ROOT CAUSE ANALYSIS What's the problem? Why did it happen? What will be done to prevent it?

1. 2014
2014-09-04
INNOVATION CENTRIC GROUP
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ROOT CAUSE ANALYSIS

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What is a Root Cause Analysis?
Is an approach for identifying the underlying causes of why an incident occurred
so that the most effective solutions can be identified and implemented.
It's typically used when something goes badly, but can also be used when
something goes well.
Within an organization, problem solving, incident investigation and root cause
analysis are all fundamentally connected by three basic questions:
What's the problem?
Why did it happen?
What will be done to prevent it?

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Root Cause Analysis Basis
Above de
surface
“Obvious”
Symptom of “The Weed”
the problem
Bellow the
surface “Not
Obvious”
Underlying “The Root”
Causes

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Cause Mapping Method of
Root Cause Analysis
In the Cause Mapping method, the word root, in root cause analysis refers to the
causes that are beneath the surface.
Most organizations mistakenly use the term "root cause" to identify the one, main
cause. Focusing on a single cause can limit the solutions set resulting in better
solutions being missed. A Cause Map provides a simple visual explanation of all
the causes that were required to produce the incident.
The root is the system of
causes that reveals all of the
different options for solutions.

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Cause Mapping Method of
3 Basic Steps
Define / GOALS
Analyze / CAUSES
Prevent /
SOLUTIONS
Define the issue by its
impact to overall goals
Analyze the causes in a
visual map
Prevent or mitigate any
negative impact to the
goals by selecting the
most effective solutions.

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Root Causes Phases
1
• Define the Problem.
• Define process defect (CTQ) NAL resources to participate in this activity (see ICG six sigma
presentation)
2
• Measure the Problem
3
• Root Cause analysis (5 Why's, fishbone tools) / Run monthly reports / Review individual transactions. Review JE
back up/ Quantify issues (type) resulting in J/E's (process defect). Incorrect coding, wrong AFE, Wrong CC,
incorrect accounting month. / Rationalize data by : vendor, Originator, Issue type
4
• Plan and develop plan/process to communicate defects to NAL internal resources. Training,
compliance, vendor performance, etc.
5
• Effectiveness of measure future state against initial process baseline. Repeat step 3 Improvement
6
• Develop communication plan, internal policies and procedures inclusive of training and Control
Monitor/ongoing measure ongoing process step 3, 4, 5

7. USL Target Operational
Definition # Defect
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ROOT CAUSE ANALYSIS TOOLS
CTQ Performance Standards
Output Project Y (Little y ) Measure
Characteristic
To Big Y
CTQ Performance Characteristics
LSL
How Process Will
Be Measured Defect
Project Y Metric – Continuous Data
Opp per Unit
Timeliness The amount of time
between receipt off
invoice and/ or
terms due date and
payment
The number of
days between
invoice
matching and
check
payment
- 5 days + 5 days 5 days Any
Invoice
beyond
the
USL
and
LSD
1

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ROOT CAUSE ANALYSIS TOOLS
DMAIC
Process Characterization
Define
Measure
Analyze
Process Optimization
Improve
Control
Executive
management
Champions
Master Black
Belts
Black Belt
Team
Team
Team
Black Belt
Team
Team
Black Belt
Team
Team

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The DMAIC process
Define
Control
Analyze
Measure
Improve

10. Define “as is”
and “to be”
opportunity for
project.
Measure current
process
performance.
Analyze the
problem to find
out root causes.
Improve…
Identify potential
solutions and
begin to
implement them.
Control the
performance to
continue to
achieve higher
results.
10
Improvement Process: DMAIC

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How do we do it?
What makes DMAIC unique is that it
focuses on eliminating problems by
looking at the processes that create
them, not on assigning blame to people
or functions. DMAIC helps us research
and analyze our processes, which then
leads us to more effective and
permanent solutions.

12. Define
Control
Analyze
Measure
Improve
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The DMAIC process

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The DMAIC process
• Deliverable:
• Identify Customer(s)and project *CTQ’s
(Critical to Quality)
A. Identify Project
CTQs
• Deliverables:
• Develop business case
• Develop the Problem and Goal statements
• Determine the project scope
• Select team and define Roles
• Set project milestones
B. Develop Team
Charter
• Deliverable:
• High level process map
C. Define process
map
Define Phase

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The DMAIC process
• Deliverable:
• Identify Measurable CTQ that will be
improved
A. Select CTQ
Characteristics
• Deliverables:
• Determine and confirm Specification
limits for your Y
B. Define
performance
standards
• Deliverable:
• Measurement system adequate to
measure Y
C. Establish data
collection plan, validate
measurement System
and collect data
Tools:
QFD
Process Mapping
FMEA
Pareto
Cause and Effect Diagram
Tools:
Continuous Gage R&R
Test/Retest
Attribute Gage R&R
Measure Phase

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The DMAIC process
• Deliverable:
• Baseline Current Project
A. Establish
Process
Capability
• Deliverables:
• Statistically Define the goal of the
Project
B. Define
performance
objectives
• Deliverable:
• List of statistically Significant Xs,
Chosen based on Analysis of
Historical Data
C. Identify
Variation
Sources
Tools:
Basic Statistics
Graphical Analysis
Sampling
Continuous Zst, Zit
Normality
Discrete Zst, Zit
Tools:
Benchmarking
Tools:
Process Analysis
Graphical Analysis
Hypothesis Testing
Regression Analysis
GLM
Analyze Phase

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The DMAIC process
• Deliverable:
• Determine the Vital few Xs that are
causing changes in Y
A. Screen
potential
causes
• Deliverables:
• Develop business case
• Develop the Problem and Goal statements
• Determine the project scope
• Select team and define Roles
• Set project milestones
B. Develop
Team Charter
• Deliverable:
• High level process map
C. Define
process map
Improve Phase

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The DMAIC process
• Deliverable:"
• Identify Customer(s)and project CTQ’s"
A. Identify Project
CTQs "
• Deliverables:"
• Develop business case"
• Develop the Problem and Goal statements"
• Determine the project scope"
• Select team and define Roles"
• Set project milestones"
B. Develop Team
Charter"
• Deliverable:"
• High level process map"
C. Define process
map"
Control Phase

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ROOT CAUSE ANALYSIS TOOLS
PROJECT ACTION PLAN
Monthly Action Plan
Initiative:
Process Owner Date
What How Who When Deliverables
(Action to Take) (Action Steps) (Accountable) Start Finish

19. Why can’t
we pay bills
on time
Measurement Methods System
*Cycle time too long before receipt
of approved bill for payment.
*Lack of standardized process/
procedures.
*Bills are not being sent to a central
location.
*Approval hierarchy not established/
define
*Inaccurate terms date in
the system.
*Poor understanding of
current system
capabilities.
Accounts Payable | Payment Process
* Deals being made outside of
vendor NET terms.
* Holding on to bills too long.
*Net vendor terms impossible
to meet
*No POD’s being sent
consistent.
Mother Nature People Materials
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ROOT CAUSE ANALYSIS TOOLS
FISHBONE

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ROOT CAUSE ANALYSIS TOOLS
BRAINSTORM
Brainstorm Potential Root Causes
Problem Statement:
Rank Potential Root Cause Supporting Data & Analysis?* Source? Who? When?
*Common types of data and analysis Analysis description:
Detailed Process
Review Careful walkthrough of the process step by step to determine the source, nature and frequency of the problem
Process Mapping Detailed process flow analysis to understand all the steps of the process, how the problem occurs and to document the process flow
Visual Analysis Visual examination of the problem and visual documentation such as digital photos and videos
Cause and Effect
(Event) Analysis Examination of the potential relationship of factors and or event conditions on the problem
Data Collection and
Analysis Measurement of performance from the product or process and an analysis of current data and associated factor effects
Additional Tests and
Experiments Additional tests or experiments designed to understand the current situation and determine the root cause

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ROOT CAUSE ANALYSIS TOOLS
DATA COLLECTION PLAN
Data Collection Plan
Define What to Measure
Define How to Measure
Who will
Sample Plan
Do it?
Type of
Operational
Measurement
Data Tags
Needed
Data
Collection
Person(s)
What?
Where?
When?
How
Many?
Measure
Measure
Definition
or Test
Method
to Stratify the
Data
Method
Assigned
Name of X or Y Clear definition of Visual Data tags are Manual? State What Location How
The
number
parameter attribute or
the
measurement inspection defined for the Spreadsheet? who has measure is for often of data
or condition discrete defined in such a or automated measure. Such
Computer
based? the being data the points
to be data,
way as to
achieve test? as: time, date, etc. responsibility? collected collection data collected
measured product or
repeatable
results
Test
instruments location, tester, is per sample
process from multiple are defined. line, customer, collected
data observers buyer, operator,
Procedures for etc.
data collection
are defined.

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ROOT CAUSE ANALYSIS TOOLS
Data Collection Purpose
We are collecting data to give us a statistical understanding of our ability to pay invoices in accordance with the
performance standards of +/- 5 days from the net terms invoice due date
What to Measure (output measure(s) and segmentation factors)
Measure
Name
Measure
Type (Y, X)
How to Measure
Data Type
(Discrete/
Continuous)
Sampling Plan (Scheme, Frequency, Size)
COPIS
Location
(O,P,I)
Operational Definition
Timeliness Y Continuous O The timeframe between invoice receipt date (compliant)
and payment date vs. non compliant invoices
Collect sample invoices during a week’s period which we believe to be a fair representation of the US payables flow .
We captured all payables during this period and sample size is #of invoices.

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ROOT CAUSE ANALYSIS TOOLS
Xs & Ys
Measure Relationships
Responses or Outputs (Ys)
Factors (Xs)
Dependent Variable USL LSL Target Independent Variable(s) USL LSL Target

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ROOT CAUSE ANALYSIS TOOLS
ROUTE CAUSE ANALYSIS TIMELINE
Project Name: Start Date: 2014-08-01
Use lines and or color bars to indicate start and stop dates for each activity
Phase: Activity Start Date End Date Assigned to: 2014-08-01 2014-08-02 2014-08-03 2014-08-04 2014-08-05 2014-08-06
1. Define and
Contain the
Problem
2. Measure the
Problem
3. Perform
Root Cause
Analysis
4. Plan and
Implement
Improvement
5. Assess
Effectiveness of
Improvement
6. Standardize
and Control
7. Realize and
Reflect

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ROOT CAUSE ANALYSIS TOOLS
DPMO CALCULATOR
DPMO Calculator
This template calculates the DPMO using the number of defects.
Total number of units: 2500
Number of defects: 4
Opportunities for Error in one unit: 20
DPMO = 80
Not sure of what goes into the units?
The Data Processing Dept supervisor wants to calculate the DPMO of data entry errors in her dept.
A total of 2,500 forms were processed that day, and the supervisor finds 4 fields with error.
There are 20 entry fields on each data entry form.
For this scenario:
Total number of units = 2,500
Number of defects = 4
Opportunities for error in one unit = 20

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ROOT CAUSE ANALYSIS TOOLS
MEASUREMENT SYSTEM ANALYSIS
u In order to measure our project, we will be utilizing the
following methods:
ü FMEA
ü Pareto Charts
ü Customized reports/Spreadsheets (pre-Six Sigma
process actuals - vs. Post-process actuals
annualized)
u The measuring journey is continuous in order to
guarantee success. Over time, customers change,
processes change, people change, suppliers
change.

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ROOT CAUSE ANALYSIS TOOLS
FMEA INFORMATION SHEET
Potential Failure Modes and
Effects Analysis (Information
Sheet)
PFMEA Number:
Process Name:
Process
Responsibility:
Prepared By:
Affected Product(s):
PFMEA Key Date:
PFMEA Origination
Date:
PFMEA Revision Date:
Core Team Members:

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ROOT CAUSE ANALYSIS TOOLS
PROCESS/ PRODUCT FMEA
Process Step
What is the
process step
Key process Input
What us the
key process
input
Potential failure mode
What is the
impact on the
Key Output
Variables
(Customer
Requirements)
or internal
requirements?
SEV
How Severe is
the effect to
the cusotmer?
Potential Causes
What causes
the Key Input
to go wrong?
OCC
How often
does cause or
FM occur?
Current Controls
What are the
existing
controls and
procedures
(inspection and
test) that
prevent eith
the cause or
the Failure
Mode? Should
include an
SOP number.

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ROOT CAUSE ANALYSIS TOOLS
F SEVERITY
Effect Criteria: Severity of Effect Defined Ranking
Hazardous:
May endanger operator. Failure mode affects safe vehicle operation and / or involves noncompliance
Without Warning
WITHOUT 10
with government regulation. Failure will occur warning.
Hazardous: With
Warning
May endanger operator. Failure mode affects safe vehicle operation and / or involves noncompliance
with government regulation. Failure will occur WITH warning.
9
Very High Major disruption to production line. 100% of product may have to be scrapped. Vehicle / item
inoperable, loss of primary function. Customer very dissatisfied.
8
High Minor disruption to production line. Product may have to be sorted and a portion (less than 100%)
scrapped. Vehicle operable, but at a reduced level of performance. Customer dissatisfied.
7
Moderate
Minor disruption to production line. A portion (less than 100%) may have to be scrapped (no sorting).
Vehicle / item operable, but some comfort / convenience item(s) inoperable. Customers experience
discomfort.
6
Low Minor disruption to business. 100% of transactions may have to be reworked. 5
Very Low Minor disruption to business. Defect noticed by most users 4
Minor Minor disruption to business . A portion (less than 100%) of the transactions may have to be reworked
Defect noticed by some users
3
Very Minor Minor disruption to business. A portion (less than 100%) of the may have to be reworked 2
None No effect. 1

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ROOT CAUSE ANALYSIS TOOLS
F OCCURANCE
Probability of Failure Possible Failure Rates Cpk Ranking
Very High: ≥ 1 in 2
< 0.33 10
Failure is almost inevitable 1 in 3 ≥ 0.33
9
High: Generally associated with
processes similar to previous 1 in 8 ≥ 0.51
8
processes that have often failed 1 in 20 ≥ 0.67
7
Moderate: Generally associated with
processes similar to 1 in 80 ≥ 0.83
6
previous processes which have 1 in 400 ≥ 1.00
5
experienced occasional failures, but not
in major proportions 1 in 2,000 ≥ 1.17
4
Low: Isolated failures associated with
similar processes 1 in 15,000 ≥ 1.33
3
Very Low: Only isolated failures
associated with almost identical
processes
1 in 150,000 ≥ 1.5
2
Remote: Failure is unlikely. No failures
ever associated with almost identical
processes
≤ 1 in 1,500,000
≥ 1.67
1

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ROOT CAUSE ANALYSIS TOOLS
F DETECTION
Detection Criteria: Liklihood the existence of a defect will be detected by test
content before product advances to next or subsequent process
Ranking
Almost Impossible Test content detects < 80 % of failures
10
Very Remote Test content must detect 80 % of failures
9
Remote Test content must detect 82.5 % of failures
8
Very Low Test content must detect 85 % of failures
7
Low Test content must detect 87.5 % of failures
6
Moderate Test content must detect 90 % of failures
5
Moderately High Test content must detect 92.5 % of failures
4
High Test content must detect 95 % of failures
3
Very High Test content must detect 97.5 % of failures
2
Almost Certain Test content must detect 99.5 % of failures
1

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ROOT CAUSE ANALYSIS TOOLS
Process Control Plan
The control phase will consist of the
deployment of a process to permanently
sample and take actions regarding the
current process DPMO metrics.
Develop a process to monitor a couple
of pre-defined output variables on a
regular basis.

33. 2014
2014-09-04
INNOVATION CENTRIC GROUP
33