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What is Root Cause? It’s an IDENTIFIED REASON for the presence of a defect or problem. It is the MOST BASIC REASON, which if eliminated, would prevent recurrence. Click 3

What is the MOST BASIC reason? When fixed, you can turn it on and off Click 2

How do I get to the point of turning the problem on or off? Use DMAIC Principles Lean Principles – Six Sigma Tools Define, Measure, Analyze, Improve, Control Click

How do I get to the point of turning the problem on or off? 5 Why’s Three Simple and Easy to Use Tools Fishbone Diagram or Commonly referred to as a Cause & Effect Diagram DEFINE Click, Time 5

DEFINE If the FINDING is not clear enough for you: Get clarity (in writing) from the issuer Rewrite the finding in your own terms and words on your Investigation Work Sheet View the finding from the viewpoint of THE CUSTOMER – as if it were your own product or service you wanted. Define what the problem is Defining the problem The reason for the issuance of the CAR Click

5 Why’s When you repeatedly ask WHY, you peel away the layers of symptoms which can lead to the TRUE ROOT CAUSE of a problem. peeling away the layers Repeatedly asking WHY? When Is use of the 5 Whys most useful? human factors or interactions When problems involve human factors or interactions. day-to-day business life When resolving issues in day-to-day business life. Click

How do I complete the 5 Why’s? peeling away the layers 1.Write down the specific problem. Writing the issue helps you formalize the problem and describe it completely. It also helps a team focus on the same problem. 2.Ask Why the problem happens and write the answer down below the problem. 3.If the answer you just provided doesn't identify the root cause of the problem that you wrote down in step 1, ask Why again and write that answer down. 4.Loop back to step 3 until the team is in agreement that the problem's root cause is identified. Again, this may take fewer or more times than 5 Whys. Click

How do I complete the 5 Why’s?Example: You go into your garage in the morning and find A FLAT TIRE ON YOUR CAR. DEFINE THE PROBLEM: Walking into my garage this morning, I found I had a flat tire on the front right tire. All the other tires were fine with no indication of any flats. Click

How do I complete the 5 Why’s?Example: You go into your garage in the morning and find A FLAT TIRE ON YOUR CAR. the RIGHT 5 Whys Ask the RIGHT 5 Whys: 1) Why is the tire flat on the car? A) There's a nail in the tire Click

How do I complete the 5 Why’s?Example: 2) Why is there a nail in the tire? A)There's a pile of nails on the floor and I must have driven over a nail Click

How do I complete the 5 Why’s?Example: 3) Why is there a pile of nails on the floor? A) The box the nails were stored in broke apart Click

How do I complete the 5 Why’s?Example: 4)Why did the box the nails were stored in break apart? A) The box let go because it was wet Click

How do I complete the 5 Why’s?Example: 5)Why did the box the nails were stored in become wet? A) There's a puddle of water on the shelf the box of nails was sitting on. Click

How do I complete the 5 Why’s?Example: 6) Why was there a puddle of water on the shelf where the box of nails was sitting on? A) There's a hole in the roof. Click

How do I complete the 5 Why’s?Example: 7) Why is there a hole in the roof? A)During the last storm an overhanging tree branch broke off from the tree trunk and fell on the roof poking a hole through the roof and nobody repaired the hole in the roof. Click

How do I complete the 5 Why’s?Example: A)Everybody thought Somebody would do it. Anybody could have done it. Everybody knew it was going to rain last night and it ended up Nobody did it. Because Nobody did it, the box of nails got wet from the rain pouring through the hole in the roof last night. Click 8)Why did Nobody fix the hole in the roof before last night’s rain storm?

How do I complete the 5 Why’s?Example: 9) Why did it rain? A) Rain happens – and the one thing Nobody can control? Is when it rains. Click

How do I complete the 5 Why’s?Example: 9) Why did it rain? Not 5 WHY’s in this case, there are 9 WHY’s….. Click

How do I complete the 5 Why’s?CONCLUSION: A) Rain happens - One cannot control when it rains. Your TRUE ROOT CAUSE will normally be the one just before the WHY you CANNOT control. The TRUE ROOT CAUSE becomes the fact NOBODY repaired the hole in the roof in a timely manner. Remember this? When is use of the 5 Whys most useful? human factors or interactions When problems involve human factors or interactions. day-to-day business life When resolving issues in day-to-day business life. HUMAN FACTORS or INTERACTIONS More times than not, TRUE ROOT CAUSE will involve HUMAN FACTORS or INTERACTIONS. Click

How do I complete the 5 Why’s?CONCLUSION: A) Rain happens – and one cannot control when it rains. Your TRUE ROOT CAUSE will normally be the one just before the WHY(?) you CANNOT control. My TRUE ROOT CAUSE becomes the fact NOBODY repaired the hole in the roof in a timely manner. Why wouldn’t the fact not removing the tree limb overhanging the roof not be the TRUE ROOT CAUSE? Because removing the tree limb before the next storm would be a PREVENTIVE ACTION Click

Fishbone Diagrams Cause and Effect Diagrams: An EFFECTIVE TOOL used to help identify the ROOT CAUSES of a problem Click, Time

Fishbone Diagrams Cause and Effect Diagrams: An Effective TEAM BASED Tool to help determine the POTENTIAL ROOT CAUSES of a particular problem. Breaks the problem down into “bite-sized” pieces. Displays many possible causes in a graphic manner. Also know as a 4-M or Ishikawa diagram Shows how various causes interact. Follows brainstorming rules when generating ideas. Involves other members of the team to generate ideas. Click

Fishbone Diagrams Cause and Effect Diagrams: The “ISHIKAWA” DIAGRAM  Dr. Kaoru Ishikawa (1915 – 1989)  Authored several books on Quality Control that defined “TQC” or Total Quality Control  Developed techniques to eliminate “Sectionalism” i.e.”, the “It’s not my job” mentality.  Developed the concept of Quality Circles and “the next operation” as a CUSTOMER.  The C&E Diagram was named in his honor as it brings his concepts together. Also know as a 4-M or Ishikawa diagram Click

Fishbone Diagrams Cause and Effect Diagrams: 1. Manpower 2. Material 3. Method 4. Machine 5. Measurement 6. Mother Nature Environment Click, Time 6

Fishbone Diagrams Cause and Effect Diagrams: MachineMaterialMeasurement MethodManpower Mother Nature Environment The Problem Statement Cause Click 4

Fishbone Diagrams Cause and Effect Diagrams: Divide the Process into (3) Steps 1 – Brainstorming – Gather ideas to fill in ALL the POSSIBLE CAUSES No Idea is a bad idea 2 – Prioritize – Rank the Possible Causes from Highest Priority to Lowest Priority 3 – Develop the Action Plan to eliminate the cause(s) in Priority Order ( use of 5 Why’s methodology can be repeated here ) Click

Immediate Actions 1 st and FOREMOST: IDENTIFY IMMEDIATE ACTIONS THAT MUST BE TAKEN 1 – ALL HEALTH AND SAFETY FINDINGS REQUIRE: IMMEDIATE (“TEMPORARY”?) CORRECTIVE ACTION – without fail. IMPLEMENTATION and CONTAINMENT (if necessary) should be immediate or at least within 24 Hours or sooner, depending on severity of finding, but no greater than 24 Hours. 2 – ALL PRODUCT/PARTS Findings Require: IMMEDIATE CONTAINMENT ACTIONS How extensive does the finding reach out for other product/parts affected? Are there planes flying with this potential problem? ALL OF THESE ACTIONS MUST BE DOCUMENTED Click

Corrective Actions When Completing a C/A: You MUST: Provide and/or have available: Documentation supporting your RRCA (Relentless Root Cause Analysis) Documentation supporting your EFFECTIVE CORRECTIVE ACTION  Time lines of implementation (Commitment Dates)  Follow-Up records for actionee items tasked to someone else  Reasons/documentation why a delay in implementation may be necessary  Budgetary reasons, logistics reasons, etc. (Each must have a commitment date if a part of the final ECA) ALL OF THESE ACTIONS MUST BE DOCUMENTED Click

Tools To Achieve Effective Corrective Actions Mistake Proofing: Potential Countermeasures to Human Interactions and Errors:  Forgetfulness  Misunderstanding  Identification  Beginner’s Errors  Willful Errors  Inadvertent Errors  Slowness  Lack of Standards  Surprise Errors  Intentional Errors  Lack of adequate control Type Error Possible Fixes  Checklists – Visual Aids  Training/Checklists; Work Standardization; Visual Aids; Work Instructions  (Things that look the same) – Training and Visual Aids  Training/Skill Building; Standardization of Work; Visual Aids; Work Instructions  Training; Work Instructions  Discipline/Skill Building; Standardization of Work; Visual Aids; Checklists  Standardization of Work; Visual Aids; Work Instructions  (Inadequate Instructions) – Standardization of Work; Detailed Work Instructions  Total Process Maintenance; Standardization of Work  Education and Discipline  Variation Management – Process Controls Click

Tools To Achieve Effective Corrective Actions Standardization of Work: Creating Standards has the following benefits:  Standards are the best, easiest, and safest way to perform a job  They preserve employee know-how and expertise  They provide a way to measure performance  Correct standards show the relationship between CAUSES and EFFECTS  Standards provide a basis for maintenance and improvement  They provide a set of visual signs on how to do the job  Standards are a basis for training initiatives  They are a basis for auditing and finding opportunities for improvement  They are a means to prevent RECURRENCE of ERRORS  Standards minimize variability in the performance of the task  They can help in sustaining control Click

Tools To Achieve Effective Corrective Actions 6S Concepts: Incorporate 6S Philosophy into Corrective Actions:  Sort – Separate out all that is unneeded and eliminate it  Straighten – Put things in order; Everything has a place and everything is in it’s place  Scrub or Shine – Clean everything – make the workplace spotless  Standardize – Make cleaning and checking routine  Sustain – Commit to the previous 4 steps and maintain them  Safety – work to continuously improve safety in and around the work place Click

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