RCA

ROOT CAUSE ANALYSIS
Concept & Methods

Feb, 2018
SURAJIT DEB, TSD INSTITUTE
First version: June’2010

Updated July’12, Jun’2014, Nov’2015, Nov’ 2016, Jun 2017
Chapter
Introduction
Feb, 2018 TSD INSTITUTE 2

Improvement Technologies
Analytical Measurement
Technology Technology
Individual
Technology
Analytical Technology: methods of extracting and identifying missing

factors and defects
Individual Technology: specialized techniques and skills required for
creating things
Measurement Technology: measurements of changes in phenomena
occurring/ points of processing/ processing conditions
Application of Root Cause Analysis
Problem Analysis
• Breakdown Analysis
• Defect Analysis
• Accident Analysis
• Delay Analysis
• etc

Why problem analysis is required ?
• To prevent recurrence of the problem

- To find out root cause against which
“preventive counter-measure” can be taken
• To develop our skill to solve problems and

face the future challenges
(same phenomenon for same cause should not repeat)

What is a repetitive failure
• A failure which has happened before.
• More clearly, the same pheonomenon, for the

same cause.
• May be in a different machine.

Why does the same Is it possible to achieve
problem recur? zero recurrence?
 No recurrence prevention measures are in place (no measures are taken to address changes in factors).
 The other factors are left unattended (no regular factor inspections are carried out).
Sensor
Vibration
Recurrence due to
Sensor shield displacement
Loosening
But Loosening of a
screw recurred
Cause:
loosening of
a screw
Countermeasure
Cause: loosening of a screw due to vibration
Recurrence prevention measure
Tightening of Non loosening
the screw
Spring washer
WWk – 10
What is cause, what is pheneomenon ?
• Phenomenon is: “ what has happened”
• Phenomenon Observation: is the understanding of

“what has happened”.
• Cause is : “what has contributed to the phenomenon”/

the ‘reason behind the phenomenon’
• Root cause: is “exactly where the cause has originated”
• Counter-measure: The action which you take against

the root cause, so that the same phenomenon for the
same cause will not repeat.
Analysis Tools for Failure & Defects
Sporadic
Use
Failure Time or Defects
Why-why Analysis
Kaizen
the Current Status
PM Analysis
Chronic
Basic approach points for doing an RCA
• Be impartial
- do not proceed with any assumption
- do not jump into a conclusion
- proceed absolutely logically
• Do Observation of the Phenomenon
- focus on the genba and genbutsu
- study phenomenon with 5W-1H
• Study the problem with data
- collect information
- collate the data
• Arrive at the Cuase using a logical approach
Steps & Rules of RCA
1) Form a team. Never do it alone, do it in a team. Team should
be cross functional
2) Phenomenon observation should start immediately on

receiving FIR
- Phenomenon observation to start at Genba, on genbutsu
3) Talk to local operators & technicians / fitters
4) Take photos of failed component / defect
5) Write the problem statement in specific words, short sentence

(do not use due/because/proper etc)
6) RCA starts after phenomenon observation is done

Rules of RCA …contd
7) Make sketch of the item / process / mechanism
8) Link the observation points to link the why logic chain (why)
9) Verify the logic from opposite direction (  hence)
10) Root cause should touch one of the 5 basic causes
11) Consider counter-measure opposite to the root cause

12) Counter measure ideas to be evaluated for possible negative
impact
13) Implement the Countermeasuere & check the effect
14) Standardise the countermeasure for sustenance
15) Look for horizontal deployment scope
16) Compile & file the RCA record
Notes

How to write the problem statement
• The problem statement should be short, simple
• It will cover only the fact ( only what has happened) and
no assumption
• The cause should not be written in the problem

statement
– “due to”, “ because” words are not to be used
• What, where, when, who, which are to be covered in

phenomenon description

And, to summarize
• Think of yourself as an inspector in the scene of a crime
• Base your verdict on phenomenon observation, data and

facts
• Be impartial,
Do not assume,
Do not jump into conclusions
• Proceed only with logic
• Use sketch /illustration to understand & visualize problem

• Work in a team,
A couple of team members should be outsiders (third party)
Fresh Chapter:
PHENOMENON OBSERVATION

Phenomenon Observation

Problem approach by
Phenomenon observation
• 90% of problems can be solved only by

observing the phenomena & simple why-why
• 9% problems may need an advanced why-why

analysis
• Very few problems (~1%) may need a higher

level analysis tool like PM analysis

Problem approach by
Phenomenon observation
• Understand the phenomenon

- observe the problem closely, at the spot, on the actual
thing, collect all related information
• Phenomenon observation will lead to a

conclusion
• The conclusion may lead to the root-cause or

will lead to the starting of the why-why

Studying phenomena with 5W-1H
Who Any Variation among people involved in the operation ?

- Any Shift difference, Any difference among Operators, relievers, fitters.
What Classifying
Any Phenomena
variation due to with 5W+1H
production materials?
- Supplier change, Raw Material change, lot changed
Where Any variation due to equipment , fixtures and components?
- In what stage /section of process/machine does the problem occur.
When Any variation related to time or period?
- Start of the work, after change over, any seasonal change, any time
difference associated with problem.
Which Are there any characteristic trends over time?
- Do problem increase or decrease with time
How Any variation in circumstances of occurrence ?
- Does it occur frequently or rarely, Does it appear abruptly or
gradually ,Does it appear continuously or discontinuously
Cont...
Grasp the phenomenon accurately
１. Grasp the actual phenomenon visually at the working place.
Types of surface defect

Ex. Surface defect (Many kinds as below)
・Scratch
Which process is it found? ・Abrasion
・Hit
・Dent
・Chuck
Example 1: In which moment of the process the
phenomenon occurs?
- A bottle drops when passing through a conveyor
2．Grasp the difference of part of the process ( or location)
Point： Think as if you are the bottle

A
B Guide
Belt conveyer
Bottle C
Conveyer D
Crossing
board
Feb, 2018 Conveyer TSD INSTITUTE 22
Example 1. contd….
In which moment of the process the phenomenon occurs ?
3．Focus / narrow down on the spot of happening
A: Conveyor & Bottle

B: Bottle & Guide & Conveyor
C: Bottle & Guide & Crossing board & Belt
Ｄ：Belt Conveyor & Conveyor

Example 2: Which moment of the process the
phenomenon occurs?
4．Do not express by general words(be specific)
Ex. A Robot Arm picks up bottles, moves, and places bottles –

and drops a bottle occasionally.
Point： Watch each movement closely to close down

to exact which sub-process /ub-movement of the arm
A: Arm moves down

B: Positions itself at the bottle spot
on carrying C：Grasps the bottle
D：Lifts the bottle
E: Starts moving after lifting the bottle
24
Feb, 2018 F：Arm moves forward
TSD INSTITUTE
Do not write phenomenon by assumption
People tend to include the cause in the same sentence

which indicates the phenomenon.
Point 1： Write the facts clearly
Point 2： Assume nothing
No cap on the bottle fact of the phenomenon only
Missed to put the cap on the bottle (writing

by imagining the phenomenon.)
What is the phenomenon – be specific
Inspect the phenomenon closely and do not express

in a vague way. Be specific.
Ex.The temperature of the inside of the furnace is low.

Factors
①～was low. Set up line
②～became low. Deteriorate
③～is sometimes low. Fluctuating

Notes

Clue to Phenomena Observation:
Visually study the problem
• Make sketch / illustration to study the problem

- clear skecth cannot be made unless the part configuration is
known clearly and needs closes observation at the site
• Use block diagrams/ flow diagrams to visualize the

location of the problem
• Use videography where necessary to continuously

observe a phenomenon (to detect abnormal situations)

Phenomena Observation: For repetitive problems
Work with data & facts
• For repeated breakdowns / repetitive problems, detailed

data study reveals a pattern
• Defect analysis is mostly based on data and

phenomenon observation
• Data is very important to study for repetitive breakdowns

Fresh Chapter:
WHY BREAKDOWNS HAPPEN ?
Theory of Deterioration &

the 5 Basic causes of Breakdown

Why breakdowns happen
5 causes of Breakdown
1. Basic condition not maintained

2. Operating Condition not maintained
3. Deterioration unattended
4. Lack of Skill
5. Weak Design
• (Video explanation)

Theory of Deterioration
TSD TECNOLOGY
Feb, 2018 TRAININGS & SERVICES INSTITUTE
TSD INSTITUTE 32
Forced Deterioration & Role of Jishu Hozen
Feb, 2018 TSD TECNOLOGYTSD INSTITUTE 33

TRAININGS & SERVICES INSTITUTE
Restoration against Deterioration at Fixed
Interval ( Time Based maintenance)

Corrective Maintenance for extending MTBF

Causes of Breakdown with respect to
Deterioration diagram

5 Causes and Role of Maintenance
TBM & JH
TBM &
CBM
Skill Training
MP Info

Notes

Phenomenon observation clues–
to link with 5 basic causes
• Start with the history of the equipment
- when was it installed ,
- when was the last maintenance done
- Any modification done in recent past
• Next collect the history of the breakdown
- When the problem started appearing,
- is it the first time,
- how many times it happened till now since it started happening,
- What action was taken each time
• Next collect information about the change in operation pattern in
recent past
- Any increase in load,
- Any new operator working (5W-1h)
- Any new grade being processed / new spare being tried (new trial)
• Study the failed component (it is a black treasure)
Feb, 2018• GENBA & GENBUTSU are always the focus of attention
TSD INSTITUTE 41
Phenomenon observation clues–
• 1. Start with the history of the equipment

- 1.1 when was it installed [Natural Deterioration (lowering of strength) ]
- 1.2 when was the last maintenance done [Lack of Skill (Increase of stress)]
- 1.3 Any modification done in recent past [Weak Design (low strength)]
- 1.4 Is equipment under JH, and JH is active [Forced Detern(lowering strength)
• 2. Next collect the history of the breakdown

- 2.1 When the problem started appearing, (from the beginning, frequent ?)
- [Weak Design (low strength)]
- 2.2 Is it the first time, (go to question 1.1)
- 2.3 If happened earlier, what action was taken each time [CMNT ?]
• Next collect information about the change in operation pattern in

recent past
- Any increase in load, [Operating Condition not maintained (Increase of stress)]
- Any new operator working (5W-1h) [Lack of Skill (Increase of stress)]
- Any new grade processed [Operating Condn not maintained (Increase stress)]
- new spare being tried (new trial) [Weak Design (low strength)]
• Feb,
Study2018the failed component TSD
(it isINSTITUTE
a black treasure) 42
Fresh Chapter:
Why – Why Analysis

Why – Why Analysis
An analytical method
designed to help you
identify all factors contributing to a phenomenon
one by one
in an orderly fashion,
rather than a hit-and-miss attempt to work out the factors
Aims of Why Why Analysis
１．Develop the habit of ４．Develop the consciousness

thinking analytically. about the abnormalities
causing troubles in the
２．Develop the understanding workplace.
of the relation of the
phenomenon with theories
５．Develop the way of
& fundamental principles.
prevention of recurrence.
３．Develop the knowledge of
the function, structure and
Aim to level up the
mechanism of the
equipment / process. ability of the people

Rules of Why-why Analysis
1) Should be done in a team
2) Verify facts from gemba, gembutsu
3) Connect the why-s in a chain of logic
4) Should end up where the cause can be prevented
5) Use the ‘hence’ logic to check of the chain of logic is

continuous
6) No assumption, No guesses
Simple Why-why analysis
Repeat ‘why’ n-times (till root cause is found)
- Applicable for one single event
- Stop the why chain when you reach basic 5-causes
- Can be done by gemba people based on actual findings

Idea of countermeasure
• Just opposite of the Root-cause identified

The final why in the why-why analysis
Final “why” Measure

No oiling standards are Establish oiling
in place if so standards
Provide educational/ training
Education and knowledge
programs and implement
are insufficient if so regular evaluations
Rigidity of materials is Enhance the rigidity of

low if so materials
The real culprit is not the thing (e.g. work, jig, or facility part)
but the management mechanism (e.g. design principle, method,
inspection or education).
WWk – 9
Example of simple why-why – 1 (Eqpt B/Dn)
• Coolant spray not coming after starting the Pump
(at xyz machine, date ………..)
Why coolant not coming ?

- Nozzle mouth clogged
Why nozzle mouth clogged ?
- Dirt flowed in with coolant
Why dirt flowed in ?
- Dirt present in coolant
Why dirt present in coolant ?
- Dirt has not been cleaned completely from colat
Why dirt has not been cleaned completely from coolant ?
Dirt arrestor (Filter) could not arrest the dirt completely
Why dirt arrestor could not clean completely ?
Dirt arrestor clogged
Why dirt arrestor clogged ?
- Dirt has accumulated on Dirt arrestor
Why dirt has accumulated ?
- Regular cleaning not done
Why regular cleaning not done?
- Filter cleaning standard not exist
Root cause
- Root Cause:
(Basic condition not maintained)
Filter cleaning standard not exist
- Preventive countermeasure:
Periodic cleaning of same in JH or TBM

Example of simple why-why – 2 (office)
• Material not reached at site on time (one single case)
( xyz vendor, item ………..)
Why material not reached on time ?

- Material was despatched late
Why material was despatched late ?
- Material was not ready within schedule
Why material was not ready within schedule ?
- Material specification reached late
Why material specfcn reached late?
- Matl specfcn not sent with p.o.
Why material specfcn not sent with p.o.?
- Purchase man (new) missed to send it together
Why Purchase man (new) missed to send it together ?
- Purchase man was not trained
- Root Cause: (Lack of Skill)
- New persons’ training not done
- Preventive countermeasure: Introduce training system for new persons
Notes

Do Exercise on
Simple Why why Analysis

Fresh Chapter:
Advanced Why – Why Analysis

Advanced Why-why analysis
Two approaches:
(1) Approach by Ideal conditions
(2) Approach by Fundamental Principles & rules

Approach by “Ideal condition”
• Identify the ideal conditions

under which the problem will not happen:

Advanced Why-why analysis: Ideal condition approach
Example: Torch not working
Ideal Condition check
1. Bulb is OK ?
2. Switch is OK ?
2.1 Spring is OK ?
2.2 Contact point is OK ?
3. Wiring is OK ?
4. Battery is OK ?
5. Etc.
Advanced Why-why analysis: Ideal condition approach
Example: Torch not working ..contd
Ideal Condition check
1. Bulb is OK ? Yes
2. Switch is OK ?
2.1 Spring is OK ? Yes
2.2 Contact point is OK ? No
3. Wiring is OK ? Yes
4. Battery is OK ? Yes
5. Etc.
Why – why starts from here

Approach by “Fundamental principles & rules”
Approach the problem from the
fundamental / theoretical principles

(laws of physics / chemistry / electricity etc)

Advanced Why-why analysis:
(based on fundamental Principles)
(i) The First Why is derived from the physical fundamental principles,
which is working behind the mechanism and phenomenon
(ii) Subsequent why-s are branched out logically, based on ‘immediate
contributing cause’ sequence
On-site confirmation
2-1-1-1
Why 3
Why 1 2-１－１ Why does
1-1 occur?
Why 2 2-１
Why does
2-1-1-2
1 occur?
Why 1
Why does the
phenomenon 2-１－２ 2-1-2-1
Phenomenon occur?
(based on
fundamental
principles) 2-２－１
２-2 Why does

2 occur?
Feb, 2018 TSD INSTITUTE 2-２－２ 2-2-2-1 61

WWk – 8
Basic approach point of
advanced why-why
Approach based on
basic theoretical principles and rules
• Each aspect of the basic principle is proceeded into

causes and sub-causes
• Each cause route is proceeded upto physically verifiable

level
• Each cause line is actually verified by site observation

• Applicable where multiple causes are playing
• Applied when the breakdown is recurring
• When simple why-why does not solve the problem
• Needs thorough understanding of the equipment (its

parts and functions)
• Meant for engineers and senior technicians
• Should be done in a team

Keys to implementing an Advanced why-why analysis,
based on Fundamental Principles
Key 2
What to do in advance of the Key 4
why-why analysis After completing the why-why
analysis, go it over in reverse Continue to ask “why” until
(a) Sort out (classify) problems you reach factors that can
and distinguish the facts. order (from the final “why”
part to the “phenomenon”), to contribute to the prevention
(b) Understand the mechanism of recurrences.
and roles of the things in ensure logical coherence.
question.
Phenomenon Why Why Why

Problems
Key 3
Check whether all factors affecting
the phenomenon are considered by All boxes
examining the opposite (whether Key 1
the phenomenon would not occur Sentences to be put in the
if each of the factors did not occur). “phenomenon” and “why” columns
should be written in a short, concise
manner, in the form of
“someone/something did something.”
WWk – 34
Notes

Explanation of the
Approach by Fundamental / Theoretical
principles & rules

What is Principle & Rule ?
Fundamental theories (like laws of motion / laws of force

/thermodynamics / electrical theories / chemistry / electro-
chemical / electro-mechanical etc) ,
Rules are guiding principles of the fundamental theory
Focus
on the reason
why the child
is crying.
Concentrate only on the actual basic fact.

Example of Approach by theory & rule
The child is crying To be

continued
He tumbled down The bucket struck him
Pain
The box struck him
The bucket in which the

Sad The goldfish was dead
goldfish got overturned
Trying He applied drops of He tried to catch the

water goldfish in the bucket
Fearful He was scolded by his

The gold fish which his
father
father treasured was killed
Spanner fell from due to his carelessness
Surprised above
68
Feb, 2018 TSD INSTITUTE
Why②
The force bigger than
the strength was
pressed momentarily.
Phenomenon Why① The strength of the lead

was declining gradually.
The lead of the The force applied
pencil was broken. was greater than
The strength was not
its strength. enough from the
beginning
Point : Narrow down on the cause
Why②
The applied force bigger than
the strength of screw shaft has
acted momentarily
Phenomenon Why① The strength of screw

shaftt was weakening
gradually
The shaft of the screw The stress applied was
was broken bigger then the shaft’s The strength was not
strength enough from the
beginning
Point
Feb, :2018
Narrow down on the causeTSD INSTITUTE 70
Why③
The flange surface
Why② is corroded
Phenomenon Why① The flange could The gasket has

not hold the deteriorated
Gap has formed pressure
The liquid leaked between the flange
from the flange and the gasket The bolt became
loose
The pressure of
the inside fluid ok
OK Stop
Point : Narrow down on the cause became high
Notes

Example format: Advanced Why-why analysis

Example of Advanced Why-why Analysis Sheet
È
º È
º
ª
Í u
È
@

u
\
º
@
È
È
¢
º
\
º
E
È
¢
@
ª
E
º
\
@
Í
ª
E
\
³
v
Í
É
E
v
µ³
É

¢
µ
½
g¢
Á
½Ä
g¢
ÁÌ

Ä
¢û
û
E
Ì
³
¯
³
E
¯
Ó
µ
Ó
_
µ¢ ¢
_
è è ðð
×
×
·
·é
é
H
ê
· Û
@· W
@· ì
@¬

i
Ì
á
E
s
Ç
E
`
Râ
E
ÐQÉwÚ¤
j A
´
Aö
´
Í
öÞ
Í ¿
Þ E
¿û
E@û
Ü
@ÅÜÜ
Å Ü
ßß
Ä Ä
uÈ
u È
ººvuv
È
u È
º
º
vv
ð
ð
J
Jè
è
Ô
Ô
·
· ü
ù
F
(
»¨
ð
©È
ª
çu
Èº È
º
ª
Í
v
ð
s ¤
j B
ª
BÍ
ª
Í
Í
ì
Í Æ
ì ÒÆ
Æ
Ò E
Æ
§
E §ª
ª
êê É
É
È ÈÁÁ
ÄÄ¡¡ Å
Å
s
s¤
¤
¬
Ø
]
H
ÆF
¶
Y
Z
p

C
¼ » |
Ý
õ Ý
õ
¼ R d
C
F
R
x
A
[ J
¼
T
¼ À
{
Ú à
@@
@@
e S
\
è À
{
æ
ª

¶
ú Q
O
O
O
N
R Q

R
ú
i
à
j
P
T P
O
ª ú Q
O
O
O
N
R Q

R
ú
i
à
j
P
WP
O
ª I
y
[
^
|
C
g
b
X
v Û î
ì
¬
R 3/24

¶
Yâ
~ Ô @R
g
¶
s
Ç î
Ö
Ì
½
f v Û

R d
CF à
R x
[
©
ç à
ª
±
Ú
ê R x
A
[
Ì
x
A
O
æ
Ö
¦ d
R CF à ó
¯
ü
ê
¶
æ
ª |
J
P
Ì
»
ì v Û

¬ª
s
ÇÆ
È
Á½ @
¶ ¨ à
R x
A[
ü
Ç
Û
S
Ì
À
{
@
H ¨
d
C
F z
b
p [ ñ v Û

¶
à u ö ¨
d
C
F l
o
î
ñ
V
[
g

s v Û

e Î
ô
Ì
½
W
J v Û

Ä

v Û

»
@
@
@
@
@
Û È
º
@ È
º
A È
º
B È
º
C È
º
D »
è Î
ô
Ä

h
~ S
ú
ú
®
¹
ú
e
V
[
[
²
ó
¯
ª
j
¹
µ
½

²
ó
¯
x
È ²ó
¯
É
Î
× ²ó
¯Æ
² ²
ó
¯ª
Y zZ
bg
ª
ä
i»
¨
ðÏ
@ µ½ Æ±ë
A e V [
ã
É
Í
ª
Á d
ª
Á
í
Á½ S
ü
ª
Y
Ä Ä
¢
½ é
ñ
Å
¢
½

² ó
¯ª j
¹ µ½
ã É A
[
V t
í
Á½
lW
É b
N
l
W
ðæ
¢
½
g
ª Õµ½ Æ
l ¦
çê é B»Ì
±
Æ© è
t
¯A
ä
é
ÜÈ
¢
\
ç
Ae V [ ² ó ¯Ì
¹ Ì
Ý ¢
É
·
é
ð
» ÛÆµ
Ä æèã °é j ²
ª
Y
Ä
¢
zZbg
ª
÷ ß
t ¯ã É
K
¸ A

J 3/24
½
m
f
ä
é
ñ
Åà í C
}
[ Nðt
¯A
î
©
ç
È¢ ð
w ±·
é
n
j
²ó
¯Ì

x ²
ó
¯ª
Õ ²
ó
¯
à
É
û
µ
Ä
¢
½ û
Ê
ª
s
«

@
¶
@
ó
@
µ ª
á
º
µ½
ª
È

ÈÁ½ µ
Ä¢
½
i
ª
}
j

O Xª
è ú
I
Éê
²ó
¯à
É
Ù
P ñ ½
è
Ì è
Ê
Å éO XJ
bv K
X
¨
ª
ü
Á½ û
Ê
ª «è
È
Á ð
s u bN
Éæè
©
½ t
¯Aè
ú I
Éæè
Ö
¦ é

n
j
û
Ê
Ì
»f û
Ì µ© ½
y
Ñ 3/24
î
ª
s
¾
m m
f ¿
Ê
Ì » f
î ð
R
¾
Á
½ | C g bX É

Ü
Æß A
© ç
ÅSõ
É
ñ · é

»
è
Example image

Points to be remembered:
Proceed each step logically
• Move only with logic
• Carefully proceed to next step by cross-checking the

logic
• In a why-why analysis, the 1st why to last why should

be connected by a ‘hence’ logic in reverse direction
( a verification method of correctness of a why-why)

Use the logic of elimination
Example: Game of SUDOKU
1 2 3 4 5 6 7 8 9
2 8
3 7
4 6
5 5
6 4
7 3
8 2
9 8 7 6 5 4 3 2 1
Game
Feb, 2018
of SUDOKU – TSD
is INSTITUTE
played on logic of elimination
77
And, to summarize
• Think of yourself as an inspector in the scene of a crime
• Base your verdict on phenomenon observation, data and

facts
• Be impartial,
Do not assume,
Do not jump into conclusions
• Proceed only with logic
• Use sketch /illustration to understand & visualize problem

• Work in a team,
A couple of team members should be outsiders (third party)
Do Exercise on
Advanced Why why Analysis

Overall Exercise
1. A SUDOKU puzzle – to practice deducing with logic
2. A simple why-why analysis

- Find the Root cause of oil leakage of pump XYZ on
date………
3. An advanced why-why analysis

- Find the root-causes of oil leakages in your plant

Happy
problem
solving

Notes

RCA

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

RCA

Uploaded by

Copyright:

Available Formats

ROOT CAUSE ANALYSIS

Concept & Methods

First version: June’2010

Feb, 2018 TSD INSTITUTE 2

Analytical Technology: methods of extracting and identifying missing

Feb, 2018 TSD INSTITUTE 4

• To prevent recurrence of the problem

• To develop our skill to solve problems and

(same phenomenon for same cause should not repeat)

Feb, 2018 TSD INSTITUTE 5

• A failure which has happened before.

• More clearly, the same pheonomenon, for the

• May be in a different machine.

Feb, 2018 TSD INSTITUTE 6

• Phenomenon is: “ what has happened”

• Phenomenon Observation: is the understanding of

• Cause is : “what has contributed to the phenomenon”/

• Root cause: is “exactly where the cause has originated”

• Counter-measure: The action which you take against

2) Phenomenon observation should start immediately on

- Phenomenon observation to start at Genba, on genbutsu

3) Talk to local operators & technicians / fitters

4) Take photos of failed component / defect

5) Write the problem statement in specific words, short sentence

6) RCA starts after phenomenon observation is done

Feb, 2018 TSD INSTITUTE 11

9) Verify the logic from opposite direction (  hence)

10) Root cause should touch one of the 5 basic causes

11) Consider counter-measure opposite to the root cause

Feb, 2018 TSD INSTITUTE 13

• The problem statement should be short, simple

• The cause should not be written in the problem

• What, where, when, who, which are to be covered in

Feb, 2018 TSD INSTITUTE 14

• Base your verdict on phenomenon observation, data and

• Proceed only with logic

• Use sketch /illustration to understand & visualize problem

Feb, 2018 TSD INSTITUTE 16

Feb, 2018 TSD INSTITUTE 17

• 90% of problems can be solved only by

• 9% problems may need an advanced why-why

• Very few problems (~1%) may need a higher

Feb, 2018 TSD INSTITUTE 18

• Understand the phenomenon

• Phenomenon observation will lead to a

• The conclusion may lead to the root-cause or

Feb, 2018 TSD INSTITUTE 19

Who Any Variation among people involved in the operation ?

１. Grasp the actual phenomenon visually at the working place.

Types of surface defect

2．Grasp the difference of part of the process ( or location)

Point： Think as if you are the bottle

3．Focus / narrow down on the spot of happening

A: Conveyor & Bottle

Feb, 2018 TSD INSTITUTE 23

4．Do not express by general words(be specific)

Ex. A Robot Arm picks up bottles, moves, and places bottles –

Point： Watch each movement closely to close down

A: Arm moves down

People tend to include the cause in the same sentence

Point 1： Write the facts clearly

Point 2： Assume nothing

No cap on the bottle fact of the phenomenon only

Missed to put the cap on the bottle (writing