Finding the Root Cause

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Quotable
"You can't build a reputation on what you're
going to do."
"Obstacles are those frightful things you see
when you take your eyes off your goal."
"Whether you believe you can do a thing or
not, you are right."
Henry Ford
“Success is how high you bounce
when you hit bottom.”
Gen. George S. Patton
Support Systems - OKC
History
Boeing began on-site
customer support at
Tinker AFB in 1956
with the B-52 Program.
In 1986 Boeing established an OKC Headquarters for
the support of commerical derivative aircraft.
Boeing
Presence in Oklahoma
Over 900 employees
Vance AFB
•T-38
Platforms Supported:
•KC-135
•E-3
•VC-25
•E-4B
•E-6
•B-1/B-2/B-52
•Derivative A/C Programs
•T-43
•T-38
•C-32
•C-40
•KC-10/KDC-10
•E-8/C-9
•AH-64 TSS
•C-3 TSS
•C-17
Del City
Midwest City
Oklahoma City
TAFB
Altus
•C-17 TSS
•C-17 LCCS
Fort Sill
•FCS
Our Journey Towards
Excellence
To date, Boeing has been the Recipient of the following Awards:
™ 2007 OKEthics Compass Winner of Large Business category
™ 2006 OKEthics Compass Finalist Award
™ 2004 Oklahoma Quality Award for Excellence
™ 2003 Oklahoma Quality Award for Achievement
™ 2006 Nevada Pioneer Award
™ 2006 Nevada Award for Quality Leadership
™ 2004 Nevada Trailblazer Award
™ Boeing Aerospace Support received the National Quality Award in 2003
Support Systems - OKC
Engineering & Logistics Services
From
Flight Line
Leadership..
Our mission is to
provide quality
engineering and
logistics products,
services, and
support.
to
World
Leadership
Our People
Establishing the Balance
Satisfiers
Motivators
Quality
of
Life
Quality
of
Opportunity
Self
Actualization
Compensation
Pay
Benefits
Safe &
Healthy Work
Environment
Esteem
Love/Belonging
Appreciation &
Respect
Safety/Security
Basic Physiological Needs
Maslow’s Hierarchy of Needs
Advancement &
Involvement,
Development &
Education
People Initiatives
• People Council
• Lunch with Ben and Nancy
• Quality of Life
– Benefits Alignment
– Benefits Expo
– Safety Day “Green Dots”
– Health Screening – New
– Monthly Benefit Highlight
• Quality of Opportunity
– Diversity Mentoring
– “High Flyer” Program
– “Right Start” Program
– Recommitment “Brown Bags”
– “Spotlight” Program
– Tuition Assistance Program
– Learning Together Program
Summary
• Our focus is on:
• Meeting and Exceeding Our
Customer’s Expectations
• Taking Care of Our People
• Exceeding Our Mission
• Supporting Our Community
“Facts are stubborn things; and whatever
may be our wishes, our inclinations, or the
dictates of our passion, they cannot alter
the state of facts and evidence.“
John Adams
Corrective and Preventive Actions
Clause 8.5.2
Corrective Action
The organization shall take action to eliminate the
cause of non-conformities in order to prevent
recurrence.
Clause 8.5.3
Preventive Action
The organization shall determine the action to
eliminate the causes of potential non-conformities in
order to prevent their occurrence.
RCA
Flow Charts
Ishikawa (Fishbone)
5-WHY Analysis
PRACTICAL PROBLEM SOLVING
1. Definition of a Problem
2. How to Solve a Problem
3. Different Levels of Causes
4. Finding the Root Cause
5. Eliminating the Root Cause
6. The Problem Solving Process
7. Problem Solving Steps
Definition of a Problem
“A question proposed for a solution”
“A state of difficultly that needs to be
resolved”
How to Solve a Problem
Every problem has a cause.
Some problems have multiple causes, but
most problems have one main cause or a
root cause.
The goal of problem solving is to find the
root cause and eliminate it in order to
prevent its recurrence (ISO Clause 8.5).
Examples
1. A sawmills boards were not being cut
to the proper length?
2. An electrical contractor was losing
$200,000 annually due to rework.
3. Aircraft parts were being delivered
without the proper FAA paperwork.
Different Levels of Causes
Some problems have multiple causes, but
most problems have one main cause or
root cause.
¾Symptoms: not the cause, but signs of a
problem.
Failure to perform a root cause analysis
will lead you to treat the symptoms
instead of the illness, and result in the
patient dying from the treatment.
Different Levels of Causes
¾First Level: directly lead to a problem
¾Higher Level: directly lead to the first
level
Example: A well known aviation
maintenance company received a fine for
improper HAZWASTE disposal.
Finding the Root Cause
Visible
Problem
First Level
Cause
Higher Level
Cause
Root
Cause
Symptom
Finding the Root Cause
Visible
Fine
Problem
Did
First
notLevel
know
the
Cause
law
Higher
Reactive
Level
Management
Cause
No process
Root
to monitor
Cause
regulatory
change
Improper
Symptom
HAZWASTE
discharge
Finding the Root Cause
Example: An aviation painting company
in Texas was sued for painting the wrong
shades. The color schemes were correct,
but the colors were noticeably wrong.
Eliminate the Root Cause
If you concentrate your efforts on the
symptoms, the actual cause will persist
and may not be easily recognized.
If you concentrate your efforts on the
first/higher level causes, the root cause
will manifest itself in another problem.
Once the root cause has been addressed,
you must monitor the system for other
areas of deficiency.
The Problem Solving Process
PROBLEM
AUDITS/
IDENTIFICATION
SELF-REVIEWS
SYMPTOM
MONITORING
Act
Check
Plan
PROBLEM
DEFINITION
Do
ROOT CAUSE
ELIMINATION
PROBLEM
UNDERSTANDING
Deming Wheel
ROOT CAUSE
IDENTIFICATION
The Problem Solving Steps
MONITOR
ELIMINATE
FIND THE ROOT CAUSE
UNDERSTAND (Ownership/Buy In)
DEFINE
RECOGNIZE THE PROBLEM
Root Cause Analysis
Typically, when there is a
problem, those who are
closely involved tend to
believe they can quickly
identify the solution.
Unfortunately, this often
leads to a “band-aid”
approach for correcting a
discrepancy or nonconformity, and does not
prevent recurrence.
We often accept substandard
performance and failure as:
¾“That’s just the way it is”
¾“It has always been a problem”
¾“It can’t be fixed”
¾“Not my job”
The following example is real,
the event took place at a
Fortune-500 company.
The company and the names of
the employees have been
changed to protect the guilty.
I see water on
the floor in the
electric shop
Plant Manager
Mr. Wall
Assistant Plant Mgr
I’ll have it
cleaned up
immediately
Mr. Veers
Monday
In the Electric Repair Shop
Clean up that
mess on the
shop floor
Mr. Veers
Shop Supervisor
Joe
I’ll get
someone
right on it
Monday
“I still see water on
the floor in the
electric shop”
Mr. Wall
Mr. Veers
“I told Joe to take care
of it. If anything gets
done around here, I have
to do it, myself!”
Tuesday
What was the
root-cause
of this problem?
¾Failure to follow
proper procedures?
¾Negligence?
In the Electric Repair Shop
I thought I told
you to clean
that mess up!
Mr. Veers
We did, it’s a leaky
pipe joint, when
we mop it up, it
comes right back.
Joe
Tuesday
What was the
root-cause
of this problem,
now?
In the Electric Repair Shop
Then get
maintenance
to replace the
gasket!
Mr. Veers
They have, 3
times!
Joe
Tuesday
What was the
root-cause
of this problem,
now?
Maintenance
Can any of your
idiots properly
install a gasket!
Mr. Veers
Maintenance Lead
Any one of my idiots
can install a gasket, but
the gaskets are no good,
they all leak! We don’t
buy them we just install
them.
Wednesday
What was the
root-cause of this
problem, now?
You sure?
Material/Supply/Parts
Why are you
buying cheap
substandard
repair parts?
Mr. Veers
Supply Lead
I was directed to
purchase all repair
parts from the
lowest bidder?
Wednesday
What was the
root-cause of this
problem, now?
You sure?
Material/Supply/Parts
Mr. Veers
Who was the
idiot that told
you to do that?
You were!
Wednesday
Complex problems,
especially those where
an entire process has
been brought into
question require a
more thorough
analysis.
Definition of a RCA
“A structured investigation that aims to
identify the true cause of a problem, and
the actions necessary to eliminate it and
prevent its recurrence. “
Root- Cause Analysis (RCA) is a
systematic approach to determining all
the contributors to a problem before
attempting to implement a corrective
action plan.
RCA Tools
There are a number of tools that can be used for
root cause analysis:
9 Flowcharts
9 Critical Incident
9 Spider Charts
9 Performance Matrices
9 Pareto and Scatter Charts
9 5-Why Analysis
9 Ishikawa or Cause and Effect
5-Why
A system to drive to the root cause by forcing the
user to continue to ask “why”.
The main purpose is to progressively dive deep
into a problem area and avoid prematurely
identifying a symptom as a cause.
You must question each “why” until you have
exhausted and removed the extraneous variables.
Simply put, a “5-Why”
analysis adds discipline
to the problem investigation
to ensure that as many
contributors as possible are
reviewed up front.
WHY
WHY
WHY
WHY
WHY
Basic 5-Why chart
WHY?
WHY?
Discrepancy or
Non-Conformance
WHY?
WHY?
WHY?
Negligence
Failure to follow
procedures
Water on the floor
Lazy
Didn’t notice it
Unable to fix it
Negligence
Failure to follow
procedures
Water on the floor
Lazy
Didn’t notice it
Unable to fix it
Negligence
Failure to follow
procedures
Water on the floor
Had they attempted
to cleaned it up?
1.
Is there a procedure
2. Is it adequate
3. Was it followed
Lazy
Saw it but, just left it?
Didn’t notice it
Too busy?
Unable to fix it
Attempted to
get it fixed?
The Ishikawa or “Fishbone” Diagram”
Manpower
Methods
People
Procedures
Potential
Root Cause
Plant
Machinery
Environment
Modified Ishikawa or “Fishbone” Diagram”
Maintenance
Personnel
Training
Enough
Bad Parts
No Parts
Plant
Materials
Procedures
Work Instructions
Don’t exist
Inadequate
Rain or Ice
Too hot/cold
Weather
Potential
Root Cause
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