Professional Documents
Culture Documents
PhD in IE
Topics to be Covered
Summary
CAUSE EFFECT
Events/conditions Symptoms that
that led to provide evidence
the problem of the problem
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Dave Wessel, “An Ounce of Prevention”, Quality Progress, Dec, 1998
Root Cause Analysis - ASQ
Gary Jing 11/14/06 Slide 5
The same thing is both a cause and an effect at the same time.
Causes and effects are part of an infinite continuum of causes.
EFFECTS CAUSES
Injury caused by Fall
Fall caused by Wet Surface
Wet Surface caused by Leaky Valve
Leaky Valve caused by Seal Failure
Seal failure caused by Poor Maintenance
...
5 Why’s Reference: Apollo Root Cause Analysis, Dean L. Gano
Where to stop?
- The trick is not to find the “true”
true” root cause per se.
- The trick is where to stop and treat what you have as
the root cause. That wisdom is what differentiates an
adult from a 2-
2-year old; an expert from a novice.
– The bottom-line is High ROI – low cost with high return.
- Three tips:
– Leverage Point Thinking
– Pareto Principle
– Span of Control / Sphere of Influence
Where Geographically?
Physically on the part?
When When was the defect
first observed? When Where, when and
since then? When in the what size could the
product life cycle?
defect have been
Size How many objects with
the defect? How many but it was not?
defects per object? Size
of defect? Trend?
N N
Problem/
Desired
N N Improvement
N
C
C
C New spin 2: Categorizing / labeling Causes:
Machinery Manpower
Opportunity: Controllability:
H: High C: Within control
M: Medium I: Have influence
L: Low N: No influence
Man
Machine Methods
Five Key
Sources of + Environment
Variation
Materials Measurement
Use
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People
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Five Key
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Variation
Place Measurement
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_______________________________________
_______________________________________
_______________________________________
_______________________________________
Requirement
Requirement
Requirement
Requirement
Requirement
Requirement
Requirement
Requirement
Requirement
Requirement
Requirement
Requirement
Requirement
Requirement
Total
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
9 0
10 0
11
12
C&E Matrix.xls 0
0
13 0
14 0
15 0
16 0
17 0
18 0
19 0
20 0
0
0
Total
Lower Spec
Target
Upper Spec
Rating of Importance
10 6 9 8
to Customer
1 2 3 4 5 6
Implementation
TOTAL %
me it’s
Commonality
Someti
(accuracy)
PROCESS INPUTS
Efficiency
rank
used to puts.
Change
ne in
Yield
Fishbo
1 Customer Input 8 6 8 8 252 11.36%
2 Equipment Specs 8 5 10 8 264 11.90%
3 Bill of Materials 7 5 10 5 230 10.37%
4 # of Revisions 8 6 10 8 270 12.17%
Label
5 Documentation 8 2 8 9 236 10.64%
6 CC Drawings 5 3 2 2 102 4.60%
7 Pre-CCP Metting 5 5 2 2 114 5.14%
8 Ownership 8 10 8 8 276 12.44%
9 Approval Cycles 8 8 5 8 237 10.69%
10 AMK Delays 8 8 5 8 237 10.69%
2218
01-004488 0.003 0.001 0.005 0.009 0.061 0.337 0.027 -0.134 0.027 -0.134 2 2 7
8100-0100-01 0.012 0.009 0.000 0.067 0.000 0.206 0.564 0.564 7 403 8
200 0.003 0.009 0.034 0.005 0.013 0.117 0.071 -0.135 0.071 -0.135 13 18 9
7500-0585-07 0.003 0.024 0.017 0.008 0.004 0.071 0.258 -0.092 0.258 -0.092 30 52 10
1032-047 0.018 0.052 0.000 0.014 0.000 0.069 0.570 0.569 32 403 11
PKG-782 0.017 0.131 0.000 0.009 0.000 0.096 0.530 0.530 20 403 12
01-009871 0.002 0.002 0.005 0.018 0.030 0.212 0.072 -0.083 0.071 -0.084 6 3 13
01-009644-17C02 0.001 0.000 0.001 0.006 0.017 0.103 0.047 -0.107 0.046 -0.103 17 11 14
9700-7036-01 0.003 0.004 0.002 0.049 0.018 0.241 0.141 -0.037 0.141 -0.037 4 8 15
01-001651 0.003 0.003 0.005 0.015 0.020 0.152 0.073 -0.070 0.073 -0.070 9 7 16
160 0.001 0.000 0.001 0.000 0.016 0.079 -0.095 -0.094 25 13 17
01-018514 0.016 0.034 0.000 0.073 0.000 0.238 0.203 0.203 5 403 18
01-021524 0.001 0.001 0.003 0.008 0.016 0.109 0.062 -0.069 0.047 -0.071 14 12 19
01-009897 0.003 0.002 0.008 0.003 0.011 0.076 0.029 -0.076 0.029 -0.077 27 21 20
01-021554 0.001 0.000 0.002 0.001 0.012 0.069 0.013 -0.073 0.014 -0.087 31 19 21
Example of RCT
AGB project: Potting Leaks
Rules, Guidelines
I have less
? disposable income
Rules, Guidelines
Cause Insufficiency
– Be sure you have identified and included all of the major contributing
causes
– To be contributing, causes must depend on one another
– Two questions:
• Is the cause alone enough to deliver the effect?
• If I take away one of the causes, will I still have the effect?
“AND”
Additional Cause
– Consider all possible independent causes
– A cause may consist of several independent causes, any of
which would have produced the effect
– Each independent cause would increase the magnitude of
the observed effect
Accounts receivable
are too high
Rules, Guidelines
Circular reasoning
The effect is the rationale for the existence of the cause
– More common in conversation than on graphs
– Example:
• The fisherman brought home several large fish
• WHY? - The fishing was good
• HOW DO YOU KNOW? - He brought home several large fish, didn’t he?
What’s the The readings B1. Where do C1. Lot SRA transform Cross E1.
repeatability are the we measure to lot during contamination Product
and calculated SRA, R&R. H,C variation. manufacturing. when lines absorb
reproducibility Sulfate H,N M,I shift products. SRA
of customer concentration L,I overtime.
data. L,N of product / H,I
resin? B7.
(surface B2. Resin
Sample Bag
only?) or the B3. Test test. M,I During
What’s the size. M,I contamination.
Correlation sulfate prime molding. L,C
between concentration product? L,I SRA
our data of test H,C transform
During Contamination
and their coupon / Cleaning. overtime.
B6. Air Exposing through leaking M,N
data. L,N water? L,N L,C to air. M,N
B4. Test quality bag. L,I
cleaned . M,C
product?
Correlation doesn’t mean H,C Resin absorb
Outside
causation. Is Sulfate really the cleanroom SRA from Product
primary contributor? air. M,C Cleaning release
(Otherwise it may not help the B5. Test / removes / SRA
problem.) – Need to work with monitor cleaning Inside Parts absorb SRA from absorb overtime.
customer and their data. M,I solution? H,C cleanroom air inside cleanroom. M,C SRA. M,C L,I
Summary