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    Root Cause Analysis Presentation (RCA)

    Uploaded by

    beri
    Standardize the learning to prevent recurrence.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Root Cause Analysis Presentation (RCA)

    Uploaded by

    beri
    98 views21 pages
    Standardize the learning to prevent recurrence.

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Standardize the learning to prevent recurrence.

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    98 views21 pages

    Root Cause Analysis Presentation (RCA)

    Uploaded by

    beri
    Standardize the learning to prevent recurrence.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Root Cause Analysis (RCA)

    A TPM Tool for a Learning Organization


    Course Topics:

    This course will cover the following topics:


    Why-Why RCA Process
    Role of Why-Why Analysis in TPM
    Application of Why Why
    Section 1
    Why-Why Process
    Causes of :Losses
    Multiple Causes -
    Need Complex
    countermeasures combination
    Single Cause - for each cause
    Easy to discover of causes
    & Address
    cause Problem
    cause
    cause

    cause cause cause


    cause
    Causes of Losses are Often Complicated :
    Common Failure scenario:
    1. Management system breakdown
    2. Failure to implement counter-measures
    3. Premature equipment failure
    4. Employees fails to follow procedure
    5. Failure to ID & Respond
    6. Large Loss Results
    Equipment failure
    Mgmt
    breakdown Failure to Follow
    procedure

    Loss
    The Loss Pyramid

    m a jor
    ca ll/ t
    LTA Re efec
    Traditional d
    Programs R ie v al
    r
    Ret ct
    Measures MT or k d e f e
    w .
    Reactions R e / m ed f e ct
    First o ld r de
    Aid n H
    m ino S TD
    O c / UB
    e S
    Near f S p N S,
    Misse to TIO NS
    s O u I A
    EV TIO
    AT R
    IS K BE S S D ONDI
    HAVI O CE C
    OR P R
    TPM RCA is Proactive
    Addresses the Underling Causes of Losses

    • Why- Why identifies the Root Causes of Losses


    • Supports Implementation of Countermeasures
    • Promotes Transfer of Learning
    Steps in Why - Why RCA
    1. Identify the Problem
    – observe, gather facts
    2. Understand Ideal Situation
    3. Identify & Understand the Phenomenon
    - answer 5 W’s & 1 H of incident (what, when, where, who,
    which, how severe)
    4. Ask Why loss occurred...
    – Consider both equipment & behavioral branches
    – Ask successive Why for each branch
    – ID Root Causes
    5. Implement Countermeasures
    6. Standardize (One Point Lesson)
    Step 1 - Identify Problem
    Exercise

    Quantify
    Loss
    How does it Work?

    Step - 2 Understanding the Ideal Situation


    • Draw a equip sketch
    One needs to of all parts and
    Where analysis understand equipment locations of the related
    involves equipment functions, structures subjects.
    and manufacturing and operational
    principals • Learn operational
    related matters principals
    One needs to • Draw a work flow chart.
    Where analysis understand flow of
    work and what is • Gather together and know
    involves operational what forms and papers
    matters involved in each
    situation there are to fill out
    Step - 3 Identifying the Phenomenon

    Problem Phenomenon Phenomenon Means:


    • Observing the facts with
    your own eyes & all senses
    • The facts without
    presumption

    Complex
    combination of
    causes
    Utilize 5W’s 1H When Identifying the Phenomenon

    What Material/ Prod No’s Lots/Types


    When Trend Continuous Rate
    Time / Period Start-up On Processing
    Where Process Line/ Equipment
    Location Part /Range
    Who Skill Level Shift / Experience
    Which Trend Direction (+) (-)
    How Status
    How (many) % / Piece
    Step 4 - Ask Why...? (Ask Successive Whys)
    (Follow Phenomenon - Factor Relationship)
    Phenomenon Factor (Why)

    Phenomenon Factor (Why)

    Phenomenon Factor (Why)

    Phenomenon Factor (Why)

    Phenomenon
    CAUSE
    Develop a Cause Tree to Order your Thinking

    (1.1.1)
    (1.1) What triggered 1.1?
    (1.1.2)
    (1) What triggered 1? Why
    (1.2.1)
    (1.2) What triggered 1.2?
    Why
    (1.2.2)
    Phenomenon What triggered this phenomenon?

    (2.1)
    : Last “why’s”
    (2) What triggered 2? Why (original sources of factors
    that had led to phenomenon)
    (2.2)
    5W1H
    Root Cause Analysis - 5 Why
    Plant (where):
    Date (when):
    Case / Injury (What): Loss / Problem
    Who: #1 Why?
    Which:
    How severe:
    Behavioral Branch
    Equipment Branch

    #2 Why? #2 Why?

    #3 Why? #3 Why?

    #4 Why? #4 Why?

    #5 Why?

    Recommendations:

    1 2 3 4 5 6
    Causes to Consider

    Equipment Branch
    • Improper Equipment Ordered
    • Poorly Designed Equipment
    • Inadequate Maintenance
    • Wear & Tear
    • Abuse or Misuse
    Causes to Consider

    Procedural Branch
    • Lack of Procedures
    • Inadequate Procedures
    • Misunderstood Procedures
    • Failure to Warn or Respond
    Note: Large losses often occur because of failure to
    take timely action
    Causes to Consider

    Behavioral Branch
    • Lack of Knowledge
    • Lack of Skill
    • Physically Incapable
    • Lack of Motivation
    Why - Why Steps 1- 4 –
    1. Identify Problem 2. Identify & Draw
    Ideal Situation

    3. Identify Phenomenon 4. Follow Phenomenon-Factor


    What: Relationship – Draw Cause
    When: Tree (Ask Why?)
    Where: WHY 1?
    Who: WHY 2?
    Which: WHY 3?
    How Many: WHY 4?
    WHY 5?
    Phenomenon:
    Step 5 - Countermeasures

    Last “Why’s” Countermeasures

    Lack of lubrication Prepare lubrication


    standards standards

    Material strength is not Strengthen


    enough materials

    Installation positions are Mark all positions where


    not clear things are to be installed
    Step 6 - Standardize
    After improving work methods or equipment, it is
    important to standardize them to prevent people from
    slipping back into old habits.

    Typical standards include the following:


    •Cleaning, Inspection and Lubrication Standards
    •Maintenance Standards
    •Education Standards (i.e. One Point Lessons)
    •Engineering Standards

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