Root Cause Analysis Presented By: Team: Incredibles

1. Root Cause AnalysisPresented By: Team: Incredibles San Jose State University CMPE 203, Fall 2009

2. Agenda Introduction What is RCA? Why do we need? Types of RCA Techniques/Tools - Kepner-Tregoe Method - FMEA - Fishbone Diagram Case study of RCA

3. Root Cause Analysis What is Root Cause Analysis? - Finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms Reactive method Goals - Failure identification - Failure analysis - Failure resolution Iterative Process: - Complete prevention of recurrence by a single intervention is not always possible.

4. Steps for Root Cause Analysis Collection of data - Phase I - A fact-finding investigation, and not a fault-finding mission Event Investigation - Phase II - Objective evaluation of the data collected to identify any causal factor that may have led to the failure Resolution of occurrence - Phase III - Realistic assessment of the viability of the corrective action that the previous phase revealed. - The phenomenon must then be monitored periodically to verify resolution.

5. Why do we need it Benefits of RCA - Real cause of the problem can be found - Problem recurrence will be minimized

6. Types of RCA Safety-based RCA Production-based RCA Process-based RCA Systems-based RCA

7. Types of RCA • Safety-based RCA - Investigating Accident and occupational safety and health. - Root causes:- unidentified risks, or inadequate safety engineering, missing safety barriers. • Production-based RCA - Quality control for industrial manufacturing. - Root causes:- non-conformance like, malfunctioning steps in production line.

8. Types of RCA Process-based RCA - Extension of Production-based RCA. - Includes business processes also. - Root causes:- Individual process failures System-based RCA - Hybrid of the previous types - New concepts includes:- change management, systems thinking, and risk management. - Root causes:- organizational culture and strategic management

9. Methods of Root Cause Analysis Change Analysis Barrier Analysis MORT: Management Oversight and Risk Tree Human Performance Evaluation (HPE)

10. Kepner-Tregoe Method Developed in 1958 Fact-based approach to systematically rule out possible causes and identify the true cause. Composed of fives Steps: - Define the Problem - Describe the Problem - Establish possible causes - Test the most probable cause - Verify the true cause Kepner-Tregoe is a mature process with decades of proven capabilities. Kepner-Tregoe Problem Analysis was used by NASA to troubleshoot Apollo XIII.

11. Tools for Root Cause Analysis

12. Failure Mode effect and Analysis (FMEA) Methodology for analyzing potential reliability problems early in the development cycle. Failure modes are any errors or defects in a process, design, or item, especially customer related. Effects analysis refers to studying the consequences of those failures.

13. FMEA Example

14. FMEA Benefits: Improves the quality, reliability, and safety of products. Increases customer satisfaction. Stimulates open communication and collective Expertise. Disadvantages: Assumes cause of problem is a single event. Examination of human error overlooked.

15. Fishbone Analysis Definition - Technique to graphically identify and organize many possible causes of a problem Advantages - Helps to discover the most likely ROOT CAUSES of a problem - Teach a team to reach a common understanding of a problem.

16. Fishbone Analysis Machine Material Measurement cause cause reason Problem cause cause reason • Components : - Head of a Fish : Problem or Effect - Horizontal Branches : Causes - Sub – branches : Reason - Non- service Categories : Machine, Manpower, Method etc. - Service categories : People, Process, Policies, Procedures etc. Management Method Man Power

17. Fishbone Analysis Car stopped Middle of the road Ran out of Gas WHY WHY Didn’t buy this morning WHY Didn’t have money Lost them in last night’s poker Not very good in “bluffing” WHY WHY 5 WHY’S

18. Case Study – Safeway.com Safeway outsourced a module of Safeway online to HCL, India Project Details – Add a new module for selling Patio furniture online on http://Safeway.com . Agreed duration - 8 months, June, 07 to February, 08 Actual delivery – June ’08 After the project was finished TCS performed a Root Cause Analysis to analyze the delays and to avoid problems in future.

19. Case Study – Fishbone Analysis Control Inventory Inventory Update Every 12 hours No Clear Understanding Real time inventory Scope Definition No Clear deadlines Separate Systems Separate Systems for Sales & Supplier Wrong Estimates Project Delay Managed Systems No backup for Critical Resources Different Suppliers Inadequate Resources Lack of Standards Communication Time and Format of Systems different No Communication plan Benchmarking Resources

20. Conclusion Learning for the future projects. Encourages Team based problem solving approach. Errors are frequent and inevitable. Saves cost and helps in identifying solutions.

21. References • http://www.systems-thinking.org/rca/rootca.htm • http://www.workplacechallenge.co.za/pebble.asp?relid=649 • http://www.itsmsolutions.com/newsletters/DITYvol2iss24.htm • http://www.envisionsoftware.com/articles/Root_Cause_Analysis.html • http://www.au.af.mil/au/awc/awcgate/nasa/root_cause_analysis.pdf • http://www.isixsigma.com/library/content/c020610a.asp • http://www.quality-one.com/services/fmea.php • http://www.npd-solutions.com/fmea.html