1. Root Cause Analysis Presented By: Team: Incredibles
San Jose State University
CMPE 203, Fall 2009
Root Cause Analysis Presented By: Team: Incredibles

2. Agenda Introduction What is RCA? Why do we need? Types of RCA
Techniques/Tools
- Kepner-Tregoe Method
- FMEA
- Fishbone Diagram
Case study of RCA

3. Root Cause Analysis What is Root Cause Analysis?
- Finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms
Reactive method
Goals
- Failure identification
- Failure analysis
- Failure resolution
Iterative Process:
- Complete prevention of recurrence by a single intervention is not always possible.

4. Steps for Root Cause Analysis
Collection of data - Phase I
- A fact-finding investigation, and not a fault-finding mission
Event Investigation - Phase II
- Objective evaluation of the data collected to identify any causal factor that may have led to the failure
Resolution of occurrence - Phase III
- Realistic assessment of the viability of the corrective action that the previous phase revealed.
- The phenomenon must then be monitored periodically to verify resolution.

5. Why do we need it Benefits of RCA
- Real cause of the problem can be found
- Problem recurrence will be minimized

6. Types of RCA Safety-based RCA Production-based RCA Process-based RCA
Systems-based RCA

7. Types of RCA Safety-based RCA
- Investigating Accident and occupational safety and health.
- Root causes:- unidentified risks, or inadequate safety engineering, missing safety barriers.
Production-based RCA
- Quality control for industrial manufacturing.
- Root causes:- non-conformance like, malfunctioning steps in production line.

8. Types of RCA Process-based RCA - Extension of Production-based RCA.
- Includes business processes also.
- Root causes:- Individual process failures
System-based RCA
- Hybrid of the previous types
- New concepts includes:- change management, systems thinking, and risk management.
- Root causes:- organizational culture and strategic management 8

9. Methods of Root Cause Analysis
Change Analysis
Barrier Analysis
MORT: Management Oversight and Risk Tree
Human Performance Evaluation (HPE) 9

10. Kepner-Tregoe Method Developed in 1958
Fact-based approach to systematically rule out possible causes and identify the true cause.
Composed of fives Steps:
- Define the Problem
- Describe the Problem
- Establish possible causes
- Test the most probable cause
- Verify the true cause
Kepner-Tregoe is a mature process with decades of proven capabilities.
Kepner-Tregoe Problem Analysis was used by NASA to troubleshoot Apollo XIII. 10

11. Tools for Root Cause Analysis
Add diagrams Diagrams 11

12. Failure Mode effect and Analysis (FMEA)
Methodology for analyzing potential reliability problems early in the development cycle.
Failure modes are any errors or defects in a process, design, or item, especially customer related.
Effects analysis refers to studying the consequences of those failures. 12

13. FMEA Example 13

14. FMEA
Benefits:
Improves the quality, reliability, and safety of products.
Increases customer satisfaction.
Stimulates open communication and collective Expertise.
Disadvantages:
Assumes cause of problem is a single event.
Examination of human error overlooked. 14

15. Fishbone Analysis Definition
- Technique to graphically identify and organize many possible causes of a problem
Advantages
- Helps to discover the most likely ROOT CAUSES of a problem
- Teach a team to reach a common understanding of a problem. 15

16. Fishbone Analysis Machine Material Measurement Problem Management
Components :
- Head of a Fish : Problem or Effect
- Horizontal Branches : Causes
- Sub – branches : Reason
- Non- service Categories : Machine, Manpower, Method etc.
- Service categories : People, Process, Policies, Procedures etc.
Machine
Material
Measurement
cause
cause
reason
Problem
cause
cause
reason
Management
Method
Man Power 16

17. Fishbone Analysis 5 WHY’S WHY WHY WHY WHY WHY Car stopped
Middle of the road
Ran out of Gas
Didn’t buy
this morning
WHY
WHY
WHY
Didn’t have
money
Lost them in
last night’s poker
WHY
WHY
Not very good
in “bluffing” 17

18. Case Study – Safeway.com
Safeway outsourced a module of Safeway online to HCL, India
Project Details – Add a new module for selling Patio furniture online on .
Agreed duration - 8 months, June, 07 to February, 08
Actual delivery – June ’08
After the project was finished TCS performed a Root Cause Analysis to analyze the delays and to avoid problems in future. 18

19. Case Study – Fishbone Analysis
Control
Inventory
Inventory Update Every 12 hours
No Clear Understanding
Real time inventory
Scope Definition
No Clear deadlines
Separate Systems
Wrong Estimates
Separate Systems for Sales & Supplier
Project Delay
No backup for Critical Resources
Managed Systems
Inadequate Resources
Different Suppliers
Communication
Lack of Standards
No Communication plan
Time and Format of Systems different
Resources
Benchmarking 19

20. Conclusion Learning for the future projects.
Encourages Team based problem solving approach.
Errors are frequent and inevitable.
Saves cost and helps in identifying solutions. 20

21. References http://www.isixsigma.com/library/content/c020610a.asp