 Sky is blue
 Action

(Heat)Match
struck
observed
?
Condition

Fire Fuel Desired

observed condition

Condition

Desired
Air condition
observed
Validate all potential causes

What proof is available that the cause exists?

 Is it measurable?
What proof is available that this cause leads to the effect?
What proof is available that the cause resulted in the
problem?
 How do you know that it wasn’t something else?
Is anything else needed for the stated cause to produce the
effect?
 Is something else needed to product the effect?
Can anything else besides the cause lead to the effect?
 Are there other explanations that fit the cause better?

Slid
e 56
 STEP 4. IDENTIFY EFFECTIVE SOLUTIONS
The Best Solutions Must:
 Prevent Recurrence
 Be Within Your Control
 Meet Your Goals and Objectives
 Cost effectiveness
 Risk of implementation
 Ease of implementation

Solutions Matrix
Meet Goal and
Cause Solution Prevent Reoccurence Objective Within Our Control Cost
Operator Error Training YES YES YES N 5000
 STEP 4. IMPLEMENT THE BEST SOLUTIONS

Develop Corrective Action Plan (CAP)

Cause Corective Action Responsibility Start Date End Date Status

STEP 5. IMPLEMENT THE BEST SOLUTIONS

Will the corrective action prevent recurrence?

Is the corrective action feasible?
Does the corrective action allow meeting primary (business)
objectives or mission?
Does the corrective action introduce new risks? Are the assumed
risks clearly stated? Note that the safety of other systems must
not be degraded by the proposed corrective action.
Are the current immediate actions taken appropriate and effective?
MONITOR AND EVALUATE
Track effectiveness of implemented solution
 Repeated failures
 Mean Time Between Failures
 Mean Time to Failure
 Deferment reduction
 Cost reduction
 OEE (Overall equipment effectiveness)

 Others
APPLYING SOLUTION
SOLUTION MATRIX
Prevents Within our Goals and
Cause Solution Recurrence Control Objectives Cost

Cross check signs on

Directed by tank with supervisor
Supervisor statement YES YES YES $0
Tank not clearly Place large signs on
marked tank YES YES YES $2,000
Store acid in off-site
Tank contained Acid facility YES YES NO

Make unique fittings

Both fittings 3” for different materials YES YES YES $5,000
W

info@assuredreliability.com
www.assuredreliability.com
W

Thank
You
info@assuredreliability.com
www.assuredreliability.com