Presentation on theme: "Root Cause and Corrective Action Tutorial"— Presentation transcript:
1 Root Cause and Corrective Action Tutorial January 21, 2014
2 Course OverviewThis presentation is an introduction to performing Root Cause and Corrective Action (RCCA).The RCCA process includes:Clearly defining and analyzing a defectIdentifying solutionsCarrying out solutionsValidating the effectiveness of applied corrections to eliminate a defect.
3 ApplicationRCCA applies to the activities associated with correcting and preventing defects related to:all phases of production from raw material to finished productproduction processesall aspects of your company’s businessRCCA can be beneficially applied to all departments and functions in a company.
4 Goals The Goals of this presentation are: To provide a working understanding of the roles, responsibilities & activities associated with RCCA;To assist our suppliers in performing this important function when responding to a SCAR;To provide tools to our suppliers that may help in identifying and addressing defects before they are delivered to Marvin Engineering.
5 Hands on ExperienceThis afternoon we will provide an opportunity to apply the concepts provided in this presentation to:Conduct a problem investigation (fact finding).Determine the Root Causes (causal analysis)Define actions to eliminate the problems (identify solutions)
6 Root Cause AnalysisRoot cause analysis is an approach to identify the underlying causes of why an incident occurred so that the most effective solutions can be identified and implementedRCCA comes down to three basic questions: What's the problem?What allowed it to happen?What will prevent it in the future? The word root, in root cause analysis, refersto the underlying causes, not the one cause.
7 If effective RCCA is not performed, the problem will reoccur. Root Cause DefinitionRoot Cause: A condition or action that begins a chain that ends in a defectThere are multiple root causes that can result in the same problemAddressing only 1 of many causes won’t eliminate the defect.If effective RCCA is not performed, the problem will reoccur.
8 Symptom vs. Root Causes Symptom Approach Root Cause Approach Old New “Errors are often a result of worker carelessness.”“We need to train and motivate workers to be more careful.”“We don’t have the time or resources to really get to the bottom of this problem.”“Errors are the result of defects in the system. People are only part of the process.”“We need to find out why this is happening, and mistake-proof it so it won’t happen again.”“This is critical. We need to fix it for good, or it will come back and burn us.”
9 The RCCA Process Simplified Phase 1: Understand the problem (Investigation)Phase 2: Identify the causes (Analysis)Phase 3: Identify and implement solutions (Decision)
10 The RCCA Process Detailed Define and confirm the problemCapture (contain) all affected itemsRestore (rework) the discrepant items to complianceFind the causes of the problemDevelop an action plan prevent a recurrenceImplement the planEvaluate the effectiveness of the solutionsProvide Objective Evidence of the implemented solutions
11 When to initiate RCCA Corrective Action triggers: Customer SCAR issued A Supplier NotificationRecurring nonconformityAudit findingSub-tier supplier defect foundThe Corrective Action and Preventive Action system provides for the resolution of deficiencies related to design, purchasing, Supplier / Subcontractor deficiencies, manufacturing, test and other operations affecting quality.
12 Define the Problem Phase 1: Investigation A well-written problem statement answers four simple questions:What is the specific problem?Where did it happen?When did it happen?How many or how much is involved?
13 Problem Statement Phase 1: Investigation The statement of a documented problem (from a Marvin Engineering SCAR)S/B /-.001 Dia. Hole, B/P sheet 3, zone C-4, section A-AIS O/S to .228
14 Restate the Problem Phase 1: Investigation Problem Restated: PN 1534AS1234 has an oversized hole: S/B /-.001 dia.; IS O/S to .228; B/P : sheet 3, zone C-4, section A-A.Work orders: 216, 178 and 230Machines: Drill Presses #2 and #9Qty. = 121 pcs. on SCAR, 78 pcs. In work
15 Containment Action Phase 1: Investigation Search to find all items affected by the problem. Isolate them to ensure they are not processed further, or shipped to the customer.Investigate all areas inside and outside the company:Work in processOpen P.O.sAt outside suppliers, e.g. plating, heat treatShipped to customer
16 Determine the Root Causes Phase 2: AnalysisDo not sit at a desk, read the problem statement, and then “solve” the issue alone.Instead, involve others who have knowledge to offer:The Purchasing AgentThe Machine OperatorThe Quality Inspector
17 Something Must Change if an Escape Occurs EscapesWork Cell or FacilityAn escape is movement of a defect to the next work area, or to the customerEscapeProcess BProcess AEscapePLUG THE HOLE!Get the bleeding stopped before you try to set the broken leg.Process CMarvin EngineeringEscapeSomething Must Change if an Escape Occurs
18 Eliminate the defect as far up the stream as possible. At the source. Why Perform RCCA?Defects eat your profit. The later they are found, the more they costDesignComponent LevelAssemblyTest or InspectionBy Customer?Eliminate the defect as far up the stream as possible. At the source.
19 Corrective Actions: Fix the nonconformity and prevent its recurrence Defect or unwanted eventShort TermCorrective Actions fix the DefectContainmentRestore affected items to complianceRoot CausesLong TermCorrective Actions fix Root Causes and Prevent RecurrenceCorrective Actions
20 Corrective Action Phase 3: Decision Short Term Corrective Action(s) fix the immediate problem(s)Long Term Corrective Action(s) fix the systemic problems at the root cause levelGenerate no additional problemsIMPORTANT
21 Not All Corrective Actions are Created Equal Corrections that are systemic in nature, like automatic checks or gates are significantly better than just cautioning an employee to be more carefulCorrective Action ContinuumweakSTRONGEmployee CounseledFormal TrainingWarning on/ in tools, instruction, work areaMandatory checks & reviewsDesign, tooling, kitting, shadow boxes, automated checkingControl of process inputs, resulting in controlled outputs
22 Mistake Proofing Phase 3: Decision When to use Mistake Proofing: Human error can cause mistakes or defects to occurThe customer can make an error which affects the outputAt a hand-off step in a processConsequences are expensive or dangerousElevator“..mistakes will not turn into defects if errors are discovered and eliminated..” Shingo
23 Verification & Validation Did we do what we said we were going to do?ValidationWere the actions effective in eliminating the problem and preventing it from recurring?Were other problems created because of the changes?
24 Objective EvidenceEach SCAR response requires that evidence of the changes made are provided to Marvin Engineering along with the SCARExamples:Training sign-in sheets for employee training on a new or changed procedureA copy of the new or changed procedureThe inspection data validating the First Article Inspection part from a changed CNC programA copy of a revised inspection sheet adding a previously skipped characteristic
25 Without these the defect cycle will repeat SummaryThe fundamental Root Cause & Corrective Action (RCCA) process involvesContainment, Correction, Root Cause Analysis, Corrective Action, Verification, ValidationEffective RCCA depends upon:A well written problem description - define the requirement being violatedA robust causal analysis - use quality toolsA diligent validation - with data showing elimination of the root causeWithout these the defect cycle will repeat