This webinar discusses and investigates how to conduct root cause analysis. Root cause analysis is something that companies really struggle with. There will be plenty of practical advice in the webinar to help with you understand the concepts and the tools. If you would like to watch the recording of this webinar then copy and paste the below link into your web browser: http://www.mangolive.com/blog-mango/root-cause-analysis-tools-webinar

1. Root Cause Analysis
Tools, Tips and Tricks
Presented by: Sean Banayan
Presented on: 8th June 2016

3. Sean Banayan
• Business Improvement Manager, Etel Limited
• Sean.banayan@eteltransformers.co.nz
• +64 27 511 9212
• LinkedIn

4. Qualifications
• Master of Mechanical Engineering, Auckland University of Technology, NZ
• PRINCE2 Practioner, APMG Australasia, NZ
• Six Sixma Black Belt Certified, Aveta Business Institute, USA
• Lean Manufacturing Operations Management, Aveta Business Institute, USA
• TQM(Total Quality Management), Aveta Business Institute, USA
• ISO 9001 Management Systems, Telarc, NZ
And…
•Have learned the Japanese thinking behind
Lean and its successful application across a
range of industries in Lean Japan Tour,
Shinka Management, Australia

5. Agenda
•Definition
•Direct Cause vs. Root Cause
•Data Driven Decisions
•Data Collection & Visual Control
•Clarify the Problem
•Quality & Data at Source
•Basic Problem Solving
• Practical Example
•Visual Control
•Problem Description
•Problem Solving Steps
•Identifying the Direct Cause
• Fishbone (Cause & Effect Analysis)
•Identifying the Root Cause (5 Why)
•Sustain & Share Best Practice
•Questions

6. Definition
Root Cause Analysis (RCA) is:
•A method of problem solving used for identifying the root cause of
faults or problems.
•Is the fundamental breakdown or failure of a process which, when
resolved, prevents a recurrence of the problem.
•It is a systematic approach to get to the true root causes of our
process problems.

7. Direct Cause vs. Root Cause
Direct Cause
•It does not prevent its recurrence within certainty.
•Usually blames someone
• Its only as good as a Band-Aid

8. Direct Cause vs. Root Cause
Root Cause
•It does not attribute blame to anyone.
It looks for failure in the system, or process.
•It will prevent recurrence of the Direct Cause
•It is a proven source of the Direct Cause

9. Root Cause Sample
Machine that stopped because it
overloaded and the fuse blew
Investigation shows that the machine overloaded
because it had a bearing that wasn't being
sufficiently lubricated
The investigation proceeds further and finds
that the automatic lubrication mechanism
had a pump which was not pumping
sufficiently, hence the lack of lubrication.
Investigation of the pump shows that it
has a worn shaft.
Investigation of why the shaft
was worn discovers that the
Pump Cover which prevents
metal scrap getting into the
pump has been damaged.
This enabled scrap to get into
the pump, and damage the
shaft.

10. Data Driven Decisions
Reason for choosing the problem
• Background information or KPI’s
• Effect on you or your group
• Links to higher level goals
• Customer identified

11. Gather data and use facts
• Record what is happening
• Manually gather information
• Grasp the situation before trying to fix it
Data Collection & Visual Control

12. Data Collection & Visual Control
Collect DATA on defects, changes, incidents and other Key Performance Indicators (KPI’s)
Display the DATA as graphs to display combination of standard or target with current situation
Supplier Issues Defects per month (%) for 2016 - 2017
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%

13. Clarify the Problem
Breakdown the initial Problem Perception to “one problem you can
solve”. This should be the one which has the largest overall impact.
Problem Breakdown
Employees
& Shift
Department
Category
& Type
Problem Prioritisation
Level of
Impact
Level of
Importance Level of
Urgency

14. Quality & Data at Source
Quality Check
Quality Check Quality Check Quality Check Quality Check
•Quality is built-in to each process – Never send Quality defects to next process
Data Gathering
Data Gathering Data Gathering Data Gathering Data Gathering

15. Basic Problem Solving
• A problem goes into the
Problem Solving funnel
Root Cause Fix
• Then leaves with a Root
Cause Fix
PROBLEM
STATEMENT

16. Basic Problem Solving
 Initial Problem Description – Explain
the problem
PROBLEM
STATEMENT
ROOT CAUSE FIX
 Fishbone Analysis
 5 Why Investigation
 Follow Up Check
 Standardisation
 Share Best Practice

17. Basic Problem Solving (Practical Example)
 Please note – This is a training simulation
 A problem has occurred in Fabrication department!
 A number of jobs have failed final quality inspection due to
incorrect build
 We will work through this problem using some basic problem
solving tools during this training presentation

18. DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
OK NG >
> 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
5
4
3
2
1
Final Inspection Test Bay Other Dept Own Dept
Quality
AREA: FABRICATION
DATE
1
MONTH/YEAR:
No. of defects found during month
Defect Category
Sep-15
KEY - Where Defects Found
Defects
132 3 4 5 6 7 14 158 9 10 11 12
Incorrect Part Position
Incorrect Plasma Cutting
Incorrect Folding
Not to Drawing
Visual Control (Practical Example)

19.  We are going to use this example from our Quality Balanced
Score Card in Fabrication
 So, what was the Problem Description….?
… Jobs failing fabrication inspection due to incorrect build…(Not
to Drawing)
Problem Description (Practical Example)

20.  Now that we have a clear Problem Description, we are going to
work through the following steps –
Problem Solving Steps (Practical Example)
1
• Identifying the Direct Cause
2
• Applying a short term immediate action (Band-Aid)
3
• Identifying the Root Cause
4
• Applying a long term Root Cause Fix
5
• Sustain & Sharing Best Practice

21. Identifying the Direct Cause
 First we must identify the Direct Cause and implement a short
term immediate action (band aid)
 It usually means we have to add more cost to our process by
adding activities such as more inspection etc.
 This is a very reactive way of working, but we need to do it until
a Root Cause to the problem can be found.
 We can use a Data Analysis graphs to look at a lot of different
breakdowns to guide us to what can possibly be directly causing
the problem.

22. Root Cause Analysis Problem Solving
Describe
Describe the problem
Quality Defects in Fabrication
Clarify
Clarify the size of the problem
0
2
4
6
8
10
12
14
16
CARS in Fabrication
Defect Inspection in
Fabrication
0 5 10 15
Aug/14
Sep/14
Oct/14
Nov/14
Dec/14
Jan/15
Feb-15
Farbrication Defects
Fabrication Error
Leaking Welds
Oil Leak
Welding Quality
Operator error
Missing ID
Welded
Wrong
Parts
11%
Missing ID
2%
Missing Welds
11%
Oil Leak
13%
Parts Missing
6%
Welded in
Wrong
Position
55%
Welding
Splatter
2%
FABRICATION ERROR BREAKDOWN
Base hold down
brackets
4%
Door locking
brackets
5%
Excessive Weld
Splatter
5%
Internal locating
brackets
71%
lifting lugs
5%
M8 set screws on
the HV door.
5%
Pole
mounting
bracket
5%
"WELDED IN WRONG POSITION" BREAKDOWN

23. Fishbone (Cause & Effect Analysis)
 This is a good Team brainstorming event which helps to bring lots of ideas
forward, regarding the Direct Cause of the Effect, in a short period of time
EFFECT
(Problem
Observed)
METHOD MAN
MATERIAL MACHINE
Enter your
Problem
Description in
the head of the
fish
Use your Problem Solving Template – Write down lots of ideas that could
be causing the problem in the head of the fish
Try to group your ideas into the correct categories
No Procedures for
Checking Parts
No Std Method
of Positioning
Measuring
Tools
Torches to
check inside
tanks
Lack of
Training
Drawing Not
Clear
Welder’s Neglecting to
check
Wrong
Tools
Attention to Details
Quality Check
Method
Incorrect Position
of Internal
Locating Bracket
Key Point – No Idea is a Bad
Idea!

24. Fishbone (Cause & Effect Analysis)
 Get the Team to vote on what they believe are the most likely direct
causes of the problem in the head of the fish. This can be done by
placing a tick on the idea
Incorrect
Position of
Internal Locating
Bracket
MANMETHOD
MATERIAL MACHINE
No procedure
for checking
parts
Direct Cause
Operators do not have
standard way of
positioning the
Internal Locating
Brackets
Quality
Check
Method
Drawing is
unclear
PP
P
P
P
No Std Method
of Positioning
P
P
P
P
P P
PP
P Measuring
Tools
Torches to
check inside
tanks
Drawing Not
Clear
Wrong
Tools

25. Fishbone – Direct Cause
• Remember the importance of CAPTURING DATA?
 Let’s enter that into our Problem Solving Template
• The next thing we must do is put a short term immediate action
in place to act as a band aid whilst we find the Root Cause
• What could we do? Talk to the Operators? Re-train? More
inspection? Manager to check that the job is correct every hour?
 Update your Problem Solving Template with your short term
immediate action (band aid)…
P
P

26. Problem & Containment Action
 Also document the Problem Description and Short Term immediate
action into the Problem, Cause, Countermeasure Sheet on the Board
Q A 07 Jun
Internal Locating Bracket
not in correct position
Re-train the operator & ask
quality inspector to double
check
September Fabrication
P

27. Identifying the Root Cause
• So, we have our Direct Cause ‘No Standard Procedure for Positing
the Internal Locating Bracket’…
• …we can use a tool called 5 Why to drill further into the Direct
Cause to uncover the Root Cause of the problem
• It is called 5 Why, but you don’t need to ask “Why” 5 times, you
can use as many or as little as you like!

28. 5 Why Example
Direct Cause of problem – No Standard Method of Positioning Part
•Why No Standard Method of Positioning Part? – Because operators don’t follow instruction
of the drawing
•Why operators don’t follow instruction of the drawing? – Because not all drawings are up
to date.
•Why aren’t the drawings up to date? – The Operators never feedback to engineers for
drawing updates.
•Why operators never feedback to engineers for drawing updates? – Because there isn’t a
formal process to capture the issues and assign corrective actions against a time based
plan.
This is the Root Cause – If a countermeasure is applied
here, it should completely eliminate the problem

29. 5 Why – Root Cause
• Now we have our Root Cause – ‘No formal process to capture the
issues and assign corrective actions against a time based plan’…
 Let’s enter that into our Problem Solving Template
• The next thing we must do is put a Long Term preventive action in place
at the Root Cause level to eliminate the problem completely – This will
replace the short term immediate band aid we put in earlier!
• What could we do?
 Update your Problem Solving Template with your Long Term Root
Cause preventive action… Make sure you put a completion date!
P
P

30. Root Cause & Fix
 ?Now, let’s write the Root Cause & Root Cause fix action into the
Problem, Cause, Countermeasure Sheet on the Board
Q A 07 Jun
Internal Locating Bracket not in
correct position
Re-train the operator & ask
quality inspector to double check
September Fabrication
No formal process to capture the
issues and assign corrective
actions against a time based plan
19 JuneJ.Smith
Implement a Formal Process to
capture the issues…
P
Don’t forget to enter the Person responsible for
carrying out the action… & If they aren’t there at the
time, please let them know!

31. Direct Cause Vs Root Cause
Let’s have a recap on the differences between Direct Cause & Root
Cause
DIRECT CAUSE
 Reactive
 Direct Cause often assigns blame to
people
 If a countermeasure is implemented at the
Direct Cause, it will not prevent a future
recurrence
 Usually requires a short term containment
action that is costly in time or resources
ROOT CAUSE
 Preventive
 Root Cause does not blame anyone – The
failure will always be in a system or
process
 If a countermeasure is implemented at the
Root Cause it will prevent a future
recurrence of the Direct Cause
 The Root Cause is the proven source of
the Direct Cause
PO
O
O
O
P
P
P
PO

32. Sustain & Sharing Best Practice
•Standardise Successful Processes by documenting in instruction sheets, train members and
confirming.
•Why do we not standardise in the beginning?
Process
Company’s Ideal State
Standardisation in the beginning
before finding the Root Cause
Standardisation After finding the
Root Cause

33. Questions