Welcome to the session Objectives Learn and be able to apply a fishbone diagram Utilize Why analysis technique to uncover causes 2 2 Why Analysis Question asking technique used to explore the cause and effect relationships underlying a particular problem ID: 606094
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Root Cause Analysis
Welcome to the session!Slide2
Objectives
Learn and be able to apply a fishbone diagram
Utilize “Why” analysis technique to uncover causes
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2Slide3
“Why” Analysis
Question asking technique used to explore the cause and effect relationships underlying a particular problem
Four to five iterations of asking
why
is generally sufficient to get to a root cause, but may go moreEXAMPLE: The vehicle will not start (problem statement)
Why? – The battery is deadWhy? – The alternator is not workingWhy? – The alternator belt is brokenWhy? – The belt was beyond its useful life Why? – The vehicle was not maintained per the recommended schedule3Slide4
Tips For Successfully Using “Why” Analysis
Root cause of the vehicle example appears to be the lack of scheduled maintenance… this is a process that can be improved
You know when you have gotten to the cause when the answer points to a process that is not working or does not exist
The root cause generally is not time, money, or manpower
Processes fail, not people or money, so ask the question “
Why did the process fail?”4Slide5
Why Analysis Example 1
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Why Analysis Example 2
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Why Analysis Example 3
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Why Analysis Example 4
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Why Analysis Example 5Slide10
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Why Analysis Example 6Slide11
What is a Fishbone Diagram?
The Fishbone diagram (or Ishikawa Diagram) is used to identify possible causes for an effect
Causes are grouped into major categories to identify the sources of variation through the 6M’s
Manpower
MachinesMaterialsMethodsMeasurements
Mother nature [environment]11Slide12
Fishbone Diagram Example 1
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POOR CRANE
PRODUCTION
New
Driver
Untrained Driver
Driver in Bad Mood
Manpower
Methods
Materials
Machines
Mother Nature
Measurements
Condition of Crane
Broke cell guides
Type of Crane
Additional long travels
Physical Terminal Layout
High
winds
Service Overdue
Operating with Defect
Incorrect Stow Plans
Unrealistic Deadlines
Yard Planning
Stuck Cones
Damaged containers
CAUSES
EFFECTSlide13
Fishbone Example 2
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Fishbone Example 3
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Why Use a Fishbone?
Groups potential causes for defects into logical categories
Helps teams work together to get to root
cause (inquiry
)Highlights where additional data gathering needs to occur
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Step 1: Determine the Problem/Issue
To construct a fishbone:
Start with stating the problem in the form of a question, such as “Why is crane production low?”
Agree on the problem (effect) and place it in a box at the “head” of the fishbone
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Why is Crane production low?Slide17
Step 2: Establish the Categories
Determine which categories you will use to find causes and draw the lines (bones)
Feel free to modify the categories for your project and subject matter
Most common categories called 6 M’s:
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ManpowerMachinesMaterialsMethods
Measurements
Mother nature [environment]Slide18
Machines
The Machines category groups root causes related to tools or equipment
Examples of questions to be asked:
Was the correct tool/tooling used?
Does it meet production requirementsIs the machine properly maintained?Was the equipment used within its capabilities and limitations?
Are all controls clearly labeled and/or color-coded or differentiated?18Y
MachinesSlide19
Methods
The Method category groups root causes related to how the work is done
Examples of questions to be asked:
Are the work instructions clearly written & complete?
Are mistake-proofing devices/techniques employed?How many “if necessary” and “approximately” phrases are found in this process?Are features of the process critical to
safety clearly spelled out?Is the work standard upgraded and to the current revision?19Y
MethodsSlide20
Materials
The Materials category groups root causes related to parts, supplies, forms or information needed to execute the process
Examples of questions to be asked:
Is all needed information available and accurate?
Was the material substituted?Was the material defective?Was the raw material the wrong
type for the job?Was the material handled properly(stored, dispensed, used & disposed)?20
Materials
YSlide21
Measurements
The Measurement category groups root causes related to the measurement and measuring of a process activity or output
Examples of questions to be asked:
Is there a metric issue?
Is there a valid measurement system? Is the data good enough?Is data readily available?
Does the measuring gage have proper measurement resolution?21
Measurements
YSlide22
Manpower
The Manpower category groups root causes related to people, staffing and organizational structure
Examples of questions to be asked:
Was the proper training to perform the task administered to the person?
Was too much judgment required to perform the task? Were guidelines for judgment available? Is fatigue a contributing factor?
How much experience does the individual have in performing this task?22
Manpower
YSlide23
Mother Nature (Environment)
The Mother Nature category groups root causes related to the work environment, market conditions, and regulatory issues
Examples of questions to be asked:
Is the workplace safe and suitable/ comfortable?
Are outside regulations impacting the business?Is the process affected by temperature changes over the course of a day?Are associates distracted by noise,
uncomfortable temperatures, fluorescent lighting, etc.?23Y
Mother NatureSlide24
Step 3: Brainstorm Causes
For each category, brainstorm possible root causes of the problem that may be related to the problem/ issue
For each cause identified, continue to ask “why does that happen?” and attach that information as another line (bone) of the category branch
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Step 4: Review the Diagram
The diagram should now show all of the possible causes of the problem that you can think of
Prioritize the key causes identified on the fishbone
Agree on which of these possible causes are actually contributing
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Summary
Identify the problem or issue
Draw horizontal line across center of page
Write problem at fish head
Establish the categories
Use the 6M’s: Manpower, Machine, Method, Measurement, Material, Mother Nature (Environment) - or choose your ownDraw lines (bones) and the labelsBrainstorm/ record ideas onto fishboneCreate sub-branches as neededReview completed diagram and set focusScore / Vote or Rank as appropriate to group thoughts, or prioritize the issues by data analysis (most frequently occurring) or cost impact on the process or risk of failure/ work stoppage, etc.26Slide27
Exercise: Create a Fishbone Diagram
With your team, construct a detailed Cause and Effect Diagram on the process / example presented
Identify and label categories
Examine using the “why” analysis
Brainstorm as many inputs as possible with each branch and/ or sub-branch
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Review
Learn and be able to capture thoughts using a fishbone diagram
Learn to apply “Why” analysis technique to uncover root causes
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