Root Cause Analysis

FI Pillar – Loss Eradication Tools

Updated: Dec, 3rd 2017

Safety Moment
 Objectives
Show the tools and methodologies used for Problem Solving, ensuring critical,
deep analyzes that generate positive results for the line / area / section /
plant.

One Page RCA is a tool managed by the Focused

Improvement pillar. Other pillars apply these tools
and methodologies to eradicate their losses.

The main KAIs are:

# RCA elaborated
% RCA completed
% Core Team Participation on RCA
# Actions created by RCA
% Actions completed
 Finding Root Cause: where we can improve?

Phenomenon
Cause
(Result)
Phenomenon Cause
(Result) Cause
Phenomenon Keep going until you have the
Verification
(Result) root cause !!
Verification Phenomenon
Verification
(Result)
Bulb replace is
Example: immediate action,
Projector does not work – after all checks using 4M, established that bulb was broken but not root
cause
Why? Answer Action

Why did he bulb Break The Filament was broken Replace Bulb

Why did the Filament break The bulb overheated Check against standard

Why did the bulb overheat The PROJECTOR was incorrectly turn off – Check Procedures
unplugged from mains before bulb is cool down
Why was the Projector turned off Because the operator did not know Review Communications
incorrectly there was a specific procedure
Why did the operator not know the No labels on machines to advise Improve Training and Labeling
procedure
So Where we go from here?
 Finding Root Causes

“I am not feeling very well…..”

Clarifying and focusing in the problem

5W+1H

7
 The Problem Statement: 5W+1H
To create a focused problem statement ask clarifying
questions:
... do you see, what is issue do you want fixing? What is wrong?
What... What broke / failed? (The component and its characteristics)

… do you see the problem happening? In particular region, in a category,

Where… plant, supplier, customer? The system / subsystem / position of the
component that broke / failed
... do you see problem happening? Always? Sometimes? Seasonal
When... issue? When launching new products? After cleaning or maintenance
activities?
… is associated with the problem? Variation amongst people / shifts?
Who... Who is involved? Whom is affected? Can the problem be related to
ability? Which ability?

… product / formats / processes are more affected? Is there a tendency

Which... in the occurrence of this problem?

… is it different from what you expect? What are the deviations from
How... ideal state, pre-set standards?

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 Example Problem Statement: 5W1H (Manufacturing)
2. Define the Problem (5W1H)
2.1 What? (Material: What is wrong? What broke / failed? Component and its characteristics)
Conveyor left side damaged, loosing parts and impacting on product's quality
2.2 Where? (Location: which system / subsystem / position is the component of the break / failure / issue)
Main conveyor SA 0102 (feeding CMY 06, 07 and 08)
2.3 When? (Time: What moment did the problem occur?)
During operation on 04:00am. After the 4th day of production after cleaning/maintenace
2.4 Who? (People: Who is involved? Whom is affected? Can the problem be related to ability? What?)
Operator ability (level 2 on Skill Matrix): the guides may have been installed incorrectly after cleaning.
2.5 Which? (Trend: Is there a tendency in the occurrence of this problem?)
It occurs every time when the conveyor get out of correction
2.6 How? (Status: The change in relation to the original state or expected result)
The main conveyor SA0102 rised on the side of the guide and started to loose parts on the product that
is fed in CMY machines 06, 07 and 08.

• Problem statement: After the line cleaning, during the operation, the main conveyor SA0102 rised on the side of
the guide and started to loose parts on the product that is fed in CMY 06, 07 and 08. Was observed that the conveyor
left side was damaged. The issue may be related to ability if the guides was installed incorrectly and has a tendency in
the occurence when the conveyor get out of correction.
 Example Problem Statement: 5W1H (CS&L)
• What is the issue?
. Poor Service level AMEA
. Forecast error 35% month of January
• Where does that happen?
. Snaking category
. Primarily in Australia
. Total retail
• Which product/formats are affected?
. Share packs: gifting & bitesize
• When does that happen? Always? Sometimes?
. Last month – during campaign on promotional items
• Who is involved? Variation amongst people/teams?
Multiple commercial teams & demand planners
• How this different from expectations?
. Promotion never has been part of medium term plan nor part of last month IBP review
. Fail on production delivery due to lack of gifting boxes

• Problem statement: last month shipment loss was driven by 35% forecast error on promotional
items (gifting & bitesize) – event not recorded on IBP process and reviews, affecting production
performance
Increasing the ability to
Improving find to
ability abnormal conditions
find abnormalities

Working Principles
(ideal state, std process)
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 Working Principles – finding key components

Purpose:
o Working principles captures details about base conditions and
operational standards while reinforcing the need and importance of
deep equipment knowledge

Why They are Important:

o Working principles let us understand and fully define the base/ideal
operating conditions—without this knowledge we can’t effectively
identify or eradicate root causes of minor stops, breakdowns, quality
defects
o Understanding the ideal design and conditions enhances significantly the
ability to ask the correct questions in conducting root cause analysis—a
must for achieving a true zero loss condition
 Working principles tool – Overview
After the 5W-1H identify all the working principles involved using the specific
tool (Advanced RCA format only)

Part A Part B
General drawing
Specific drawing of the
of all working
component mechanism
principles

Microsoft Excel
97-2003 Worksheet

Describe the Based on the 4M write the

function of each ideal state of each one and
working principles evaluate the gaps
Part C Part D
 Working Principle Example: Manufacturing
Sketches of equipement / process:

Part A: General Drawing of Working Principles

Part B: Specific Component Drawing

 Working Principle Example: Manufacturing
Function of each working principle:

• Capture in Part C and use in support of 4M Analysis (Part D)

 Working Principle Example: Manufacturing
4M Template:

• Link up with part D of last step

Define all possible conditions /

parameters in the 4M (Man,
Material, Method, Machine)
for each of the defined steps

After that, establish ideal state

for each of the conditions/
parameters and identify gaps.
 Looking
Improving ability to for
findabnormalities
abnormalities

Fishbone
Diagram
21
 Fishbone Diagram

Dr. Kaoru Ishikawa (1915-1989)

Japanese quality control statistician, invented the fishbone diagram. (Ishikawa
diagram./ Cause and effect diagram)

 To stimulate thinking during a

brainstorm of potential causes

 To understand relationships between

potential causes

 To track which potential causes have

been investigated and which proved to
contribute significantly to the problem
 How to create fish bone diagram

Brainstorm all potential root causes of the problem with the team and prioritise them

Machine
Material
Conveyor material quality Conveyor roller wear

Conveyor's material is fragile (1) Locked roll EFFECT

New problem description
Conveyor misaligned (2)
(5W+1H)
Rasper with excess pressure on conveyor
After the line cleaning, during the
operation, the main conveyor SA0102 rised
on the side of the guide and started to
loose parts on the product that is fed in
CMY 06, 07 and 08. Was observed that the
conveyor left side was damaged. The issue
may be related to ability if the guides was
installed incorrectly and has a tendency in
the occurence when the conveyor get out
Rasper adjusted incorrectly after the cleaning Valve actuator locked (3) of correction.

Guides adjust failure Manometer pression of the conveyor strecher out of spec (4)

Man Method
Finding Root Cause and reviewing standards

5 Whys
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 Finding Root Cause and reviewing standards

3. Continue Why until

1. Bring the issues / abnormalities
2. Always check for logical factor leading to
identified in the fishbone diagram and
correctness by tracing countermeasure to
prioritized as potential cause. For each
phenomenon from last prevent recurrence is
of them, apply 5 Why analysis to find
why. found (normally human
root causes.
failure related cause)

Why? Why? Why?

Problem

Why?
 5Whys Example: Manufacturing Case
Priority

Edge went up
1 Conveyor loosing Conveyor left Feeder guide Guide locked
on the left side incorrectly after
parts side damaged out of position
guide cleaning
Potential causes from Fishbone Diagram

Conveyor Correction Rod has passed

2 Exceeded There's no rod
correction system device out of the corretion slider limiter
correction point
failure position point of the correction

Main conveyor
No periodic
3 Excess dust/dirt
inside the valve
air valve not
included on
maint. plan
maintenace plan
for valves

Missing
Manometer
4 whitout range
specified
Range not
specified on CIL
information
about correct
pressure

5
 5 Whys Exercise - Jefferson Memorial
Jefferson Memorial
Structure Structure was deteriorating
Ddeteriorating

Why ?

Using harsh chemicals

Why ?

To clean pigeon droppings

Why ?
Root Cause
They eat spiders&
there are a lot of spiders
at monument Why ?

They eat mosquitos &

Why ?? flies there are a lot of
flies/mosquitos at monument
Because !! Why ?
They are attracted to the
light at dusk!
Acting to eradicate the problem causes

Action Plan for

Countermeasures

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 Action Plan elements
To guarantee the problem will be eradicated, it’s very important to put (at least one)
countermeasures for each root cause found.

A good action plan must have some elements:

1. Action: The countermeasure action that will be provided to eradicate the root
cause
2. Owner: Who will be responsible for the execution of the action
3. Date: The action deadline
4. Status: Current status of each action (eg: planed, complete, delayed)
 Action Plan Example

ROOT 4. Actions: Containment or Root Cause elimination 5. Responsibilities 6. Status

CAUSES Write down the actions related to each root cause and specify if Ensure all actions
Name Date
they are containment or root cause elimination are closed

Guide locked Carla 27-jun OK

Create a checklist to use in startup after clean
incorrectly after
cleaning

Lack of rod slider A. Install limiter in the end of the course for rod of the A. Ediclei
limiter conveyor correction sense
of the correction B. Fábio/Daniel 30-mai OK
B. Install a safety sensor at each end of the conveyor belt
sense C. Replace centerline of main conveyors C. José Maria

No periodic
Include periodic inspection of the conveyor
maintenance plan for Carla 30-jun OK
valves valves

Missing information Install centerline on the pneumatic system

about correct manometer of main conveyor repair and include José Maria 26-jun OK
pressure (manometer) the manometer range on CIL
 Standardization
After the Action Plan conclusion, we have to guarantee the problem’s prevention by
developing or updating the standardization tools:

 OPL (One Page Lesson)

 Skill Matrix
 Centerlining
 SOP (Standard Operational Procedure)
 Maintenance Preventive Plan
 CIL (Cleaning / Inspection / Lubrication Standard)
 Manufacturing Standards (SPC, etc)
 One Page RCA: the take away

5W + 1H = focus analysis.
Used to make RCA theme extremely specific: problem statement

Identify design/ideal state for identified problem

statement (working principles)

Use fish bone to make hypothesis vs standard learned on working

principles – gap validated after verification

Use 5 Why’s for each gap identified

Set up action plan, verify success and standardize new

condition (loss prevention)
 Take Away

1) Robust and detailed loss analysis: focus on major offenders

(use 5W+1H to clarify the real problem you want to solve)
2) Build capability of your teams: understand (working)
principles and process/systems design that generate the loss
under consideration
3) Apply tools thoroughly to identify root causes: 4M followed
by 5 Why’s
4) Track progress and standardize procedures to sustain the
gains
 100% Participation to get ZERO losses

ROOT CAUSE ANALYSIS

Do really have right people involved

on analysis and solution?
RCA: templates
 One Page RCA
Template Mondelez Std RCA Templates
Model A – Simplified format for plants starting their Model B – Advanced format for plants reaching a more
IL6S Journey (Phase 0 and beginning of Phase 1) mature stage of IL6S Journey (middle of Phase 1 and above)

FRONT
PAGE

BACK
PAGE
 Problem/Area of Improvement

Problem/Area of Improvement
KPI - Monthly Trend / 5W+1H Loss Analysis (fish bone vs Ideal State)

Action Plans 5 Why?s Analysis

Due
Activity Responsable Status
Date
Common Problem Solving Pitfalls
1. Poor problem definition (use of 5W+1H)
2. Jump to conclusions, not applying problem solving sequence and
techniques
3. Blame people, ignore systems design/methods
4. Not confirming likely causes
5. Tackling problems without understanding of ideal state.
6. Failing to involve the right people, work beyond scope of team
7. Failing to execute and track effectiveness of solutions
8. Solutions not updated to SOP, Standard Operating Procedure
9. Knowledge and standards generate as result of RCA not passed
on to all individuals involved on affected processes
10. Work towards elimination of issue: may need more than one
cycle of analysis before issue is successfully eradicated
Check for understanding…