Professional Documents
Culture Documents
Root Cause Analysis
Root Cause Analysis
20
Topics
• Objectives
#AhmedEltayef
• Brainstorming
• Prioritization
– Multivoting
– Importance-Difficulty Matrix
• Next Steps
21
Objectives
• Learn and apply in a case study the concepts and
#AhmedEltayef
techniques of
– Why Reality Charting
– Ishikawa Diagramming
– Multivoting
– Importance-Difficulty Matrix
• Be prepared to
– Select a root cause analysis (RCA) process by May 13, 2015
– Complete the RCA for your selected mission-critical occupations
(MCOs) by July 15, 2016
22
The Most Interesting Dog in the World
#AhmedEltayef
23
Arch Enemies
#AhmedEltayef
24
#AhmedEltayef
25
Fresh Look at RCA
• Although an RCA process was introduced during the previous
#AhmedEltayef
26
Purpose
#AhmedEltayef
27
An Investigative Approach
#AhmedEltayef
28
Digging Deep
#AhmedEltayef
29
RCA Process Criteria
#AhmedEltayef
Note: If a FAST chooses to use an already established process for the RCA that is
different from the techniques discussed today, it must meet these criteria.
30
Cautions
• There may be several root causes for an event or a problem, thus
#AhmedEltayef
• In cases of human error, people are rarely the true root cause.
Seek the system, policy, or process that allowed the error to occur.
31
#AhmedEltayef
Brainstorming
32
Why Brainstorming?
#AhmedEltayef
33
Guidelines
To get the most out of your brainstorming:
#AhmedEltayef
34
Guidelines (cont’d)
You should also:
#AhmedEltayef
35
#AhmedEltayef
Root Cause
Identification
36
Today’s Processes
• We will engage in two root cause identification processes
#AhmedEltayef
38
Apollo RCA Principles
40
“Why’s” in Reality Charting
#AhmedEltayef
41
5 Steps to Problem Solving
Step 1:
#AhmedEltayef
42
5 Steps to Problem Solving
Step 2:
#AhmedEltayef
43
5 Steps to Problem Solving
Step 3:
#AhmedEltayef
44
5 Steps to Problem Solving
Step 4:
#AhmedEltayef
45
5 Steps to Problem Solving
Step 5:
#AhmedEltayef
47
Ishikawa Diagramming
#AhmedEltayef
48
What is an Ishikawa Diagram?
• Dr. Kaoru Ishikawa, noted for his quality management innovations,
#AhmedEltayef
49
Primary Benefit
#AhmedEltayef
50
Components of the Fishbone Diagram
Rectangles at the end show
Category
the main category causes
#AhmedEltayef
Cause
The spine is the large arrow going horizontally The problem (or effect)
from left to right and points to the effect you are investigating is
Problem placed on the right side
of the diagram
Primary causes are listed on arrows that
connect to the categories Cause (+) Cause (-)
Arrows going from left to Arrows going from right to
right indicate causes that left indicate causes that
increase(+) the main diminish the problem
problem
Category
51
Typical Diagram
#AhmedEltayef
52
Steps to Creating a Fishbone Diagram
Using a flip chart, Microsoft Word or Visio, etc.
#AhmedEltayef
53
Your Turn
• Use the same information from our case study
#AhmedEltayef
56
#AhmedEltayef
58
#AhmedEltayef
Multivoting
59
About Multivoting
#AhmedEltayef
60
Benefits
#AhmedEltayef
61
How it Works
#AhmedEltayef
62
Voting Procedures
Voting Options
#AhmedEltayef
63
Trimming the List
64
Let’s Multivote!
• Using the collective unique root causes identified, we will facilitate
#AhmedEltayef
• Please ensure you cast all of your allocated votes in each round
65
Importance-Difficulty Matrix
#AhmedEltayef
Difficulty
Importance
66
The Matrix
• A quad chart to plot options according to their relative
#AhmedEltayef
Importance Difficulty
The impact an item has on your vs. The amount of effort, resources,
problem statement and the and time potentially needed to
extent to which addressing it address an item, including
could better the situation overcoming anticipated barriers
67
How to Plot Items
1. On a large sheet of paper, draw your quad chart and label the
#AhmedEltayef
Importance
69
Matrix Exercise
• Use the same list of root causes from our multivoting exercise
#AhmedEltayef
70
#AhmedEltayef
Next Steps
71
RCA Deliverables
#AhmedEltayef
72
Selecting Your RCA Process
• FASTs may select
#AhmedEltayef
• FASTs will notify OPM of their selections through the RCA Process
Certification Form due May 13, 2016
73
Conducting Your RCA
#AhmedEltayef
74
Submitting Your Results
#AhmedEltayef
75
#AhmedEltayef
76
#AhmedEltayef
77