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Root Cause Analysis: in The Environmental Testing Laboratory
Root Cause Analysis: in The Environmental Testing Laboratory
in the
1
Agenda
Corrective Action Program
What is corrective action
Documentation of corrective action
Examples of administrative and technical
Cause Analysis Principles
Definition(s)
Procedure
Records
Follow-up
Cause Analysis Examples
Administrative Examples
Technical Examples
Slide 2
Objectives
Corrective Action
Complaints
RCA
Forms
Evaluation
Follow-up
Principles of Performing Root Cause Analysis
Based on ISO/IEC 17025
Examples Root Cause Analysis
Slide 3
Corrective Action
Corrective action is
Slide 4
Correction vs. Corrective Action
Slide 5
Corrective Action
Slide 6
Corrective Action Steps
Slide 7
Administrative Corrective Action
Identify who assesses the problem
Identify who determines effect
Identify who is responsible for taking action
Define how reported data is treated or client
notified, if applicable
Specify changes needed to documentation or
process
Specify how management will review
Slide 8
Technical Corrective Actions
Slide 9
Follow-up
Slide 10
CAR Form – Part 1
Corrective A ction Form #____________
Section #1 Origination ___
Initiated By:__________________________ Client:____________________________________
Complaint or Issue:_______________________________________________________________
_______________________________________________________________________________
Section #2 Investigation/Action
Action Taken (Check all that apply)
Data Reviewed [ ] Reanalyzed [ ] Client Contacted [ ] SOP Reviewed/Revised [ ]
Training [ ] Equipment Service [ ] Other [ ] _________________________________
Corrective Action:________________________________________________________________
_______________________________________________________________________________
Slide 11
CAR Form – Part 2
Section #4 Closure
Slide 12
Root Cause Analysis
Working Definition
Slide 13
Root Cause Analysis
Goal
Slide 14
Characteristics of Root Causes
Slide 15
RCA
Different
Tools
Processes
Philosophies
Safety based
Production based
Process based
Failure based
Systems based - combination of all above
Slide 16
General Principles
Slide 17
Process
Slide 18
Basic Elements
Materials
Defective raw materials
Wrong type for job
Lack of raw material
Machine/Equipment
Incorrect instrument selection
Poor maintenance or design
Poor equipment or instrument placements
Defective equipment or instrument
Slide 19
Basic Elements
Environment
Workplace cleanliness/clutter
Layout of work area
Maintenance of work area
Techniques or demands of task
Forces of nature
Methods
No or poorly written procedure
Practice not same as written procedure
Poor communication
Slide 20
Basic Elements
Person
No or poor management activity
Inattention to task
Task hazards not guarded properly
Other - Skill set not defined - Not trained for task
Stress demands or undue pressure
Results in improper practice
Slide 21
Basic Elements
Management System
Training or education lacking
Poor personnel involvement
Poor recognition of hazard
Previous unidentified hazard or skill set not handled
properly
Slide 22
Five Whys - One Technique
Slide 23
Benefit of 5 Whys
Slide 24
Specific Steps
Gather team
One or more people
Write down problem
Agree
Why does the problem happen?
Write down the answer(s)
Is this the root cause?
Check by asking why again and see if there is another reason
the problem may exist
Loop through the steps until the team agrees that the
problem’s root cause is identified.
Slide 25
Modification of 5 Whys
5 x 5 Whys
Slide 26
Example
Slide 27
Cause Effect Diagram
Complex Problem
Identifies All Causes and the Root Cause
Shows Interactions Among Factors That Affect
Process or Situation
Enables Effective Corrective Action
Encourages Focused Brain Storming Session
Slide 28
Ishikawa Diagram
Graphical Design of Process Influences
a.k.a: fishbone diagram
Cause
6 M’s
Machine, Method, Materials, Measurement, Man, Mother
Nature (manufacturing industry)
8 P’s
Price, Promotion, People, Processes, Place/Plant/Technology,
Policies, Procedures & Product/Service (service industry
4 S’s
Surroundings, Suppliers, Systems, Skills (service industry)
Slide 29
Diagram
Category 1 Category 1
Cause 1
Cause 2
Problem
(Write it out here)
Category 3
Category 4
Slide 30
Brainstorming
Rules
Encourage participation
There are no bad ideas
No judgment given to any idea
Either positive or negative
Build on each other’s ideas
Write Down All Ideas
Organize Into Diagram to Show Relationship
Eliminate any that are outside the processes
identified
Slide 31
Process
Experience Facilitator
External for more complex problems
Appoint a Person to Write Down All Ideas
Use paper chart to record all ideas
Define Problem
Layout any criteria for scoring the causes
No More Than 8 - 10 per Group
If more then have multiple groups
Encourage Creativity and Input
Don’t Dwell to Long on One Idea
Slide 32
Other Techniques RCA
Statistical Approaches
Failure Mode and Effects Analysis
Fault Tree Analysis
Not Reviewed During this Class
Pareto Analysis and Charts
Separates important from trivial causes
Statistics 80% of problems produced by key causes (20%)
Bayesian Inference
Barrier Analysis
Change Analysis
Causal Factor Tree Analysis
Slide 33
Failure Mode and Effects Analysis
FMEA - Used in Manufacturing
Risk assessment technique
Identify system or process failure
Failure is any Errors or Defects
Affect the client (affect on reported results)
Can be potential or actual
Failure Mode
Ways a product or process can fail
Product = data in lab
Effects Analysis
Studying the consequences of those failures
Slide 34
FMEA
List Parts of the System
List Consequences If That Part of the System Fails
Evaluate the consequences - 3 criteria
Severity (S)
Occurrence (O) (May also be referred to as Probability)
Likely to occur
Detection (D)
Ability to control (1= control certain: 10 = no control exists)
Ranking of each 1 - lowest to 10 highest
Risk Priority Number (RPN) = S x O x D
Slide 35
FMEA
Weakness
Top down tool
Major failure modes identified only
Fault Tree Analysis (FTA) Is Better Suited
FMEA Is Useful to Augment or Complement FTA
Helps to Identify Failure Modes When Undesired
Effects Are Found
Slide 36
FTA
Slide 37
Summary
Root Cause
Systematic approach to problem solving
Removes the problem
If cause is really identified
Allows focus of organization on preventive
actions
Reduces number of corrective actions
Slide 38
End Course BYE ! !
Any questions?
(before you run out the door)
Slide 39