1. Relentless Root Cause Analysis
Definition: The rapid and persistent pursuit of the fundamental breakdown or failure of the process that, when resolved, prevents a recurrence of the problem.
The root cause is the fundamental breakdown of the process.
The root cause must be controllable and not an act of nature.
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2. Relentless Root Cause Analysis
What is a process?
The combination of people, material, machines,tools, environment, preventative maintenance, measuring and test equipment, and work instructions needed to produce a product or service. In other words – a series of inputs are combined with a series of actions that result in a finished part.
Actions
Inputs
Outputs
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3. Relentless Root Cause Analysis
What are the fundamental elements of root cause analysis?
Each problem is a golden nugget or treasure.
Each problem tells a story about why and how it occurred. (There are no isolated incidents.)
Solving problems requires a mindset that is alert, open-minded, patient, tenacious, and persistent.
It is critical that everyone take a personal and active role in improving quality.
The “true” problem must be understood from the data before action is taken.
Each problem must be pursued and resolved rapidly.
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4. Relentless Root Cause Analysis
Why is relentless root cause analysis important?
Defect found at:
The first process
The next process
The last process
Final Inspection
Customer production line
Cost to TSCO $1
$10
$100
$1000
$10000
Impact to TSCO
Very Minor
Minor Delay
Minor scrap/ rework
Rework
Partial work orders
High Scrap
Significant rework
Work order 0 qty.
Delay in delivery
Additional inspection
Excessive Scrap
Off-line charges
Expedited freight
Reputation
Loss of customer
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5. Symptom Root Cause Relentless Root Cause Analysis
The danger in root cause analysis – treating the symptom.
Symptom
Root Cause
Assumes at any given time a worker makes a choice to work error-free or not.
Assumes errors are the result of worker carelessness.
The method is to motivate workers to be more careful (write-ups and termination are common motivational techniques used)
Assumes that errors are the result of defects in the process. People are only part of the process.
Assumes there are multiple causes of errors.
The method of improvement involves identifying appropriate ways to improve the process (action plans involving multiple responsibilities are used).
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6. D I V E Relentless Root Cause Analysis The Problem Solving Process.
Investigate
Problem
Verify
Root Cause
Ensure a Mistake
Proof Solution
Problem Found
Form Team
Analyze data
Customer
Feedback
Implement
Corrective Action
Define Problem
Conduct
failure analysis
Verify
Corrective Action
Update
Documents
Contain problem
Lesson’s
Learned
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7. D I V E Relentless Root Cause Analysis
The DIVE Approach to problem solving D
- Define the problem I
- Investigate the problem V
- Verify the root cause E
- Ensure a mistake-proof solution is achieved and implemented
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8. Relentless Root Cause Analysis
The DIVE Approach to problem solving
LESSON’S LEARNED:
After the problem is resolved, you must:
Update the FLOW, PFMEA, CONTROL PLAN, and WORK INSTRUCTIONS
Review SIMILAR PRODUCTS and IMPLEMENT the same or similar Mistake-Proof solution.
Share the LESSON with other departments and Plant locations
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9. D I V E Relentless Root Cause Analysis The Problem Solving Process.
Problem Found
Form Team
Define Problem
Contain problem
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10. Relentless Root Cause Analysis
Step 1: Define the Problem
Write a good Problem Statement:
Problem: The turbo pipe is bad. What is bad? It is a value statement that does not communicate the problem
Better: The turbo pipe is too small. What information does this give? What information is missing? The problem description is a little more clear, but it is missing something.
Best: The turbo pipe inlet ID measures 4.5” and the spec calls for 5.0”. This statement tells what product, what location on the part, and what dimension is not meeting the customer requirement.
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11. Relentless Root Cause Analysis
Step 1: Define the Problem
Contain the problem:
Protection of the customer is crucial. Gather all suspect materials and establish how you will prevent the problem from escaping.
Identify suspect material with “HOLD for DISPOSITION” tag.
Inspect all Suspect Material for problem.
Clearly identify any material that has been checked and found good.
Disposition ALL materials in a manner that protects the customer and TSCO
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12. Relentless Root Cause Analysis
Root Cause Toolbox.
Generating Ideas:
Brainstorming
Force Field Analysis
5 WHY’s
IS / IS NOT
Finding Patterns:
Cause and Effect Diagram
Scatter Diagram
PFMEA
Control Charts
Run Charts
Check Sheets
Examining Results:
Root cause test
Solution Selection Worksheet
DOE (design of experiments)
Prioritizing Data:
Histogram
Pareto charts
Nominal Grouping
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13. D I V E Relentless Root Cause Analysis The Problem Solving Process.
Investigate
Problem
Problem Found
Form Team
Analyze data
Define Problem
Conduct
failure analysis
Contain problem
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14. Relentless Root Cause Analysis
Step 2: Investigate the Root Cause using the right tools.
Generating Ideas:
Brainstorming
Force Field Analysis
5 WHY’s
IS / IS NOT
Prioritizing Data:
Histogram
Pareto charts
Nominal Grouping
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15. Relentless Root Cause Analysis
Step 2: Investigate the Root Cause using the right tools.
Method of “throwing out” any possible idea that anyone on the team thinks could be the cause.
Brainstorming
Guidelines:
Record all ideas
No Judgment (there are no “bad” ideas.
Combine like ideas
Rank in order of likelihood
Note: Say the first thing you think of.
Rules:
One thought at a time
Don’t interrupt
Don’t criticize
Don’t discuss / analyze
Build on ideas
Record the ideas
Collect as many ideas as you can
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16. Relentless Root Cause Analysis
Step 2: Investigate the Root Cause using the right tools.
5 WHY’s
Problem: Flat tire in garage
Why? Nails on garage floor
Why? Box on shelf split
Why? Box got wet
Why? Roof leaks
Why? Shingles blown off in hurricane.
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17. Relentless Root Cause Analysis
Step 2: Investigate the Root Cause using the right tools.
5 WHY’s – there can be multiple root causes.
Problem: Parts are dirty
Why? Wash did not clean parts.
Why? No Soap was added on schedule.
Why? Operation being ran by operators from another area
Why? No operator for the process
Why? Wash did not clean parts.
Why? Pressure too low. Should be 45 psi is 14 psi
Why? Pump is not working
Why? Pump gets clogged with rags, tags, and paper.
Why? Operators not removing from baskets.
Why? Wash did not clean parts.
Why? Parts not stacked where water can penetrate
Why? No documented instructions for part placement.
Why? Tribal knowledge
Why?
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18. 5 Why Worksheet 8/02/04 Problem Statement: Why: Answer: Why: Answer:

19. Relentless Root Cause Analysis
Step 2: Analyze the data using the right tools.
Prioritizing Data:
Histogram
Sometimes called a correlation chart, a perfect 450 angle returns a value of 1. It means that as the one event occurs, the other event will always occur in direct relationship with the amount of change. X
Independent
Variable X X X X X X X X
Dependant Variable
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20. Revolutions per minute (RPM)
Relentless Root Cause Analysis
Step 2: Analyze the data using the right tools.
Prioritizing Data:
Histogram
Example: If pressing the gas pedal of my car is the Independent variable, and rpm is the dependant variable, then as I press the gas pedal my rpm will increase in direct proportion to the amount of pressure I exert on the pedal. X
Press pedal X X X X X X X X
Would this work for braking? Why or why not?
Revolutions per minute (RPM)
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21. Relentless Root Cause Analysis
Step 2: Analyze the data using the right tools.
Prioritizing Data:
Pareto charts
Method of “Ranking” issues / problems. It allows you to see which items contribute most to our problem.
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22. Relentless Root Cause Analysis
Step 2: Analyze the data using the right tools.
Focus on the top 2 or 3: called the principle of the many over the few.
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23. Relentless Root Cause Analysis
Step 2: Analyze the data using the right tools.
METHOD
MANPOWER
Finding Patterns:
Cause and Effect Diagram
Effect
MACHINES /
equipment
MATERIAL
ENVIRONMENT
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24. Settings APQP Pump PM’s Work Instructions Stacking Turn-over Water
Problem Statement (cause):Customer received CAC tubes that are dirty and have lubricant,
metal shavings, and other debris
METHOD: CP
Machine/tools: Mart Wash
PFMEA
Control Plan
Settings
Temperature ?
No clearWI
APQP
Pump
Pressure at 14 psi s/b 45
PM’s
Order of Operations
Frequency of
Operations
Disorganized?
Water jets
Work
Instructions
Stacking
Effect
Soap requirements
Turn-over
Water
SOAP
Staffing No
dedicated
resource
De-foam
Training
Manpower:
MATERIAL
ENVIRONMENT:
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WORKSHEET: Cause and Effect

25. 8/02/04 Problem Statement (cause): METHOD: Machine/tools: Effect
Manpower:
MATERIAL
ENVIRONMENT:
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WORKSHEET: Cause and Effect

26. Relentless Root Cause Analysis
Step 2: Analyze the data using the right tools.
METHOD
Inspection
MANPOWER
Skills
Work Instructions
Staffing
BP Reading
Set-up
Experience
Control Plan
Training
Set-up sheets
TUBE IS
15 mm
Undersized
Frequency
Hardness
Temperature
Camber 5S PM
Wear
In / out
Physical
properties
Storage
MACHINES /
equipment
Work Area
MATERIAL
ENVIRONMENT
Tools
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27. Relentless Root Cause Analysis
Step 2: Analyze the data using the right tools.
Finding Patterns:
Scatter diagrams
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28. Relentless Root Cause Analysis
Step 3: Verify the Root Cause using the right tools.
Examining Results:
Root cause test
Answers to these questions will tell you if you have identified the root cause.
Does the root cause statement identify an element of a process? YES
Is the root cause controllable? YES
Can you ask “why” one more time and get another controllable cause? NO
Is our identified root cause the fundamental breakdown or failure of the process? Yes
If we correct/improve the root cause we have identified, will that ensure that the identified problem will not recur? YES
Have we identified the real root cause of the problem? YES
Have you checked to see if our identified root cause is applicable to more than one part/process? YES
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29. Relentless Root Cause Analysis
Step 3: Verify the Root Cause using the right tools.
Examining Results:
Solution Selection work sheet
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