Slide 1: Not contractual, for information purposes only as of June 2015
The following slides are not contractual in nature and are for information purposes only as of June 2015. 1 ©2015, Lockheed Martin Corporation. All Rights Reserved.
Slide 2: Root Cause Analysis and Corrective Action
Corrective Action Root Cause Analysis and Corrective Action 2 ©2015, Lockheed Martin Corporation. All Rights Reserved.
Slide 3: Overview Webinar 6: Root Cause Analysis and Corrective Action
Overview Webinar 6: Root Cause Analysis and Corrective Action • What is Root Cause Analysis (RCA)? • Why is RCA important? • When is RCA required? • Overview of the Corrective Action Process • Root Cause Analysis Tools: The 5-Whys Ishikawa Cause & Effect (Fishbone) Diagrams Cause Mapping Fai
Slide 4: What is Root Cause Analysis (RCA)?
What is Root Cause Analysis (RCA)? Root Cause Analysis (RCA): The process of identifying all the causes (root causes and contributing causes) that have or may have generated an undesirable condition, situation, nonconformity, or failure. » IAQG – Root Cause Analysis and Problem Solving April 2014. 4
Slide 5: Root Cause Analysis (RCA)
Root Cause Analysis (RCA) PROBLEM = Weed (obvious) Cause CAUSE = ROOT Cause (not obvious) 5
Slide 6: Why Root Cause Analysis (RCA)?
Why Root Cause Analysis (RCA)? • Helps prevent problems from repeating or occurring. • Focus on Continuous Improvement throughout the Enterprise. • Drives Breakthrough Performance. • Focus on improving processes that actually effect organization performance metrics. 6
Slide 7: When is RCA required?
When is RCA required? • Undesirable condition, defect, or failure is detected • Safety • Product strength, performance, reliability • High impact on Operations • Repetitive Problems • Customer Request • Significant Quality Management System (QMS) issues » IAQG – Root Cause Analysis and Problem Solvi
Slide 8: The Corrective Action (CA) Process
The Corrective Action (CA) Process Identify Problem • Objective: Identify the cause(s) of problems and initiate actions to prevent recurrence. Define Problem • Extent of corrective actions shall be proportional to the effects of the related problems. Investigate Problem • Corrective action is applic
Slide 9: The Corrective Action Process
The Corrective Action Process Identify Problem Define Problem • Increased focus on Problem Definition • Requirement for Evidence-Based Causes • Requirement to always look for Multiple Investigate Problem Causes • A Corrective Action end state that includes Analyze Problem and Identify Cause(s) – Ver
Slide 10: Overview of the Corrective Action Process
Overview of the Corrective Action Process • Step 1: Identify the Problem • Step 2: Define the Problem • Step 3: Investigate the Problem (Complete Containment Actions) • Step 4: Analyze the Problem & Identify Root Cause (s) • Step 5: Generate, Select and Implement Solutions (CA) • Step 6: Verify the
Slide 11: Corrective Action Process Flow
Corrective Action Process Flow: Inputs: Identify Problem Outputs: Nonconforming Implemented/Verified Define Problem Products or Services CA Plan Noncompliant Improved Processes or Investigate Problem Capabilities/Products Capabilities Costs Reduced Audit Findings Analyze Problem and Identify Cause(s
Slide 12: Corrective Action Process
Corrective Action Process • 7 tools to determine root cause: – The 5 Why's – Cause & Effect Diagram (Fishbone) – Cause Mapping – FMEA: Failure Modes & Effects Analysis – Fault Tree Analysis – DOE: Design Of Experiments – Statistical Process Control • Perform a Cause/Failure Analysis to determine the
Slide 13: Severity/Impact Based RCA Approach
Severity/Impact Based RCA Approach High < Likelihood of the Event Recurring > Highest Risk Items Level 3 RCA Level 4 RCA Most RCA Efforts • Future failures with this and 100% at Level 5 RCA similar processes are inevitable Occurrence Medium Level 2 RCA Level 3 RCA Level 4 RCA • Likely to find future
Slide 14: What RCA Tool Should I Use?
What RCA Tool Should I Use? Typical RCA Recommended Impact RCA Requirements Analysis Output Templates Level RCA Lead Span* 1. Summary including Problem Statement • Experienced and 2. RCA Findings and Conclusions OR… • Apollo RCA using 5 High-High Certified Apollo RCA 2 – 6 Weeks 3. RCA Corrective Ac
Slide 15: Selecting a RCA Leader
Selecting a RCA Leader • Problem Complexity • Data type and availability • Type analyses required • Individual or team based Basic Advanced approach RCA • Severity of issue/impact to business • Internal/external engagement 15
Slide 16: Root Cause Analysis Tools
Root Cause Analysis Tools The 5-Whys Cause & Effect (Fishbone/Ishikawa Diagrams) Cause Mapping Failure Modes & Effects Analysis Design of Experiments 16
Slide 17: The 5 Why's
The 5 Why’s • What is a 5 Why? – A question based technique used to explore cause-and-effect relationships – Determine root cause of a problem – Ask Why? As many times as needed! • Advantages Why? Why? Why? – Easy to use and teach – Identifies more than one cause – Useful for minor problems – Used t
Slide 18: 5 Whys Template
5 Whys Template Instructions: Start with your focused problem and then ask WHY five times. Focused Problem Statement: Problem: High reject rate of parts used by downstream aircraft assembly process There is bare material exposed Why The primer paint coating does not cover the whole part Why Why The
Slide 19: A New Look at Why Templates
A New Look at 5 Why Templates THE SINGLE CAUSE TEMPLATE PROBLEM STATEMENT: ___________________________________________________ WHY? WHY? WHY? WHY? This example is a typical format for narrow problem statements where one cause-path exists. For problem statements with multiple causes, use the template
Slide 20: Proposed Operating Instruction for alternate Why Template
Proposed Operating Instruction for alternate 5 Why Template 20
Slide 21: Ishikawa Cause & Effect Diagram (Fishbone)
Ishikawa Cause & Effect Diagram (Fishbone) What is A Cause and Effect Diagram? • A – tool used to illustrate the relationship between an effect and the causes that influence the effect When to Use It? • Identify causes of a problem (Effect) • Can be used to prevent future problems CAUSES EFFECT HAND
Slide 22: Ishikawa Cause & Effect Diagram (Fishbone)
Ishikawa Cause & Effect Diagram (Fishbone) Advantages –Encourages brainstorming –Can be used when time is very limited –Helps organize many potential causes Limitations –Categories may cause investigations to stop at "categorical causes” –Creates the illusion of equal weight among causes –No guidanc
Slide 23: Ishikawa Cause & Effect Diagram (Fishbone)
Ishikawa Cause & Effect Diagram (Fishbone) – every Effect there are likely to be several Major Causes • For • Major Causes include: People, Measurements, Machines, Methods, Materials, Environment • Any major category that helps people think creatively can be used CAUSES EFFECT HAND WAVE METHODS PEOP
Slide 24: Ishikawa Cause & Effect Diagram (Fishbone)
Ishikawa Cause & Effect Diagram (Fishbone) Methods = work instructions, procedures, test methods Material = components and raw materials Measurements = standards, calibration, gages, data collection People = training and staffing Machines = tools, equipment, fixtures Environment = temper
Slide 25: Ishikawa Cause & Effect Diagram (Fishbone)
Ishikawa Cause & Effect Diagram (Fishbone) How to Construct a Cause & Effect Diagram: • Brainstorm – include Subject Matter Experts (SME) • Add the problem to the EFFECT box. • Add the Major Cause categories • Place the potential causes in the Major Cause category. • For each Cause ask, “Why does it
Slide 26: Ishikawa Cause & Effect Diagram (Fishbone)
Ishikawa Cause & Effect Diagram (Fishbone) How to Interpret? – Look for causes that appear frequently. – Reach a team consensus. – Determine the relative frequencies of the different causes. CAUSES EFFECT HAND WAVE METHODS PEOPLE ENVIRONMENT SOLDER ABSENTEEISM ESD TRAINING INSERTION DEBRIS P. C. Boa
Slide 27: Example of Cause & Effect Diagram
Example of Cause & Effect Diagram Materials Machines Measurement Gas Gauge Broken Starter Broken Lost the Keys Battery Dead Out of Gas Engine Overheated Battery Cables Corroded Car Will Not Start Not Pressing Accelerator Lack of Training Too Cold Using Wrong Key Locked Out of Car No Preventive Maint
Slide 28: Example C&E Diagram - Canopy Leakage
Example C&E Diagram - Canopy Leakage 28
Slide 29: What is a Cause Map?
What is a Cause Map? A visual explanation of why an incident occurred Connects single cause-and-effect relationships to a system of causes A Cause Map can be basic or very detailed 29
Slide 30: Cause Mapping for Root Cause
Cause Mapping for Root Cause Step 1: Problem Statement • Identify/Outline the Problem (What, When, Where, Goal) • The Outline explains why time is spent on an issue Step 2: Analysis • Identify/Breakdown the Causes • This step is where the Cause Map is built Step 3: Solutions • Identify Possibilities
Slide 31: Cause Mapping - How to read a Cause Map
Cause Mapping - How to read a Cause Map State the Problem Ask Why Questions - "Why did this effect happen?" Record Response = Cause (or causes) 31
Slide 32: Cause Map Example
Cause Map Example Standard procedure for Pushing cart picking up/delivering items to work area Evidence: Melissa Possible Safety Goals Solutions: Injured Right Impacted shoulder There is not Standard load Heavy load on current load limit can not cart limit be defined Evidence: Cart was not rolling r
Slide 33: Cause Mapping
Cause Mapping • When to Use It: – Use to develop an effective solutions to prevent recurrence of undesired effects – Use when you want to fully understand causes of success – Use to reveal the entire system of causes – Use it when you need to dive deeper into a problem • Advantages: – Reveals the en
Slide 34: Failure Mode & Effects Analysis (FMEA)
Failure Mode & Effects Analysis (FMEA) What is FMEA? A systematic method for identifying, analyzing, prioritizing, and documenting potential failure modes and their effects on a system, product, or process and the possible causes of failure. Where Is FMEA Used? Used extensively in safety oriented an
Slide 35: Failure Modes and Effects Analysis (FMEA)
Failure Modes and Effects Analysis (FMEA) • When to Use FMEA: – Identify and eliminate known or potential failures or errors from a product or a process • Engineering – mitigate risk in product design • Manufacturing – reduce and eliminate product defects • Transactional – reduce and eliminate proce
Slide 36: Failure Mode & Effects Analysis (FMEA) Types
Failure Mode & Effects Analysis (FMEA) Types of FMEAs Process: Used to analyze processes and identify potential failure modes Design/Product: Used to analyze products and identify potential failure modes early in the development cycle Defect: Used to analyze and prioritize defects to prevent recu
Slide 37: Failure Mode & Effects Analysis (FMEA) Tool
Failure Mode & Effects Analysis (FMEA) Tool Form Team Brainstorm potential Assign a severity Assign an Assign a failures that may score to each occurrence score to detection score to cause the product failure mode based each failure mode each failure mode or process to fail to on severity of based o
Slide 38: Design of Experiments (DOE)
Design of Experiments (DOE) Why Use DOE? Can be used to help improve the capability of a process by identifying the process and product variables that effect the mean and the variance of the quality characteristics of a product. Can be used as a powerful tool to achieve manufacturing cost savings
Slide 39: Design of Experiments (DOE)
Design of Experiments (DOE) When Can I Use DOE? When you want to find the input settings that optimize the output of a process When you want a mathematical model relating the outputs and / or variance of a process to the inputs When you want to identify the most important input factors that in
Slide 40: Design of Experiments (DOE)
Design of Experiments (DOE) Where Can I Use DOE? Any process with measurable quantitative or qualitative inputs and quantitative outputs is a potential application for DOE In engineering design, to find component values and tolerances that optimize the response In production, to optimize the y
Slide 41: Summary
Summary • Root Cause Analysis is not easy! • Be diligent in the pursuit of Root Cause • Address the Cause not the Symptom • The RCA Tools presented today will help ensure: Thorough Investigations Identification of Root Cause Effective Corrective Actions Root Cause + Effective Corrective Action
Slide 42: Summary
Summary Root Cause Analysis is the process of applying the cause and effect principle to solve problems. A root cause analysis program should be a systems approach to finding effective solutions to prevent problems from occurring or recurring. RCA Tools provide a means to conduct systematic anal
Slide 43: Root Cause Analysis References
Root Cause Analysis References • IAQG – Root Cause Analysis and Problem Solving (aligned with IAQG 9136 draft) www.iaqg.org/scmh • The Memory Jogger 2 – Tools for Continuous Improvement and Effective Planning • The Lean Six Sigma Pocket Tool Book • Think Reliability www.thinkreliability.com 43
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