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RCA
- Root Cause Analysis -
¥ Introduction to RCA
4 What is RCA
4 Why to Perform RCA
4 How to Perform RCA
4 Learn More About RCA
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Introduction to Root Cause Analysis
(RCA)
Eventually all manufacturing processes will experience
problems with non-conforming parts, equipment failure
resulting in lost productivity or rework expenses andpossible increased scrap. Even with the best quality systems,
training and Statistical Process Control (SPC), problems
can happen. What must be prevented are the repeat
problems. The problems you thought were resolved only to
reoccur, Repeat problems can be experienced in everyday
life. If you compare a manufacturing process to a garden, the
process problems would be the weeds in the garden. If you
pull up a dandelion and don't get the entire root it will just
keep popping back up. It is much the same with
manufacturing problems - if you don't get to the root cause
of the problem, it is eventually (if not frequently) going to re-
occur. The goal of a Root Cause Analysis (RCA) is to get down
to the true cause of the problem, the root cause.
What is Root Cause Analysis (RCA)
Root Cause Analysis (RCA) is a comprehensive term
encompassing a collection of problem solving methods used
to identify the real cause of a non-conformance or quality
problem. Root Cause Analysis is the process of defining,
understanding and solving a problem, The root cause has
also been described as an underlying or fundamental cause
of a non-conformance, defect or failure. Furthermore, the
term “root cause" can also be referred to as the precise point
in the causal chain where applying a corrective action or
intervention would prevent the non-conformance from
occurring,
Why Perform Root Cause Analysis (RCA)
Repeat problems are a source of waste in manufacturing.
Waste in the form of machine downtime, product rework,
increased scrap and the time and resources spent “fixing”
the problem. Many times we may believe that the problem is
resolved but in reality we have just addressed a symptom of
the problem and not the actual root cause. Correctly
performed, a Root Cause Analysis can identify breakdowns in
your processes or systems that contributed to the non-
conformance and determine how to prevent it from
happening again. An RCA is performed to identify whathappened, why it happened and then determine what
improvements or changes are required. Through the proper
application of RCA, repeat problems can be eliminated.
RCA methods and tools are not limited to manufacturing
process problems only. Many industries are applying RCA
methodology in various situations and are using this
structured approach to problem solving. Some examples of
where RCA is being used include, but are not limited to
* Office Processes and Procedures
* Quality Control Problems
* Healthcare Incident Analysis
* Safety-based Situations or Accident Analysis
* Failure Analysis in Engineering and Maintenance
* Change Management or Continuous Improvement
Activities
* Computer Systems or Software Analysis
The point is that RCA can be applied to almost any type of
problem that companies face every day. Another example
where RCA could be used is for a company that is
experiencing a high level of incorrect customer orders and
shipments. The process can be mapped, analyzed and the
root cause (s) of the problems can be identified and
resolved, The end result is a happy, loyal customer-base and
lower overall cost to the company.
How to Perform Root Cause Analysis
(RCA)
Root Cause Analysis (RCA) is usually a step in a larger
problem solving exercise. There are multiple tools that may
be used during a Root Cause Analysis. Some of them can
sometimes be completed by one person, but in most cases a
Cross Functional Team (CFT) approach will reap the greatest
benefits and increase chances of reaching the true “root
cause”,
There are also several problem solving methods that use
Root Cause Analysis within their problem solving process,such as Eight Disciplines of Problem Solving (8D), Six
Sigma / DMAIC, or Kaizen. The RCA is a critical step in each
of these examples,
The Problem
Before RCA can be performed, the problem must be well
defined. The following information must be determined and
documented:
* Who discovered the problem?
+ What exactly happened?
* Where in the process was the problem discovered?
* When was the problem discovered?
* How many / How often does it happen?
* How was the problem detected?
Next, the team may want to collect data or other additional
information. It may also be necessary to initiate interim
containment or corrective actions. The team should review
all gathered information and further define the problem. The
problem should be defined based on facts and data. Once
the problem is fully described the team can then begin the
Root Cause Analysis phase.
The Team
The Team should be comprised of personnel that have direct
knowledge of the process being examined and responsibility
for implementing any permanent corrective actions. In
addition, the team should include representatives from
Quality, Process Engineering and, when appropriate, team
members from the next step in the process or from other
shifts. Each member of the CFT will bring their own
knowledge and view of the process and the non-
conformance.
The Tools
There are multiple tools that could be utilized during a Root
Cause Analysis. This section will cover some of the tools
including how and when they could be of value to the
analysis. The first step is to determine what is included andwhat is not included in the problem investigation using the
Is/Is Not analysis.
Is/Is Not
The “Is/Is Not” analysis may be used at different points in the
RCA, It can be used while defining the problem to determine
what is in scope and will be considered during the analysis
and what is out of scope and will not be considered, It can
also be used when planning a solution, to help the team
decide what to include and what to exclude. The Is-Is Not
analysis allows the team to think about the problem and the
boundaries of what it is or is not. The tool helps the team
maintain their focus. If the boundary of the problem is not
clearly defined the team may stray off the initial path and
work on solving inconsequential problems.
Document what “Is" and “Is Not” part of or a characteristic of
the problem. The process works by asking the team various
questions such as:
* Who is impacted by this problem?
Does the team have the authority to resolve this issue?
What do we already know about the problem?
Is this something that will impact the customer?
Will we actually do something about this?
Ask the team enough questions until there is a clear
definition of the problem / scope of the problem solving
process.
Ishikawa Diagram
The Ishikawa or Fishbone Diagram is a useful tool in
determining the most likely causes (MLCs) of a quality
problem. The diagram is sometimes referred to as a
Fishbone Diagram because it looks much like a skeleton of a
fish with the effect or problem being listed in a box at the
end. The main sections of the diagram are used to address
the 6Ms (Man, Material, Method, Machine, Measurement and
Mother Nature (Environment). The diagrams are usually
worked right to left, with each large “bone” of the fish
branching out to include smaller bones with additional
details. It is important not to limit the teams brainstormingideas here. If an idea is in a different section of the diagram,
simply list it in the appropriate section and then go back to it
later. Once the team has brainstormed all the possible
causes of the problem, the team should rate the potential
causes according to their level of importance and likelihood
of contributing to the failure and develop a hierarchy. From
the hierarchy the team should select which causes to further
investigate.
5 Whys
The 5 Why method is simply asking the question “Why”
enough times until you get through all the symptoms of a
problem and down to the root cause. The 5 Whys is often
used during the problem solving activities. It is also used in
coordination with other analysis tools, such as the Cause and
Effect Diagram, but can also be used as a standalone tool.
The 5 Whys is most effective when the answers come from
people who have hands-on experience of the issue being
examined. To discover the root cause of a problem, keep
asking “why”. By repeating "why’, you can drive down to the
root cause of the problem, A general rule of thumb is that
you should reach the 3rd to Sth “why”, or you may just
address a symptom of the problem and not the actual root
cause. The 5 Why Form can sometimes have three separate
areas (or legs”) to address the 5 Whys: Why it occurred, Why
it was not detected and Why our systerns failed. Each area
should be explored and you may have more than one causal
progression for each area.
FMEA
Failure Modes and Effects Analysis (FMEA) is a well-
defined tool that can identify various modes of failure within
a systern or process. In many companies if a major problem
is detected in the process or product, the team is required to
review any existing FMEAs in relation to the problem. The
team should determine if the problem or effect of the failure
was identified in the FMEA and if it was, how accurately the
team evaluated the risk. If the problem is not included in the
FMEA, the team should add any known information and then
complete the following steps:List the current problem as a failure mode of the design
or process
* Identify the impact of the failure by defining the severity
of the problem or effect of failure
* List all probable causes and how many times they occur
* When reviewing a process FMEA, review the process flow
or pracess diagram to help locate the root cause
* Next identify the Escape Point, which is the closest point
in the process where the root cause could have been
detected but was not
* Document any controls in place designed to prevent or
detect the problem
* List any additional actions that could be implemented to
prevent this problem from occurring again and assign an
owner and a due date for each recommended action
* Carry any identified actions over to the counter-measure
activity of the RCA
Action Plan
Once the team has determined the root cause using any
combination of the tools listed above then they must
develop the appropriate counter-measures or corrective
actions. In addition, the team should develop an action plan
for implementation of the counter-measures.
The counter-measures are usually divided into two
categories:
1. Short-term or immediate counter-measures - generally
accomplishable in less than 1 week. If not it should be
designated as a "Long-term" counter-measure.
2. Long-term or permanent counter-measures - usually
more complex and may require additional resources to
complete. All “Long-term” counter-measures should be
able to complete in less than 1 month. If not, they should
be forwarded to the Continuous Improvement (Cl) team
for evaluation as part of a Kaizen or Black Belt project.
The corrective action must be clearly defined and achievable
by the team member assigned to complete the task. Theaction plan should also contain expected due dates for each
of the corrective actions. It is often discovered that corrective
actions without an owner or an expected due date seldom
get completed. Occasionally the counter-measures require
tasks to be completed by more than one of the team
members simultaneously or in a certain order. The action
plan should be used to track progress of individual action
items required to complete implementation of the
countermeasures.
Verification Plan
The team should also determine a Verification (or Validation)
Plan. This is used to provide a documented performance
appraisal of the counter-measures effectiveness. This could
entail recording data or auditing any special controls
developed and implemented during the RCA exercise.
Evidence should be collected to verify the effectiveness of
the counter-measures or corrective actions. In addition, it is
good practice to re-assemble the team approximately 30,
days after the permanent counter-measures are in place.
The team should review the effectiveness of the counter-
measures and determine if the problem has occurred since
implementation of the counter-measures. The team should
also review the process (if applicable) to assure all counter-
measures are being followed.
The development of a robust, well-planned Root Cause
Analysis (RCA) process can be very valuable to the company
by determining the root cause and taking action to prevent it
from re-occurring. The lessons learned during an effective
RCA can often be carried over to similar designs or
processes, This should initiate a problem solving continuous
improvement mind-set to spread throughout the company.@ Is / Is Not Example
Is Is Not ExampleFishbone / Ishikawa Diagram
‘Mother Earth
Material Machine ieneeea
Problem
Main Method Measurement
Note: Do not be concerned withthe category! It Is more Importantto capture the
cause than determine where it belongs.
Fishbone / Ishikawa Diagram@ 3 Legged 5 Why
3 Legged 5 Why
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(RCA)
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