Root Cause Analysis / Analýzy kořenové příčiny

TOOL / Nástroj USED FOR / Použití pro BENEFITS / Výhody DRAWBACKS / Nevýhody

• Tracing back the sequence of events that
led to the problem or nonconformance
5 Whys
5 Proč * Zpětné vysledování řady událostí, které
vedly k problému nebo neshodě
• Informal; easy for anyone to do
• Uncovers causes that would otherwise be
ignored or missed
* Neformální, snadno proveditelné pro každého
* Odhaluje příčiny, které by jinak byly
opomenuty nebo nepovšimnuty
• Relies on other tools to validate the actual cause with
facts
• Of limited value if there are multiple causes
contributing to the problem
* Validování skutečné příčiny vůči faktům závisí na
ostatních nástrojích
* Má omezenou hodnotu, pokud k problému přispívá
více příčin

• A creative exercise to get ideas flowing
Brainstorming * Kreativní cvičení s cílem vyvolat volný tok
myšlenek
• Easy; nonthreatening
• Good team builder
• Relies on other tools to validate the actual cause with
• Uncovers causes that would otherwise be
facts
ignored or missed
• Undervalued because it’s fun
* Snadný; neodstrašující
* Validování skutečné příčiny vůči faktům závisí na
* Dobrý nástroj k budování týmu
ostatních nástrojích
* Odhaluje příčiny, které by jinak byly
* Podceňuje se protože je to legrace
opomenuty nebo nepovšimnuty

• Presents an easy to follow picture

• Helps in understanding inputs into a process • Intimidating to individuals who haven’t used it before
Cause-and-effect • A graphic depiction of contributors to
• Provides a more holistic perspective of the • Requires more training that other tools to be useful
problem or nonconformance
analysis situation
Analýza příčin a * Grafické znázornění přispěvatelů k
* Odrazuje pracovníky, kteří ho ještě nepoužili
důsledku * Poskytuje snadno čitelný obraz * Aby byl užitečný, vyžaduje hlubší školení než ostatní
problému nebo neshodě
* Pomáhá poznat vstupy do procesu nástroje
* Podává holističtější perspektivu situace

• Presents an easy to follow picture • Don’t have the level of detail found in
• A graphic depiction of contributors to • Helps to identify significant contributors to procedures/records
problem or nonconformance known problem or nonconformance • Not always readily understood
Pareto analysis
Paretova analýza * Grafické znázornění přispěvatelů k * Poskytuje snadno čitelný obraz * Postupy/záznamy neobsahují potřebnou úroveň
problému nebo neshodě * Pomáhá při identifikování přispěvatelů ke detailu
známému problému nebo neshodě * Není vždy správně pochopen

1/13 file:///conversion/tmp/activity_task_scratch/573791931.xls/Summary

It is an effective way of analyzing the key
factual information about the problem.
KT Problem Solving
Worksheet Identifies the possible causes of failure.
KT Pracovní list pro
řešení problémů *Jedná se o účinný způsob, jak analyzovat
klíčové faktické informace o problému.
*Identifikuje možné příčiny selhání
Uncovers causes that would otherwise be
ignored or missed.
Step by Step approach of problem solving.
Requires training to understand the appalication of its
use.
*Odhalí příčiny, které by jinak byly ignorovány
*Vyžaduje trénink, aby pochopil, jaký je jeho použití
nebo zmeškány.
*Přístup řešení problémů krok za krokem.
2/13 file:///conversion/tmp/activity_task_scratch/573791931.xls/Summary
 The 5 Whys / 5 proč
Why did this problem Why? Why? Why? Why? Why? How to use it:
happen? Proč? Proč? Proč? Proč? Proč? With this tool you begin with the
Proč problém nastal? problem and make your way back by
revisiting and investigating the actions
that preceded it.
The intention is literally to ask "why" a
minimum of five times.
Determine You ask such questions as "if this
Root happened, what caused it?" and/or
Cause "What happened before this?" and/or
Určit kořenovou "Why did this happen?".
příčinu The parth that the Five Whys will take
you down may surprise you.

Jak používat?
Tímto nástrojem začnete zkoumat
problém tím, že se znova podíváte a
Why was this problem not Why? Why? Why? Why? Why? prozkoumáte akce, které mu
prevented? Proč? Proč? Proč? Proč? Proč? předcházely.
Proč se tomuto problému Záměrem je doslova položit minimálně
nepředešlo? pětkrát otázku "proč".
Kladete otázky jako např. "pokud se toto
stalo, co to zapříčinilo?" anebo "co se
stalo předtím? a/nebo "proč se to
stalo?".
Cesta, kam vás těchto Pět proč zavede
Prevent může být pro vás překvapivá.
Recurrence
Předcházet
opakování
výskytu

Why use it?

It allows you to begin at a predetermined point and trace back the sequence of events that led to the problem.

Proč používat?
Umožňuje vám začít v předem definovaném bodě a zpětně sledovat řadu události, které vedly k problému

3/13 file:///conversion/tmp/activity_task_scratch/573791931.xls/5 Whys

 Brainstorming

Why use it?

To establish a common method for a team to creatively and efficiently generate a high volume of ideas.

Proč používat?
Zajistit týmu obecnou metodu kreativního a efektivního vytváření velkého množství nápadů.

How to use it:

Can be used as a structured or unstructured process.
The central brainstorming question is stated and agreed to.
Each team member, in turn, is given the opportunity to present an idea.
No idea is ever criticized.
As ideas are generated, write them down on a large board or chart where everybody can see them.
Keep this process going for no longer than 20 minutes depending on how complex the topic is.
The unstructured process is the same except team members are not solicited in rotation and anyone can submit an idea
at any time.

Jak používat?
Může se provést jako strukturovaný či nestrukturovaný proces.
Ústřední otázka pro brainstroming je stanovena a odsouhlasena.
Každý člen týmu dostává po řadě příležitost vyslovit nápad.
Žádný nápad se nikdy nekritizuje.
Vytvářené nápady se zapisují na velkou tabuli nebo flip chart, kde je může každý vidět.
Proces se v závislosti na složitosti tématu udržuje v chodu maximálně 20 minut.
U nestrukturovaného procesu je to stejné až na to, že členové nejsou vyzýváni postupně, ale každý může vyslovit nápad
kdykoli.

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5/13 file:///conversion/tmp/activity_task_scratch/573791931.xls/Brainstorming
 Cause & Effect Diagram
Why use it?
Diagram příčin a důsledku To allow a team to identify, explore, and
display, in detail, all of the possible causes to a
Causes problem
Příčiny
Proč používat?
Material Manpower Machinery Umožnit týmu detailně identifikovat,
prozkoumat a zobrazit všechny možné příčiny
Materiál Pracovní síla Stroj problému.

1. Does the operator have 1. Does the machine need

1. Check certificate of analysis
for raw material.
2. Inspect/test raw material in
stock.
1. Podívejte se na atest suroviny
2. Proveďte kontrolu/zkoušku
materiálu ve skladu
1. Check drawing and build
specifications.
2. Review work instructions
1. Podívejte se na výkres a do
specifikací
2. Přezkoumejte pracovní
instrukce
adequate training?
2. Did the operator receive
different instructions from a
supervisor?
1. Má operátor odpovídající
výcvik?
2. Nedostal operátor od mistra
jiné pokyny?
1. Is the inside equipment
calibrated?
2. Is the tool capable of
measuring the part?
1. Je vnitřní zařízení
kalibrované?
2. Je nástroj schopný změřit díl?
adjusting?
2. Are the drills defective? How to use it:
3. Are the feed sand speeds Generate the causes needed to build the
correct for the job? diagram by using the Brainstorming
process.
1. Nepotřebuje stroj seřízení? The causes make up the "bones" of the
2. Nejsou vrtáky vadné? diagram.
3. Jsou rychlosti posuvu pro The categories Material, Manpower, etc. can
be changes.
daný úkon správné? Effect There is no perfect set of categories or
Důsledek set number.
Make the categories fit the problem.
Place the brainstorming causes in the
appropriate category.
Inspection report For each basic cause ask "why does this
shows part not happen" to lead to a more deeper cause. For
to specification. each deeper cause continue to
Z kontrolního protokolu push further, but know when to stop.
vyplývá, že díl neodpovídá
specifikacím. Jak používat?
Použitím brainstormingu zformulovat příčiny
potřebné k sestavení diagramu.
Příčiny tvoří "kosti" diagramu.
Kategorie Materiál, Pracovní síla atd. mohou
být změněny.
Neexistuje dokonalý soubor kategorií či
velikost souboru.
Volte kategorie tak, aby odpovídaly problému.
Příčiny z brainstormingu připojte k odpovídající
N/A
kategorii.
U každé základní příčiny si položte otázku
N/A
"proč k tomu došlo", abyste se dostali k hlubší
příčině. U každé hlubší příčiny postupujte dál
do hloubky, ale musíte vědět, kdy přestat.

Method Measurement Environment

Metoda Měření Prostředí

6/13 file:///conversion/tmp/activity_task_scratch/573791931.xls/Cause & Effect Diagram

Why use it?
To allow a team to identify, explore, and
display, in detail, all of the possible causes to a
problem

Proč používat?
Umožnit týmu detailně identifikovat,
prozkoumat a zobrazit všechny možné příčiny
problému.

How to use it:

Generate the causes needed to build the
diagram by using the Brainstorming
process.
The causes make up the "bones" of the
diagram.
The categories Material, Manpower, etc. can
be changes.
There is no perfect set of categories or
set number.
Make the categories fit the problem.
Place the brainstorming causes in the
appropriate category.
For each basic cause ask "why does this
happen" to lead to a more deeper cause. For
each deeper cause continue to
push further, but know when to stop.

Jak používat?
Použitím brainstormingu zformulovat příčiny
potřebné k sestavení diagramu.
Příčiny tvoří "kosti" diagramu.
Kategorie Materiál, Pracovní síla atd. mohou
být změněny.
Neexistuje dokonalý soubor kategorií či
velikost souboru.
Volte kategorie tak, aby odpovídaly problému.
Příčiny z brainstormingu připojte k odpovídající
kategorii.
U každé základní příčiny si položte otázku
"proč k tomu došlo", abyste se dostali k hlubší
příčině. U každé hlubší příčiny postupujte dál
do hloubky, ale musíte vědět, kdy přestat.

7/13 file:///conversion/tmp/activity_task_scratch/573791931.xls/Cause & Effect Diagram

 Why use it?
An easy to understand, graphic depiction of contributors to a
Pareto Analysis problem.
Paretova analýza Helps focus efforts on the problems that offer the greatest
potential for improvement.

60 Proč používat?
Grafické znázornění přispěvatelů k problému pro snadné
pochopení.
Pomáhá koncentrovat úsilí na problémy, které nabízejí největší
Measurable

50
Ukazatel

potenciál zlepšení.

40
How to use it:
Once the problem has been identified, choose the causes that will
be monitored, compared, and ranked.
30 The Brainstorming process can be used to help identify
potential causes.
Choose the most meaningful unit of measurement such as
frequency or cost.
20
Choose the time period for the study that is long enough to
represent the situation and then gather the necessary
data.
10
Jak používat?
Jakmile byl identifikován problém, vybírají se příčiny, které se budou
0 monitorovat, srovnávat a řadit podle významu.
Jako pomůcka pro identifikování potenciálních příčin se může použít
Problem 1 Problem 2 Problem 3
Problems Problem 4 Problem 5 brainstorming.
Problémy Zvolí se smysluplná jednotka měření (ukazatel) jako například
četnost nebo náklady.
Zvolí se časový úsek studie, který bude dostatečně dlouhý, aby
reprezentoval situaci a pak se shromáždí nezbytná data.

Problem 1 50
Problem 2 30
Problem 3 15
Problem 4 5
Problem 5 5

8/13 file:///conversion/tmp/activity_task_scratch/573791931.xls/Pareto Analysis

 Problem Solving Worksheet Step 1 of 4
Problem Statement:

Problem (Logically could be but) Get

IS
Description IS NOT Information
What objects that are similar
What object has the in shape, composition, form or
What Object defect? function could have the defect
WH AT

but do not?

What other similar

What Defect What is the defect? defect(s) could have been
observed but were not?

Where on the object is the

Where else on the object
defect observed
Where on could the defect have
(inside/outside, top/
object bottom, same/different
been observed but was
not?
place,...)?

Where geographically
Where geographically was could the defective object
the defective object first have first been observed
Where first observed? but was not?
observed Where in the process was Where in the process
the defective object first could the defective object
WHERE

observed? have first been observed

but was not?

Where geographically
Where geographically have
Where seen could the defective
the defective objects been
since observed?
objects have been
observed but were not?

When in time could the

defective object have
When in time was the
first been observed but
defective object first
was not?
observed?
When in the process could
When in the process was
When first the defective object have
the defective object first
observed observed?
first been observed but
was not?
When in the life cycle of
When in the defective
the defective object was
object's life could the
the defect first observed?
defect have first been
WHEN

observed but was not?

What patterns of
What patterns of occurrence could have
occurrence of the defect been observed with
have been observed with respect to time but were
What pattern
respect to time? not?
since When during use of the When during use of the
defective object is the defective object could the
defect observed? defect have been
observed and was not?

How many objects could

How many How many objects have the
have the defect but do
affected defect?
not?

What is the magnitude of

the defect in terms of What magnitude could the
What size percentages, rates, defect have, but does
patterns, trends, yield, not?
BIG

physical dimensions, etc.?

How many defects could

How many defects are
Defects per there have been per
there per defective
object defective object but were
HOW

object?
not ?

What could the trend

What is the trend
have been but was not
Trend (increasing, decreasing,
(increasing, decreasing,
cyclical, etc.)?
cyclical, etc.)?

SP GL SF 1022a
Released: 01-Aug-2012 Is / Is Not - Problem Solving Worksheet
 Problem Solving Worksheet Step 1 of 4 Step 2 of 4
Problem Statement: Differences and Changes

Problem IS Logically could be but Get

Differences Changes Date
IS NOT What is different between the IS state and the IS NOT state What has changed between the IS state and the IS NOT state
Description Information
What objects that are similar
What object has the in shape, composition, form or
What Object defect? function could have the defect
WH AT

but do not?

What other similar

What Defect What is the defect? defect(s) could have been
observed but were not?

Where on the object is the

Where else on the object
defect observed
Where on could the defect have
(inside/outside, top/
object bottom, same/different
been observed but was
not?
place,...)?

Where geographically was
the defective object first
Where first observed?
observed Where in the process was
the defective object first
WHERE
Where geographically
could the defective object
have first been observed
but was not?
Where in the process
could the defective object

observed? have first been observed

but was not?

Where geographically
Where geographically have
Where seen could the defective
the defective objects been
since observed?
objects have been
observed but were not?

When in time could the

defective object have
When in time was the
first been observed but
defective object first
was not?
observed?
When in the process could
When in the process was
When first the defective object have
the defective object first
observed observed?
first been observed but
was not?
When in the life cycle of
When in the defective
the defective object was
object's life could the
the defect first observed?
defect have first been
WHEN

observed but was not?

What patterns of
What patterns of occurrence could have
occurrence of the defect been observed with
have been observed with respect to time but were
What pattern
respect to time? not?
since When during use of the When during use of the
defective object is the defective object could the
defect observed? defect have been
observed and was not?

How many objects could

How many How many objects have the
have the defect but do
affected defect?
not?

What is the magnitude of

the defect in terms of
What size percentages, rates,
patterns, trends, yield,
physical dimensions, etc.?
BIG
What magnitude could the
defect have, but does
not?

How many defects could

How many defects are
Defects per there have been per
------------ -------------
there per defective
object defective object but were
HOW

object?
not ?

What could the trend

What is the trend
have been but was not
Trend (increasing, decreasing,
(increasing, decreasing,
-------------- ---------------
cyclical, etc.)?
cyclical, etc.)?

SP GL SF 1022b Is / Is Not - Problem Solving Worksheet

Released: 01-Aug-2012
Comparative Analysis - Rules and Guidelines

Step 3a : Differences
Differences are facts that are only true of the IS column.
They may be obtained by asking:
What is special, unique or different only of the IS when compared with the IS NOT?
The words from the IS and IS NOT columns should be substituted for the corresponding words in italics.
Step 3b : Changes
Changes are things that have changed in, on around or about the differences.
They may be obtained by asking:
What has changed in, on, around or about the difference?
The words from the difference column should be substituted for the corresponding words in italics.
The date on which the change took place should also be entered into the date column.

Step 4 : Developing Possible Cause "Change - How" Theories

Theories are fully rounded possible causes, rather that probable causes, that may have created the defect.
They may be obtained by asking:
How could this change have caused the problem statement?
The words from the changes column and the problem statement should be substituted for the corresponding words in italics.

Step 5 : Testing the Theories

Tests of the theories are destructive critical evaluations of the developed theories against the sets of IS and IS NOT columns.
They may be obtained by asking:
If the possible cause theory is the cause of the problem statement why is it only the IS and never the IS NOT?
The words from the possible cause theory, the problem statement, the IS column and the IS NOT column should be substituted for the corresponding words in italics.
If the possible cause theory logically explains the information in the IS and IS NOT columns then put a "+" in the test matrix.
If the possible cause theory cannot logically explains the information in the IS and IS NOT columns then put a "-" in the test matrix.
If it is unclear whether the possible cause theory logically explains the information in the IS and IS NOT columns then put a "?" in the test matrix.

SP GL SF 1022e
Released: 01-Aug-2012 Is / Is Not - Problem Solving Worksheet
 Problem Solving Worksheet - Step 3 of 4
Possible Causes
List Possible Cause Theories Comment Proposed testing

10

11

12

13

14

15

SP GL SF 1022c
Released: 01-Aug-2012 Is / Is Not - Problem Solving Worksheet
 Test: If the possible cause theory is the cause of the problem statement
Problem Solving Worksheet then does it fully explain the IS and never the IS NOT ?
Problem Solving Worksheet Step 4 of 4
Problem Statement: 0 Test possible root causes for probability (show as +, - or ?)
1 2 3 4 5 6 7 8 9 10

Problem Logically could be but Get

Description IS IS NOT Information

What Object
WHAT

What Defect

Where on
object
WHERE

Where first
observed

Where seen
since

When first
observed
WHEN

What pattern
since

How many
affected

What size
HOW BIG

Defects per
object

Trend

SP GL SF 1022d
Released: 01-Aug-2012
Is / Is Not - Problem Solving Worksheet