When should root cause analysis be performed? When PROBLEMS occur !! Supplier Defects Out of Control Process Excess Inventory Computer issues Scrap Problems medical errors Human Error Audit Finding When should we perform root cause analysis? All the time! When you do not dig deep enough into the detail of these problems, you should expect them to continue to reoccur time and time again Add your company lingo and terminology! Missed Deliveries Safety Issues Machine Defects Overspending Budget Workmanship Defects

Nothing is allowed to further escape to the customer How does it work? Contain the problem… PROCESS A PROCESS B PROCESS C PROCESS D Contain the problem. Make certain that the group (customer in this case) that finds the problem does not see it again! CUSTOMER Nothing is allowed to further escape to the customer

Immediate Action Step #3 Must isolate effects of problem from customer 1 8 2 7 3 6 4 5 Immediate Action Must isolate effects of problem from customer Usually “Band-aid” fixes 100% sorting of parts Re-inspection before shipping Rework Recall parts/documents from customer or from storage Only temporary until corrective action is implemented (very costly, but necessary) Must also verify that immediate action is effective The third step is to address the immediate action needed to keep the problem from spreading any further. Often times, this involves some sort of band-aid, or containment effort, such as: sorting of parts or paperwork, re-inspection, rework, or recall Whatever immediate action is done, it should only be temporary, and not stay in place after the root cause has been corrected. A check should also be made to see that the containment and immediate action actually kept the problem from spreading any further

Root Cause Why? Part reversed Worker not sure of correct part orientation Part is not marked properly The 5 Why’s implies asking why five times, but it could be more than 5. Asking at least five times forces the team to dig beyond their own knowledge of the process and make certain they don’t stop short of the root cause Engineering ordered it that way from vendor Why?

Cause and Effect Procedures Personnel Didn’t complete project on time Lack of worker knowledge Poor project plan Poor project mgmt skills Lack of resources Didn’t complete project on time The team uses the Cause and Effect Diagram to identify possible causes of the projects delay. Each cause is placed into the appropriate category Inadequate computer programs Poor documentation Inadequate computer system Materials Equipment