1. Corrective Action Workshop
Module 1
Welcome
to the
Root Cause Analysis
and
Corrective Action Workshop

2. Introduction Letter PW page 3
Points to remember about RCA:
- It is a complete process, ready to be used as a powerful tool.
- It can be used everywhere, home and work.
- ISO 9001/SQM requires a strong corrective action process in place.
Introduce sself and co-instructor
Participate actively
Fill out name cards
Class background, Allied Signal.
Pass around sign in sheets.
Participants intro themselves, tell jobs and what they hope to take away from class.

3. Workshop Agenda (The Process)
Module 1 - Introduction
Class structure
Workbook review
Applications
Module 2 - Collection
Forming teams
Gathering Data
Exercises
Module 3 - Analysis
Why-Why Method
Causes
Cause Chains
Exercises & More Exercises
Module 4 - Solution
Corrective Action Types
Testing
Exercises
Module 5 - Assessment
Followup
Effectiveness
Lessons Learned
Module 6 - Reporting
Formats
Fan Exercise
Course Evaluation
Note the module layout for course:
Lecture no more than 45 mins or less
Lots of exercises.
Class time, :30
Reference flowchart. It’s liquid - go back from one point to another. Workshop structured around chart.
Workshop Manual
Its a reference resource book
Used for workshop exercises
Tabbed for easy identification
Flowchart & 5 critical definitions inside cover in sleeve.
Tabs tie into flowchart, Tab7 is definitions section, 8 is master forms
9 is references and resources, Tab 10 are exercises..
PW - 4

4. Root Cause Analysis and Corrective Action Process Definition:
An effective process for finding the cause of an event,
facilitating effective corrective actions, and preventing
recurrence.
Remember - If you don’t know what caused the problem you can’t fix it!!
RCA analyzes a problem to discover it’s causes.
The true thrust of RCA and corrective action is prevention.
Contrary to popular opinion ther is not a line that jumps from the event directly to the solution. this is what has got us into trouble. Shooting from the hip!!
Why does this happen? People have not been trained in the proper analytical techniques in high school or College educations. Without this knowledge how can we expect to find root causes and effective corrective-preventive actions?
PW - 5

5. Participate Actively! Act on Fact! Have Fun!
Now its time to jump in and get to working the process
Participate actively!!
Act on Fact!
Have Fun!

6. Collection Module 2 Pickup attendace sheets.
Using the flowchart....point out the items in module two.

7. Event Definition: An all inclusive term for any of the following:
Product Failure
Out of control process
Audit finding
Accident
Customer complaint
Pleasant surprises
These terms are synonyms for event.
RCA can be used to find out why good things happen also....such as quality improvements, jobs done ahead of time, under cost.

8. Natural Team Definition: A group of people having vested ownership of the problem to be solved.
Stress: key words; vested ownership
Natural team should have authority as wellas responsibility. Make sure you have the right people on natural team. Don’t throw it over the fence!!
These are the people that own and control the process, product, equipment or area that the event occurred in.
Most of the time the team membership doesnt go higher than first line management.
Involving management when they dont directly own the problem will lead the team astray.
Not having the vested owners on the team will kill the process before it starts!

9. Importance of The Natural Team
Team members bring different:
- Ideas
- Needs
- Experiences
- Procedural Requirements
A natural team should never be less than two people. The synergy that comes from two or more people sharing ideas adds greatly to the process.
Team Members experience affects:
- Areas Investigated
- Methods of collection
- How corrective action is identified

10. Pick Team Names Barnstormers Rattlers Mavericks Bulls Screaming Eagles
Have participants count off and have them move to tables designated as 1,2,3,4. If class size is 15 or less count off by threes.
Assign team names. (have team one choose name for team two. Team two choose for team three. Thhree chooses for team one.
Clock watchers - people thinking eight hours is too short for a class.
Flying Fowls - Turkeys by any other name.
Stargazers - most likely to fall asleep in class.
Rocket Scientists - Have the most trouble comprehending the material.
Aces - Ones most likely to be shot down.
Post team names on wall near tables.
Barnstormers

11. Qualified Team Definition: The Natural Team, including other individuals, who can provide necessary resources to understand the problem, or can help in the root cause analysis and corrective action process.
Qualified team members may supply a valuble specialized skill or knowledge to the natural team. Examples...Systems, materials lab engineers, marketing.
Natural team members need to recognize the need for a qualified expert and contact them for help.
The flowchart may call for a qualified expert at any stage.
Qualified resources may be contacted by phone only to obtain information.
Talk to how far reaching a problem can be in this plant.

12. State The Problem! The process starts here
First you must understand the problem
Then you must find out if more than
one problem exists
Sometimes the event as reported or as found, is not indicitive of the true problem.
What is the real problem?
Is there more than one problem?
Understanding the problem is the key to this process.
Ask class...have you ever read audit findings? are they easy to read? Do they always make sense?
PW-5

13. “If you cannot say it simply, you do not understand the
Remember!
“If you cannot say it simply,
you do not understand the
problem.”
Albert Einstein.

14. Event Question Is: Does not: Tell what caused the event Short Simple
Concise
Focused on one problem
A question (Why…?)
Does not:
Tell what caused the event
State what to do next
Explain the event
Event questions
When writing an event question keep focused on asking a question that will lead you to the cause of the event.
Try to use questions that start with Why!
Do not allow the event question to be biased, make assumptions, or tell you how to solve the problem.
pw-6

15. Remember! Everything should be made as simple as possible
but no simpler.
See fire example on PW Why did the fire start?
PW 6

16. Exercise PW 7 Write an event question Identify natural team members Identify qualified team members Team reports in 10 minutes.
Hasve teams do all three event exercises in their books. Randomly select teams to answer and invite comments from other teams.

17. Capture the Scene! Take Pictures Preserve the Evidence Talk to People
PW-8
Data has a shelf life. See workbook page 8
Data should be as complete as possible. The most insignificant detail may be important.
Try to get all the information needed for RCCA process.
If an ISO procedure is involved their will be a criteria written for what information needs to be available.
Don’t dry lab the data collection process.....go out to where the event occurred.
Talk to People

18. You can’t tell which way the train went by looking at the tracks!
Time is important. Start gathering data and documenting evidence as soon as possible.

19. Gathering Data Use a Check list:
Location
Names
Date and Time
Operational Conditions
Environmental Conditions
Communications
Sequence of Events
Equipment
Physical Evidence
Recent Changes
Training
Other Events
Checklist on PW-9 is a good guideline for collecting data.
There is also a checklist master form on last page of tab 8. It helps to keep you on track when on the scene of an event.
PW-9

20. Exercise: pw-10 Write the event Question from the event, and identify the data that you might want to collect for each event.
Each team needs to have a member report decisions
made by their team.
Teams do all three questions, randomly select teams to report. Ask for commentsfrom other teams.
Have each team determine event question from event and identify data to be collected.
Event 4
Event question: Why was the window broken?
Data to collect: Whats broken? Who was around? What were the kids doing at the time? If the glass is broken, are pieces on the inside or outside? Did the neighbors see anything? What was the weather like? Anythingstolen?
Event 5
Event Question: Why dont the locks work?
Data to collect: Who drove last? Is the remote control dead? Is car battery dead? Any fuses blown? When did they last work?
Event 6
Event question: why was the floor damaged?
Data to collect: What kind of damage? Is the bed leaking? Is bed too heavy for floor? Who was in bed last? How long has it been damaged?

21. Verify That Data! Check for Accuracy Data Verification
Use a second source
Note conflicting information
Where did data come from?
Copied from a document/procedure
From an interview......interview how long after the event?
Does data conflict, hat are sources of conflicting data? this data may indicate other problems like an ambiguous procedure or document.

22. DON’T BE AFRAID TO BACK UP!
Your data may often show
you that multiple problems
exist.This may require a
parking lot. The data may also
lead you to rewrite your
event question.

23. Mill Fire Event Exercise
Using Mill Fire worksheet 1, Blue sheet under tab10:
-Write an event question
-Select team members (natural and qualified)
Note: Is there more than one problem?
Who are the customers of the report?
Participants: Go to module 10 in workbook and remove the blue page, sheet 1.
1. You get the call; rolling mill on fire. you go to the rolling mill.
2. Read the description of the event to class. Burned gloves on floor. Water left over from putting fire out.
3. Give the teams the instructions on PW-12. Ask class: Is there more than one problem?
4. When the teams are ready: go from team to team asking for answers.
Handout: completed sheets 2a and 2b. Discuss teams and data (data is on sheet 2a)
Discuss fact that there are two problems stemming from the event. (i.e. just becaus ea hous eburns down doesnt mean people have to die in it.)
Tell class to use only data on sheet for remainder of class. Return handouts to tab 10.

24. Mill Fire Scene

25. Burned Gloves Found at Fire Scene

26. Mill Fire Event The fire came first, but the burns
Why did the fire start?
(first problem)
Why was she burned?
(second problem)
The fire came first, but the burns
make the event more serious.

27. Review Who makes up the team? What do you start the analysis with?
What does the event question begin with?
- Vested owners
- Event Question
- Why