RCA 3 Hours v6

8/6/2019 RCA 3 Hours v6

http://slidepdf.com/reader/full/rca-3-hours-v6 1/40

Confidential © 2009 WNS Global Services | www.wns.com

Root Cause AnalysisTraining Module

8/6/2019 RCA 3 Hours v6


2Confidential © 2009 WNS Global Services | www.wns.com

Lets Introduce !

8/6/2019 RCA 3 Hours v6



Root cause analysis (RCA)…

“…is a class of problem solving methodsaimed at identifying the root causes of

problems or events.”

8/6/2019 RCA 3 Hours v6

http://slidepdf.com/reader/full/rca-3-hours-v6 4/404Confidential © 2009 WNS Global Services | www.wns.com

Root Cause Analysis

S y m p

t o m s

S y m p t o m s

Symptoms

S y m p t o m s

S y m p t o m s

Root Cause

S y m p t o

m s

Symptoms

The idea is to attack the root cause rather than

playing around with the symptoms of the problem…!

8/6/2019 RCA 3 Hours v6


RCA: The Need

Stepping directly into the solution after you encounter aproblem is not the correct way of solving it.

It leads to erroneous conclusions and the problemreoccurs in future.

The right way to solve a problem is to find the root

cause of it and then implement controls in the processto its recurrence in future.

8/6/2019 RCA 3 Hours v6


Root Cause Analysis: The Methodology

An action to eliminate the

detected problem

1. Determine what happened and fix the Defect

2. Determine why it happened

3. Figure out what to do to reduce the likelihood that it will happen again

A Problem is defined

the ill‐effect on the

output of a process

Fundamental cause that results

in ‘Problem’ in the output

An action to eliminate the cause

of the problem at hand

The new State Process which is

now free from the problem

identified in Step 1

8/6/2019 RCA 3 Hours v6


Determine what happened

Defining the problem and fixing the defect!

8/6/2019 RCA 3 Hours v6



What is a Problem?

A Problem could be defined as a gap between actual and

the expected level of performance.

The problem should be treated as an opportunity forprocess improvement.

The first step while doing a process root cause analysis isidentifying the Problem at hand.

This requires a vivid documentation of the problem andsetting the scope for the analysis.

8/6/2019 RCA 3 Hours v6



Determining what happened typically leads to answeringthe following questions:

– What do you see happening?

– What are the specific symptoms?

– How long has the problem existed?

– What is the impact of the problem?

Defining the problem involves drafting a formal ‘ProblemStatement’ in place!

8/6/2019 RCA 3 Hours v6


Determine why did it happen

Finding possible root causes

8/6/2019 RCA 3 Hours v6




This stage involves drilling down on the problem till wereach the root cause of it.

The typical questions to be answered here are:– What conditions allow the problem to occur?

– What other problems surround the occurrence of the central

problem?

– Why does the causal factor exist?

– What is the real reason the problem occurred?

8/6/2019 RCA 3 Hours v6




The typical tools used for this stage are:

– The 5 Why technique

A question-asking method used to explore the cause/effect relationships

underlying a particular problem.

– Cause & Effect Diagram

diagrams that show the causes of a certain event.

8/6/2019 RCA 3 Hours v6



The 5-Why Technique

The 5-Why technique:

– The 5 Whys is a simple problem-solving technique that helps

users to get to the root of the problem quickly.

– The standard rule of thumb is that if you ask why 5 times you willusually get to the root cause of the problem

W h y ? W h y ?

W h y ? W h y ?

W h y ? W h y ?

W h y ? W h y ?

W h y ? W h y ?

P r o b l e

m P r o

b l e m

R o o t C a u s e R o o t C a u s e

8/6/2019 RCA 3 Hours v6



The 5-Why Technique

The five why is a team activity.

Call in all people associated with the process.

Brainstorm for the root cause of the problem.

Remember: No idea is a bad idea!

8/6/2019 RCA 3 Hours v6



The 5-Why Technique: Example

Why is our client, ABC Corp., unhappy?

– Because we did not deliver our services when we said we would.

Why were we unable to meet the agreed-upon timeline or schedulefor delivery?

– The job took much longer than we thought it would.

Why did it take so much longer?

– Because we underestimated the complexity of the job.

Why did we underestimate the complexity of the job?

– Because we made a quick estimate of the time needed to complete it, and

did not list the individual stages needed to complete the project.

Why didn't we do this?

– Because we were running behind on other projects. We clearly need to

review our time estimation and specification procedures.

8/6/2019 RCA 3 Hours v6



Remember:

It is important to reach to the root cause

of the problem and not to stick to the

symptoms!!!

8/6/2019 RCA 3 Hours v6



Cause & Effect Diagram

A Cause and Effect diagram (also known as a Fishbone or

Ishikawa diagram) graphically illustrates the results of the analysis and is constructed in steps.

Cause and Effect Analysis is a technique for identifying ALL the

possible causes associated with a particular problem.

8/6/2019 RCA 3 Hours v6




Cause-and-effect diagrams are designed to:

Stimulate thinking during a brainstorm of potential causes

Provide a structure to understand the relationships betweenmany possible causes of a problem

Give people a framework for planning what data to collect

Serve as a visual display of causes that have been studied

Help team members communicate within the team and with the

rest of the organization

8/6/2019 RCA 3 Hours v6




Effect

Mother Nature

Measurements

Methods

Material

Machines

People

Cause-and-Effect Di agram

This categorygroups root

causesrelated to

tools used toexecute the

process


causes related toinformation andforms needed to

execute theprocess


causes related toour work

environment,

marketconditions, and

regulatory issues


causes relatedto the processmeasurement


causes relatedpeople andorganizations


causes relatedto procedures,

hand-offs, input

output issues

Place the effect at the head of the “fish” Include the 6 recommended categories shown

8/6/2019 RCA 3 Hours v6



Identifying Root Causes

Some Guidelines

8/6/2019 RCA 3 Hours v6



Sources of Variation - Machine

Types of Questions that may be Asked

How old is the tools & knowledge base?

Is it maintained regularly?

Is the tool affected by various performance factors?

How does the operator know if the tool is operating correctly?

Is statistical analysis used to verify the capability of the tool?

What adjustments must the operator make during the process?

Have any changes been made recently in the process?

Note: this is not a definitive list of questions that may be asked to identifypotential source of variation

Categories

Machine

Material

Mother Nature

Measure

Method

People

8/6/2019 RCA 3 Hours v6



Sources of Variation - Material


How is the output produced?

How is the output verified?

How old is the KB ?

How is quality judged prior to your operation?

What is the level of quality?

How is the output dispatched?


Categories

Machine

Material

Mother Nature

Measure

Method

People

8/6/2019 RCA 3 Hours v6



Sources of Variation – Mother Nature


How are environmental conditions monitored?

How are environmental conditions controlled?

How is the environment control measuring equipmentcalibrated?

Are there changes in conditions at different times of the day?

How does environmental change impact the processes beingused?

How does environmental change impact the materials beingused?


Categories

Machine

Material

Mother Nature

Measure

Method

People

8/6/2019 RCA 3 Hours v6



Sources of Variation – Measurement System


How frequently are O/p inspected?

How is the measuring equipment calibrated?

Are all O/p measured using the same tools or equipment?

How are inspection results recorded?

Do inspectors follow the same procedures? (Is there a set of

standards?)

Do inspectors know how to use the test equipment?

Categories

Machine

Material

Mother Nature

Measure

Method

People


8/6/2019 RCA 3 Hours v6



Sources of Variation - Method


How is the method used defined?

Is the method regularly reviewed for adequacy?

Is the method used affected by external factors?

Have other methods been considered?

How does the operator know if the method is operating

effectively? What adjustments must the operator make during the process?

Have any changes been made recently in the process?


Categories

Machine

Material

Mother Nature

Measure

Method

People

S f l

8/6/2019 RCA 3 Hours v6



Sources of Variation - People

Types of Questions that may be Asked:

Does the person have adequate supervision and support?

Does the person know what he is expected to do in his job?

How much experience does the person have?

Does the person have the proper motivation to do his best

work?

Is the person satisfied or dissatisfied with his job?

Is the person more- or less-productive at certain times of the

day?

Is the work load reasonable?Note: this is not a definitive list of questions that may be asked to identifypotential source of variation

Categories

Machine

Material

Mother Nature

Measure

Method

People

H d I d i ? ( i d)

8/6/2019 RCA 3 Hours v6



How do I do it? (continued)

Align Outputs with CauseCategories

Review your brainstorm outputs and align withthe recommended major cause categories,

e.g., the People, Method, Machine, Material,Environment and Measurement System.

Allocate Causes

Transfer the potential causes from thebrainstorm to the diagram, placing eachcause under the appropriate category.

If causes seem to fit more than onecategory then it is acceptable toduplicate them.

Related causes are plotted as ‘twigs’ onthe branches.

Effect

Mother Nature

Measurements

Methods

Material

Machines

People

Cause-and-Effect Diagram

BranchesBranches

TwigsTwigs

8/6/2019 RCA 3 Hours v6



Remember:

The Six Sigma philosophy says that 85% of

all root causes are due to inappropriate

processes and not people!

8/6/2019 RCA 3 Hours v6



Reduce the likelihood of its recurrence

R d d I l t S l ti

8/6/2019 RCA 3 Hours v6



Recommend and Implement Solutions

The typical questions to be answered here:

– What can you do to prevent the problem from happening again?

– How will the solution be implemented?

– Who will be responsible for it?

– What are the risks of implementing the solution?

We must look beyond the soft people issues while identifying the rootcause; ‘Negligence’ and ‘Carelessness’ are just an indication of lack of

effective controls on people.

They are not the root causes!

R d d I l t S l ti

8/6/2019 RCA 3 Hours v6




Brainstorming

– Creative brainstorming: This technique is one of the most

commonly used techniques for idea generation wherein a

team of key stakeholders are brought together for ameaningful discussion wherein the criteria at hand get

brainstormed

– While conducting brainstorming sessions we need torecognize and actively address the challenges that inhibit

creative thinking


8/6/2019 RCA 3 Hours v6




Constrained Brain-writing: The name constrained brain-writing comes the fact that on certain occasions theteam may want to have a set of constrained ideas

around a pre-determined focus, rather than rangingfreely. The key steps involved are:

– The team leader biases the idea generation by preparing brain-

writing sheets in advance and makes sure that there is no discussion

at any stage between any of the team members

– The team leader initiates the process formally by placing several

prepared sheets of paper onto the table

– Each team member takes a sheet, reads it, and silently adds his or

her ideas onto the sheet

– Repeat until ideas are exhausted. No discussion at any stage.

8/6/2019 RCA 3 Hours v6



Build quality into the process

“Make it impossible to turn out defectiveunits even if an error is committed”

Everyday Examples of Mistake-Proofing

8/6/2019 RCA 3 Hours v6



Everyday Examples of Mistake Proofing

3.5 inch diskette cannot be inserted unlessdiskette is oriented correctly. This is as far

as a disk can be inserted upside-down.

The beveled corner of the diskette pushes a

stop in the disk drive out of the wayallowing the diskette to be inserted. Thisfeature, along with the fact that thediskette is not square, prohibit incorrectorientation.

Everyday Examples of Mistake-Proofing

8/6/2019 RCA 3 Hours v6



Everyday Examples of Mistake Proofing

The dryer stops operating when the door is opened,which prevents injuries.

Corrective Action

8/6/2019 RCA 3 Hours v6



Corrective Action

Remember:

– The solutions to be implemented need to be robust enough; The

goal here is to prevent the recurrence of the root causes in future.

– The solutions should not be soft, targeting only on the softer peopleissues.

Giving recommendation to people is not a robust Corrective action!

Conform to the set standards

8/6/2019 RCA 3 Hours v6



Conform to the set standards

Once the corrective actionshave been implemented intothe work place, it must beensured that the corrective

actions are sustained for aconsiderable period of timeby:

Regular confirmation to

standards Immediate action to

rectify concerns (any deviation

to the set standards)

Recognizing outstandingeffort and achievement

8/6/2019 RCA 3 Hours v6



The RCA Template

RCA Templa te

RCA: Team Activity

8/6/2019 RCA 3 Hours v6



RCA: Team Activity

The following are the live cases where the process facedsome defects/errors.

Lets try doing a Root Cause Analysis on some of them!

Sample RCA

8/6/2019 RCA 3 Hours v6


40Confidential © 2009 WNS Global Services | www.wns.comwww.wns.com

Thank You!

Documents

RCA 3 Hours v6