Dataplate Training Konrad Burgoyne wwwdataplatecouk Introduction Aim To understand the concepts of cause analysis and to be able to apply those concepts to prevent or eliminate errors and ID: 625051
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Slide1
Introduction to Root Cause Corrective Action and the 5 Why Process
Dataplate Training
Konrad Burgoyne
www.dataplate.co.ukSlide2
Introduction
Aim - To understand the concepts of cause analysis and to be able to apply those concepts to prevent or eliminate errors and defects
Reason - This is a requirement of the aerospace industryIncentive – RCCA is a fundamental and valued skill used within many areas of business.© 2014 Dataplate
2Slide3
What is Root Cause Corrective Action?
An effective process for finding the causes of an event and facilitating effective corrective actions to prevent recurrence.
© 2014 Dataplate3Slide4
RCCA for Non Conformances
A requirement of the aerospace industry for many years.A process of determining the causes that led to a nonconformance or event.An effective method for implementing corrective actions to prevent recurrence.Requirements are not new, but they may not have been aggressively enforced in the past
.© 2014 Dataplate4Slide5
Event
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An all inclusive term for any of the following:
Product Failure
Non Conformance
Audit finding
Special Cause (SPC) AccidentCustomer complaintFailure Mode (FMEA)Slide6
The Traditional Approach to an Event
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Event
(Problem)
Fix it
Containment
Establish
Team
Identify Problem
Gather
& Analyze Data
Find the Root Cause
Determine Corrective
Action
Implement Corrective Action
Review Corrective ActionSlide7
Traditional Problem Solving
© 2014 Dataplate
7
7
Does
It Work?
You Could
Be In
Trouble!
Uh - Oh !
PROBLEM!
NO
PROBLEM !
Did
You Mess
With It?
Does
Anyone Know
You Messed
With It?
Will
You Be
Blamed For It
Anyway?
Can
It Be Fixed
Before Your
Boss Finds
Out?
Can You
Transfer Blame
To Someone
Else?
Hide It Or
Throw
Away The
Evidence!
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
J
L
Don't Mess
With It!Slide8
The Requirement - AS9100
© 2014 Dataplate8
8.5.2 Corrective Action: The organization shall take action to eliminate the cause of nonconformities in order to prevent recurrence. Corrective actions shall be appropriate to the effects of the nonconformities encountered.A documented procedure shall be established to define requirements for:
a) reviewing nonconformities (including customer complaints),b) determining the causes of nonconformities,c) evaluating the need for action to ensure that nonconformities do not occur,
d) determining and implementing action needed,e) records of the results of action taken,f) reviewing corrective action taken,g) flow down of the corrective action requirement to a supplier, when it is determined that the supplier is responsible for root cause, and
h) specific actions where timely and/or effective corrective actions are not achieved.Slide9
The RCCA Approach to an Event
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Event
(Problem)
Containment
Establish
TeamIdentify ProblemGather & Analyze DataFind Root CauseDetermine Corrective ActionImplement Corrective ActionReview Corrective ActionSlide10
Containment
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Immediate Corrective Action
Put out the fire
STOP producing bad product
Evaluate product impact
Inform customer if shipped product impact is suspected – A legal requirement.Slide11
Establish Teams
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Natural Team
Assignment of wrong personnel a common problem.
Common to assign to Quality – did quality make the error?
Who owns the problem?
Who has a stake in the outcome and the solution to the problem?Who are the vested owners of both the problem and the solution?Who knows the process – have data and experience?Who will have to implement and live with the corrective action?
Without the full buy-in and support of the stakeholders, long-term solutions are not likely.Slide12
Establish Teams
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Qualified Team
The Natural team plus
other individuals who can provide necessary resources to understand the problem further.
Those who can provide additional information
Those who have technical expertise – Subject Matter Experts (SME)Those who may need to act as advisorsThose providing management supportSlide13
Remember
© 2014 Dataplate13
Take action:
To a degree appropriate to the magnitude of the problem.
Proportionate with the risks encountered.Slide14
Identify Problem
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You must
understand
the problem.
Is there more than one problem? You must know what you don’t know, to be able to find out.Keep it simpleSlide15
The Problem
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Must be clearly and appropriately defined.
The nonconformance identified may not be the real problem – only a symptom of the problem.
Asking questions is helpful.
What is the scope of the problem?
How many problems are there?What is affected by the problem?What is the impact on the company?How often does the problem occur?Addressing appropriate questions will assist in clarifying and defining the problem(s).Slide16
Caution
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If you cannot say it simply, you do not understand the problem!Slide17
Gather & Analyse Data
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Location.
Names of Personnel.
Date and Time.
Operational Conditions.
Environmental Conditions.
Communications.
Sequence of Events.
Equipment.
Physical Evidence.
Recent Changes.
Training.
Other Events.
Look for:
Performed by Team MembersSlide18
Gather & Analyse Data
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Problem identified – begin data collection.
May need to be collected several times.
The preliminary collection phase occurs now and will guide the analysis process.
Initial data gathering starts at the scene.
Data has a shelf life.Waiting makes it difficult to obtain good information.Go to the scene.Note those present, what is in place, when the event occurred, and where the event happened.Slide19
Remember
© 2014 Dataplate19
Take action:
To a degree appropriate to the magnitude of the problem.
Proportionate with the risks encountered.Slide20
Find The Root Cause
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The Cause Chain
Direct>Contributing>Root
The direct cause is the cause that immediately caused the problem
Causes in-between are contributing causes
A root cause is the last cause in the cause chainSlide21
Find The Root Cause
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21
An Important Thing to Remember About “Root Cause.”
It’s
not
always the most significant
cause in the chain ...
Just focus on the fact that it is the
LAST
cause in the chain ... Slide22
The 5-Why Process
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The ‘5 why’ is one method that can be used to find: -
the cause chain.
A natural logical progression for thinking through a problem.
The direct cause.
The root cause.The contributing causes.Slide23
Why?
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State the Problem as an Event Question starting with:
An event question is short, concise, and focused on ONE problem.
It is a question starting with Why . . . ?
It is the first “Why” in the process.
Why . . . ?Slide24
Common Initial Considerations
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Operator error (most common).
Honest mistake.
Second shift did it.
We didn’t include the requirement in our internal procedure.
We didn’t know it was a requirement.Not familiar with the specification.Slide25
Caution : Operator Error
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Yes, it does happen, but . . .
Used as “root cause” much too often.
Used as an easy way out.
Ask:
If the operator was replaced, could the next person make the same mistake? If so, then you have not determined the Root Cause!Slide26
Is it really Operator Error?
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You must ask these five questions:
Proper Instructions?
Proper Tools?
Proper Training?
Clear Expectations / Goals?Is the process Complex or Unusual?Slide27
How many whys?
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Do not believe that the
5
Why process restricts you to asking why
5
timesA root cause may be found with 3 Whys or it may take 7 WhysSlide28
How many whys?
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Times asked whySlide29
Remember
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Take action:
To a degree appropriate to the magnitude of the problem.
Proportionate with the risks encountered.Slide30
No Big Secret
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Simple Answer
Simple Answer
Simple Answer
Simple Question
Simple Question
Simple Answer
Simple QuestionSlide31
Don’t fall into the trap
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CAUTION
Cause chain under construction.
No corrective actions allowed!Slide32
The cause chain
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Direct
Cause
Contr.
Cause
Root
Cause
How many root causes are you allowed?
EventSlide33
The cause chain© 2014 Dataplate
33
C
C
C
C
Problem
#1
Direct
Cause
Root
Cause
Two or more, if you have multiple branches.
Problem
#2
Direct
Cause
Root
Cause
C
C
C
C
EventSlide34
Fishbone Diagram
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A fishbone diagram is a graphic methodology to identify “Whys.” To make a Fishbone Diagram, start with your problem or event and brainstorm ideas about why that problem/event is happening. Each one of these ideas (or causes) becomes a “bone” that shoots off the main one. Then, brainstorm ideas that might have caused those “bones.” Eventually, it will look like a skeleton of a fish.Slide35
5 Why Example
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For job 6 (OEM Prime, job no. B140898), drawing
DX667-039 required "stress relieve at 525 +/-5°C for 30min to KPS425”
It was found that the data card,
DC2488, required 538 +/-13.9°C for 20 - 25min. Although this is in line with the requirement of KPS425,
there was no customer or delegated approval on the data card to show that this deviation from the drawing was acceptable.Nadcap Audit 54345 NCR5The ProblemIt was determined by OEM Prime that a Drawing Clarification Form should have been raised in the first instance. Drawing Clarification Forms were not formalised or understood throughout the companySlide36
5 Why Example
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The “Drawing Clarification Form” was known as a “query form” and came into use in September 2013. There is no identified formal process or procedure in place in obtaining clarification from the OEM Prime.Why is there no formal process for implementing the Drawing Clarification Form (Query form)?This form was a new form that was sent to a specific engineer
in January 2014 for project G053XX016-103, G053XX038-103 and G053XX048-101 queries.Why
was this form not put in general use for OEM Prime queries?There was no other information or instruction flowed down from OEM Prime in relation to this form
Why was there no other information requested?It was understood that this form was an informal document specific to project G053XXWhy was this form understood to be an informal document?
It was created with no process or instruction document and showed no document ID number and it is not referenced in the OEM Prime Q700 Requirements for Suppliers document?Root cause: Inadequate control of documentationContainment:The Drawing Clarification Form has now been completed for drawing DX667-039 and sent to OEM Prime (See attached) Corrective ActionQuality Alert OEM11 has been raised and distributed throughout. (See attached)Slide37
5 Why Example
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Quality Alert – OEM11– Control of Documents Aim – The aim of this quality alert is to put in place corrective action and initiate preventative action for similar situations. Reason – Control of Documents is a requirement of AS9100 Incentive – A well understood standardised quality system will improve efficiency, productivity and profitability throughout the business.
Issue A recent Nadcap audit NCR response led to a discovery of a document (issued by a customer) used without a formal process or written procedure. Action
With immediate effect, all users of documents both internally generated and externally provided shall ensure there is a formal process to follow that is referenced in the Quality Management System (QMS). In the event a document is identified having no formal process please refer to P-Q-2-11 Document Control & Control of Records Procedure for the process to follow. Slide38
Caution
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Complex problems, especially those where an entire process has been brought into question require a more thorough analysis.
Process Planning
& Materials
Requirements
& Design
Equipment
& Maintenance
Production Operations
& Quality Assurance
Root Cause Analysis (RCA) is a systematic approach to determining all the contributors to a problem before attempting to implement a corrective action plan.Slide39
Corrective Action
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A set of planned activities (actions) implemented for the sole purpose of permanently resolving the problem.Slide40
Types of Corrective Action
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Specific
corrective action changes only the direct cause or the effect.
Action(s) taken to correct the direct cause and/or the effect.
Sustaining corrective action changes contributing and root causes. Actions taken to prevent recurrence of the eventSlide41
Sustaining Corrective Action
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Sustaining corrective actions focus on changing
root cause(s)
and
contributing cause(s).If you have only identified one cause, you probably won’t
get a 100% effective fix.Remember – today’s contributing cause is tomorrow's root cause.Slide42
Corrective Action – What, Who & When
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The three W’s
What, Who, When.
What is the corrective action?
Who is responsible for doing it?
When is it going to be done?Slide43
Corrective Action
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Establish the most effective corrective action to put in place.
Must correct the root cause
Must correct contributing causes
Must be workable
Must have a effectivity dateMust be sustainableMust not be the cause of other unforeseen non-conformancesMust be reviewedSlide44
Remember
© 2014 Dataplate44
Take action:
To a degree appropriate to the magnitude of the problem.
Proportionate with the risks encountered.Slide45
Corrective Action - Review
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The corrective action can have a working review to ensure it is effective
Adjustments to the corrective action can be made and documented
A formal review is required to document effectivitySlide46
Summary
© 2014 Dataplate
46
EVENT
Form Team
Contributing
Gather & Verify Data
Mistake Proofing
Determine Corrective Actions
(Specific & Preventive)
Determine Causes
Implement & Follow up
Identify Problem
Solution
Acceptable?
No
Yes!
Root
Direct
Containment
DoneSlide47
Documentation
© 2014 Dataplate
47
EVENT
Form Team
Contributing
Gather & Verify Data
Mistake Proofing
Determine Corrective Actions
(Specific & Preventive)
Determine Causes
Implement & Follow up
Identify Problem
Solution
Acceptable?
No
Yes!
Root
Direct
Containment
Done
Document Causes
Document
Corrective Action
Document Follow-up
Write Final Report
Minutes Team
MeetingsSlide48
Remember
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Take action:
To a degree appropriate to the magnitude of the problem.
Proportionate with the risks encountered.Slide49
Questions?
© 2014 Dataplate49