San Jose State University CMPE 203 Fall 2009

San Jose State University CMPE 203, Fall 2009 Root Cause Analysis Presented By: Team: Incredibles

Agenda • Introduction • What is RCA? • Why do we need? • Types of RCA • Techniques/Tools - Kepner-Tregoe Method - FMEA - Fishbone Diagram • Case study of RCA

Root Cause Analysis • What is Root Cause Analysis? - Finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms • Reactive method • Goals - Failure identification - Failure analysis - Failure resolution • Iterative Process: - Complete prevention of recurrence by a single intervention is not always possible.

Steps for Root Cause Analysis • Collection of data - Phase I - A fact-finding investigation, and not a fault-finding mission • Event Investigation - Phase II - Objective evaluation of the data collected to identify any causal factor that may have led to the failure • Resolution of occurrence - Phase III - Realistic assessment of the viability of the corrective action that the previous phase revealed. - The phenomenon must then be monitored periodically to verify resolution.

Why do we need it • Benefits of RCA - Real cause of the problem can be found - Problem recurrence will be minimized

Types of RCA • Safety-based RCA • Production-based RCA • Process-based RCA • Systems-based RCA

Types of RCA • Safety-based RCA - Investigating Accident and occupational safety and health. - Root causes: - unidentified risks, or inadequate safety engineering, missing safety barriers. • Production-based RCA - Quality control for industrial manufacturing. - Root causes: - non-conformance like, malfunctioning steps in production line.

Types of RCA • Process-based RCA - Extension of Production-based RCA. - Includes business processes also. - Root causes: - Individual process failures • System-based RCA - Hybrid of the previous types - New concepts includes: - change management, systems thinking, and risk management. - Root causes: - organizational culture and strategic management

Methods of Root Cause Analysis • Change Analysis • Barrier Analysis • MORT: Management Oversight and Risk Tree • Human Performance Evaluation (HPE)

Kepner-Tregoe Method • Developed in 1958 • Fact-based approach to systematically rule out possible causes and identify the true cause. • Composed of fives Steps: - Define the Problem - Describe the Problem - Establish possible causes - Test the most probable cause - Verify the true cause • Kepner-Tregoe is a mature process with decades of proven capabilities. • Kepner-Tregoe Problem Analysis was used by NASA to troubleshoot Apollo XIII.

Tools for Root Cause Analysis

Failure Mode effect and Analysis (FMEA) • Methodology for analyzing potential reliability problems early in the development cycle. • Failure modes are any errors or defects in a process, design, or item, especially customer related. • Effects analysis refers to studying the consequences of those failures.

FMEA Example

FMEA Benefits: • Improves the quality, reliability, and safety of products. • Increases customer satisfaction. • Stimulates open communication and collective Expertise. Disadvantages: • Assumes cause of problem is a single event. • Examination of human error overlooked.

Fishbone Analysis • Definition - Technique to graphically identify and organize many possible causes of a problem • Advantages - Helps to discover the most likely ROOT CAUSES of a problem - Teach a team to reach a common understanding of a problem.

Fishbone Analysis • Components : - Head of a Fish : Problem or Effect - Horizontal Branches : Causes - Sub – branches : Reason - Non- service Categories : Machine, Manpower, Method etc. - Service categories : People, Process, Policies, Procedures etc. Measurement Material cause Machine reason cause reason Management Method Man Power Problem

Fishbone Analysis • 5 WHY’S Didn’t buy this morning WHY Ran out of Gas WHY Car stopped Middle of the road WHY Didn’t have money WHY Lost them in last night’s poker Not very good in “bluffing”

Case Study – Safeway. com • Safeway outsourced a module of Safeway online to HCL, India • Project Details – Add a new module for selling Patio furniture online on http: //Safeway. com. • Agreed duration - 8 months, June, 07 to February, 08 • Actual delivery – June ’ 08 • After the project was finished TCS performed a Root Cause Analysis to analyze the delays and to avoid problems in future.

Case Study – Fishbone Analysis Control No Clear Understanding Scope Definition Inventory Update Every 12 hours Inventory Real time inventory No Clear deadlines Separate Systems Wrong Estimates Separate Systems for Sales & Supplier No backup for Critical Resources Inadequate Resources Communication No Communication plan Resources Managed Systems Different Suppliers Lack of Standards Time and Format of Systems different Benchmarking Project Delay

Conclusion • Learning for the future projects. • Encourages Team based problem solving approach. • Errors are frequent and inevitable. • Saves cost and helps in identifying solutions.

References • http: //www. systems-thinking. org/rca/rootca. htm • http: //www. workplacechallenge. co. za/pebble. asp? relid=649 • http: //www. itsmsolutions. com/newsletters/DITYvol 2 iss 24. htm • http: //www. envisionsoftware. com/articles/Root_Cause_Analysis. html • http: //www. au. af. mil/au/awcgate/nasa/root_cause_analysis. pdf • http: //www. isixsigma. com/library/content/c 020610 a. asp • http: //www. quality-one. com/services/fmea. php • http: //www. npd-solutions. com/fmea. html