Root Cause Analysis Presented By: Team: Incredibles
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1 Root Cause Analysis Presented By: Team: Incredibles San Jose State UniversityCMPE 203, Fall 2009Root Cause Analysis Presented By: Team: Incredibles
2 Agenda Introduction What is RCA? Why do we need? Types of RCA Techniques/Tools- Kepner-Tregoe Method- FMEA- Fishbone DiagramCase 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 symptomsReactive methodGoals- Failure identification- Failure analysis- Failure resolutionIterative 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 missionEvent Investigation - Phase II- Objective evaluation of the data collected to identify any causal factor that may have led to the failureResolution 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
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 failuresSystem-based RCA- Hybrid of the previous types- New concepts includes:- change management, systems thinking, and risk management.- Root causes:- organizational culture and strategic management8
9 Methods of Root Cause Analysis Change AnalysisBarrier AnalysisMORT: Management Oversight and Risk TreeHuman Performance Evaluation (HPE)9
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 causeKepner-Tregoe is a mature process with decades of proven capabilities.Kepner-Tregoe Problem Analysis was used by NASA to troubleshoot Apollo XIII.10
11 Tools for Root Cause Analysis Add diagrams Diagrams11
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.12
14 FMEABenefits: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.14
15 Fishbone Analysis Definition - Technique to graphically identify and organize many possible causes of a problemAdvantages- Helps to discover the most likely ROOT CAUSES of a problem- Teach a team to reach a common understanding of a problem.15
16 Fishbone Analysis Machine Material Measurement Problem Management 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.MachineMaterialMeasurementcausecausereasonProblemcausecausereasonManagementMethodMan Power16
17 Fishbone Analysis 5 WHY’S WHY WHY WHY WHY WHY Car stopped Middle of the roadRan out of GasDidn’t buythis morningWHYWHYWHYDidn’t havemoneyLost them inlast night’s pokerWHYWHYNot very goodin “bluffing”17
18 Case Study – Safeway.com Safeway outsourced a module of Safeway online to HCL, IndiaProject Details – Add a new module for selling Patio furniture online on .Agreed duration - 8 months, June, 07 to February, 08Actual delivery – June ’08After the project was finished TCS performed a Root Cause Analysis to analyze the delays and to avoid problems in future.18
19 Case Study – Fishbone Analysis ControlInventoryInventory Update Every 12 hoursNo Clear UnderstandingReal time inventoryScope DefinitionNo Clear deadlinesSeparate SystemsWrong EstimatesSeparate Systems for Sales & SupplierProject DelayNo backup for Critical ResourcesManaged SystemsInadequate ResourcesDifferent SuppliersCommunicationLack of StandardsNo Communication planTime and Format of Systems differentResourcesBenchmarking19
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.20