RCA 3 Hours v6

Root Cause Analysis
Training Module
Confidential 2009 WNS Global Services | www.wns.com
Lets Introduce !
Root cause analysis (RCA)

is a class of problem solving methods aimed at identifying the root causes of problems or events.
Root Cause Analysis
ms p to m Sy
Symptoms
Sy mp to ms
ms pto Sym
Root Cause
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Symp
toms
Symptoms
The idea is to attack the root cause rather than playing around with the symptoms of the problem!
RCA: The Need

Stepping directly into the solution after you encounter a problem is not the correct way of solving it. It leads to erroneous conclusions and the problem reoccurs in future. The right way to solve a problem is to find the root cause of it and then implement controls in the process to its recurrence in future.
Root Cause Analysis: The Methodology

AProblemisdefined theilleffectonthe outputofaprocess
1. Determinewhathappened andfixtheDefect
Anactiontoeliminatethe detectedproblem
Fundamentalcausethatresults inProblem intheoutput
2. Determinewhyithappened 3. Figureoutwhattodoto reducethelikelihoodthatit willhappenagain
Anactiontoeliminatethecause oftheproblemathand
ThenewStateProcesswhichis nowfreefromtheproblem identifiedinStep1
Determine what happened

Defining the problem and fixing the defect!

What is a Problem?
A Problem could be defined as a gap between actual and the expected level of performance. The problem should be treated as an opportunity for process improvement. The first step while doing a process root cause analysis is identifying the Problem at hand. This requires a vivid documentation of the problem and setting the scope for the analysis.

Determining what happened typically leads to answering the following questions:
What do you see happening? What are the specific symptoms? How long has the problem existed? What is the impact of the problem?
Defining the problem involves drafting a formal Problem Statement in place!
Determine why did it happen

Finding possible root causes
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This stage involves drilling down on the problem till we reach the root cause of it. The typical questions to be answered here are:
What conditions allow the problem to occur? What other problems surround the occurrence of the central problem? Why does the causal factor exist? What is the real reason the problem occurred?
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The typical tools used for this stage are:
The 5 Why technique
A question-asking method used to explore the cause/effect relationships underlying a particular problem.
Cause & Effect Diagram

diagrams that show the causes of a certain event.
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The 5-Why Technique

The 5-Why technique:
The 5 Whys is a simple problem-solving technique that helps users to get to the root of the problem quickly. The standard rule of thumb is that if you ask why 5 times you will usually get to the root cause of the problem
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Why? Why? Why? Why? Why? Why? Why? Why? Why? Why?
ause use ot C oot C a Ro R
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The 5-Why Technique

The five why is a team activity. Call in all people associated with the process. Brainstorm for the root cause of the problem.
Remember: No idea is a bad idea!
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The 5-Why Technique: Example

Why is our client, ABC Corp., unhappy?
Because we did not deliver our services when we said we would.
Why were we unable to meet the agreed-upon timeline or schedule for delivery?
The job took much longer than we thought it would.
Why did it take so much longer?

Because we underestimated the complexity of the job.
Why did we underestimate the complexity of the job?

Because we made a quick estimate of the time needed to complete it, and did not list the individual stages needed to complete the project.
Why didn't we do this?

Because we were running behind on other projects. We clearly need to review our time estimation and specification procedures.
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Remember:
Itisimportanttoreachtotherootcause oftheproblemandnottosticktothe symptoms!!!
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A Cause and Effect diagram (also known as a Fishbone or Ishikawa diagram) graphically illustrates the results of the analysis and is constructed in steps.
Cause and Effect Analysis is a technique for identifying ALL the possible causes associated with a particular problem.
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Cause-and-effect diagrams are designed to:
Stimulate thinking during a brainstorm of potential causes Provide a structure to understand the relationships between many possible causes of a problem Give people a framework for planning what data to collect Serve as a visual display of causes that have been studied Help team members communicate within the team and with the rest of the organization
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Cause-and-Effect Diagram
Measurements
This category groups root causes related to the process measurement
Material
People
This category groups root causes related people and organizations
This category groups root causes related to information and forms needed to execute the process
Effect
This category groups root causes related to our work environment, market conditions, and regulatory issues This category groups root causes related to procedures, hand-offs, input output issues This category groups root causes related to tools used to execute the process
MotherNature
Methods
Machines
Place the effect at the head of the fish Include the 6 recommended categories shown
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Identifying Root Causes

Some Guidelines
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Sources of Variation - Machine

Types of Questions that may be Asked
How old is the tools & knowledge base? Is it maintained regularly? Is the tool affected by various performance factors? How does the operator know if the tool is operating correctly? Is statistical analysis used to verify the capability of the tool? What adjustments must the operator make during the process? Have any changes been made recently in the process?
People
Categories
Machine Material Mother Nature Measure Method
Note: this is not a definitive list of questions that may be asked to identify potential source of variation
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Sources of Variation - Material

How is the output produced? How is the output verified? How old is the KB ? How is quality judged prior to your operation? What is the level of quality? How is the output dispatched?
Categories
Machine Material Mother Nature Measure Method People
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Sources of Variation Mother Nature

How are environmental conditions monitored? How are environmental conditions controlled? How is the environment control measuring equipment calibrated? Are there changes in conditions at different times of the day? How does environmental change impact the processes being used? How does environmental change impact the materials being used? Note: this is not a definitive list of questions that may be asked to identify potential source of variation
Categories
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Sources of Variation Measurement System

How frequently are O/p inspected? How is the measuring equipment calibrated? Are all O/p measured using the same tools or equipment? How are inspection results recorded? Do inspectors follow the same procedures? (Is there a set of standards?) Do inspectors know how to use the test equipment?
Categories
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Sources of Variation - Method

How is the method used defined? Is the method regularly reviewed for adequacy? Is the method used affected by external factors? Have other methods been considered? How does the operator know if the method is operating effectively? What adjustments must the operator make during the process? Have any changes been made recently in the process?
Categories
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Sources of Variation - People

Types of Questions that may be Asked:
Does the person have adequate supervision and support? Does the person know what he is expected to do in his job? How much experience does the person have? Does the person have the proper motivation to do his best work? Is the person satisfied or dissatisfied with his job? Is the person more- or less-productive at certain times of the day? Is the work a definitive list Note: this is not load reasonable?of questions that may be asked to identify potential source of variation
Categories
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How do I do it? (continued)

Align Outputs with Cause Categories
Review your brainstorm outputs and align with the recommended major cause categories, e.g., the People, Method, Machine, Material, Environment and Measurement System.
Allocate Causes
Transfer the potential causes from the brainstorm to the diagram, placing each cause under the appropriate category. If causes seem to fit more than one category then it is acceptable to duplicate them. Related causes are plotted as twigs on the branches.
Cause-and-Effect Diagram
Measurements Material People
Branches
Effect
Mother Nature
Methods
Machines
Twigs
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Remember:
TheSixSigmaphilosophysaysthat85%of allrootcausesareduetoinappropriate processesandnotpeople!
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Reduce the likelihood of its recurrence
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Recommend and Implement Solutions

The typical questions to be answered here:
What can you do to prevent the problem from happening again? How will the solution be implemented? Who will be responsible for it? What are the risks of implementing the solution?
We must look beyond the soft people issues while identifying the root cause; Negligence and Carelessness are just an indication of lack of effective controls on people.
They are not the root causes!
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Brainstorming
Creative brainstorming: This technique is one of the most commonly used techniques for idea generation wherein a team of key stakeholders are brought together for a meaningful discussion wherein the criteria at hand get brainstormed While conducting brainstorming sessions we need to recognize and actively address the challenges that inhibit creative thinking
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Constrained Brain-writing: The name constrained brainwriting comes the fact that on certain occasions the team may want to have a set of constrained ideas around a pre-determined focus, rather than ranging freely. The key steps involved are:
The team leader biases the idea generation by preparing brainwriting sheets in advance and makes sure that there is no discussion at any stage between any of the team members The team leader initiates the process formally by placing several prepared sheets of paper onto the table Each team member takes a sheet, reads it, and silently adds his or her ideas onto the sheet Repeat until ideas are exhausted. No discussion at any stage.
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Build quality into the process

Make it impossible to turn out defective units even if an error is committed
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Everyday Examples of Mistake-Proofing
3.5 inch diskette cannot be inserted unless diskette is oriented correctly. This is as far as a disk can be inserted upside-down. The beveled corner of the diskette pushes a stop in the disk drive out of the way allowing the diskette to be inserted. This feature, along with the fact that the diskette is not square, prohibit incorrect orientation.
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Everyday Examples of Mistake-Proofing
The dryer stops operating when the door is opened, which prevents injuries.
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Corrective Action
Remember:
The solutions to be implemented need to be robust enough; The goal here is to prevent the recurrence of the root causes in future. The solutions should not be soft, targeting only on the softer people issues.
Giving recommendation to people is not a robust Corrective action!
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Conform to the set standards

Once the corrective actions have been implemented into the work place, it must be ensured that the corrective actions are sustained for a considerable period of time by:
Regular confirmation to standards Immediate action to rectify concerns (any deviation to the set standards) Recognizing outstanding effort and achievement
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The RCA Template
RCA Template
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RCA: Team Activity

The following are the live cases where the process faced some defects/errors. Lets try doing a Root Cause Analysis on some of them!
Sample RCA
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Thank You!
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Root Cause Analysis

Confidential 2009 WNS Global Services | www.wns.com

Confidential 2009 WNS Global Services | www.wns.com

Root cause analysis (RCA)

Confidential 2009 WNS Global Services | www.wns.com

Root Cause Analysis

RCA: The Need

Confidential 2009 WNS Global Services | www.wns.com

Root Cause Analysis: The Methodology

Fundamentalcausethatresults inProblem intheoutput

2. Determinewhyithappened 3. Figureoutwhattodoto reducethelikelihoodthatit willhappenagain

ThenewStateProcesswhichis nowfreefromtheproblem identifiedinStep1

Confidential 2009 WNS Global Services | www.wns.com

Determine what happened

Confidential 2009 WNS Global Services | www.wns.com

Determine what happened

Confidential 2009 WNS Global Services | www.wns.com

Determine what happened

Defining the problem involves drafting a formal Problem Statement in place!

Confidential 2009 WNS Global Services | www.wns.com

Determine why did it happen

Confidential 2009 WNS Global Services | www.wns.com

Determine why did it happen

Confidential 2009 WNS Global Services | www.wns.com

Determine why did it happen

Cause & Effect Diagram

Confidential 2009 WNS Global Services | www.wns.com

The 5-Why Technique

The 5-Why Technique

Remember: No idea is a bad idea!

Confidential 2009 WNS Global Services | www.wns.com

The 5-Why Technique: Example

Why did it take so much longer?

Why did we underestimate the complexity of the job?

Why didn't we do this?

Confidential 2009 WNS Global Services | www.wns.com

Confidential 2009 WNS Global Services | www.wns.com

Cause & Effect Diagram

Confidential 2009 WNS Global Services | www.wns.com

Cause & Effect Diagram

Confidential 2009 WNS Global Services | www.wns.com

Cause & Effect Diagram

Identifying Root Causes

Confidential 2009 WNS Global Services | www.wns.com

Sources of Variation - Machine

Confidential 2009 WNS Global Services | www.wns.com

Sources of Variation - Material

Confidential 2009 WNS Global Services | www.wns.com

Sources of Variation Mother Nature

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Sources of Variation Measurement System

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Sources of Variation - Method

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Sources of Variation - People

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How do I do it? (continued)

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Confidential 2009 WNS Global Services | www.wns.com

Reduce the likelihood of its recurrence

Confidential 2009 WNS Global Services | www.wns.com

Recommend and Implement Solutions

They are not the root causes!