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Lead Root Cause Failure analysis What was the final cause? Oh was that the real root cause Find the Root Cause Not the Visual Root Cause Tracing a problem to its origins • Cause Analysis is a popular and often-used technique that helps people answer the question of why the problem occurred in the first place. Cause Analysis seeks to identify the origin of a problem. It uses a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can: 1. Determine what happened. 2. Determine why it happened. 3. Figure out what to do to reduce the likelihood that it will happen again. *Cause Analysis assumes that systems and events are interrelated. An action in one area triggers an action in another, and another, and so on. By tracing back these actions, you can discover where the problem started and how it grew into the symptom you're now facing. Three to the Solution of One • Physical root causes are the physical component that caused the failure event. These are almost always present and are typically the overall physical reason the event occurred. Traditional “Failure Analysis” is key to determining the physical root cause. Unfortunately, if we only rely upon it, we will stop too early and implement a physical redesign because all we know is what physically failed. • Human root causes are the last human actions that led to the failure event. These usually are, but not always, present. Too often, organizations seek out the individual that did a wrong action and stop there. This is counterproductive and will make people unsupportive of Root Cause because it becomes a “witch-hunt.” • Latent root causes are the reasons why decisions were made that resulted in the error. There will usually be more than one latent root, and typically, if these did not exist, then the human root likely would have been avoided. Examples are organizational systems and processes that made the human think a certain way and make the improper action. Eliminating latent root causes will eliminate the failure event, and should be the focus of the investigation. You'll usually find three basic types of causes: Usually find three basic types of causes: 1. Physical causes – Tangible, material items failed in some way (for example, a car's brakes stopped working). 2. Human causes – People did something wrong. or did not doing something that was needed. Human causes typically lead to physical causes (for example, no one filled the brake fluid, which led to the brakes failing). 3. Organizational causes – A system, process, or policy that people use to make decisions or do their work is faulty (for example, no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid). Cause Analysis looks at all three types of causes. It involves investigating the patterns of negative effects, finding hidden flaws in the system, and discovering specific actions that contributed to the problem. Stack, Rack and Rate your Findings SPORADIC YOUR DATA Think the Magic Three Count to Three Root Cause Analysis has five identifiable steps Define the Problem • What do you see happening? • What are the specific symptoms? Collect Data • What proof do you have that the problem exists? • How long has the problem existed? • What is the impact of the problem? Identify Possible Causal Factors • What sequence of events leads to the problem? • What conditions allow the problem to occur? • What other problems surround the occurrence of the central problem? Did you Map the Cause Determine the total impact of your problems • Even a simple analysis can be eye-opening to the people who deal with the problem on a regular basis. Managers are sometimes unaware of the details that those closest to the work view as common knowledge. Realistically, the total value also includes the risk to safety, customers and operations. The Cause Mapping method provides a disciplined thought process for working through complex problems. The Cause Mapping method involves both critical thinking and creative ideas. Analyzing why an issue occurred with objective facts and creative, thoughtful insight leads to better solutions. Two Types Sporadic or Chronic. • Sporadic failure events often are one-time events that usually gain significant attention because they usually involve significant, unexpected, and severe consequences. • Chronic events, unfortunately, are those that are accepted but may have significant cumulative losses over a long period. Most failure events that occur more than once should be considered chronic. Do it Like Spock “Analysis” Ask why 5 times Think about the power of WHY • The laboratory aide was cut by a dissection knife. • The knife was left by the sink. • The area was not cleared on the previous day. • Clearing is not a daily habit. • Standard operating procedures/documentation for clearing do not exist. Scale and Map the Events In doing your investigation * Always If possible, start in a “friendly sandbox” surrounded with sponsors and peers who understand there will be glitches, but will accept these as the process is tuned. The root cause is “the evil at the bottom” that sets in motion the entire cause-and-effect chain causing the problem(s). Remember at the End You always need a Solution
"Lead Root Cause Failure analysis.pptx"