Incredibles_Root Cause Analysis by zhangyun

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									San Jose State University
CMPE 203, Fall 2009




                        Root Cause Analysis


Presented By:
Team: Incredibles
Agenda


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

• Benefits of RCA
   - Real cause of the problem can be found
   - Problem recurrence will be minimized
Types of RCA


• Safety-based RCA


• Production-based RCA


• Process-based RCA


• Systems-based RCA
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.
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
Methods of Root Cause Analysis

• Change Analysis


• Barrier Analysis


• MORT: Management Oversight and Risk Tree


• Human Performance Evaluation (HPE)
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.
Tools for Root Cause Analysis
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.
FMEA Example
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.
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.
Fishbone Analysis

• 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.


                       Material               Machine
Measurement                           cause
                      cause
                                          reason

                         cause            cause
                                                             Problem
                                    reason

 Management               Method              Man Power
Fishbone Analysis


•   5 WHY’S



         Didn’t buy    WHY                     WHY       Car stopped
                              Ran out of Gas
        this morning                                   Middle of the road


              WHY


       Didn’t have     WHY     Lost them in     WHY   Not very good
         money               last night’s poker        in “bluffing”
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.
 Case Study – Fishbone Analysis

                 Control                              Inventory
                                  Inventory Update
        No Clear
                                    Every 12 hours
      Understanding



       Scope Definition             Real time inventory


          No Clear deadlines              Separate Systems


           Wrong Estimates                Separate Systems for
                                            Sales & Supplier
                                                                    Project Delay
    No backup for Critical                   Managed Systems
         Resources

        Inadequate Resources              Different Suppliers


        Communication                 Lack of Standards


No Communication               Time and Format of
     plan                        Systems different
                   Resources                         Benchmarking
Conclusion


  • Learning for the future projects.


  • Encourages Team based problem solving approach.


  • Errors are frequent and inevitable.


  • Saves cost and helps in identifying solutions.
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

								
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