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Root Cause Analysis Analysis

Discussion in '5S, 5Why, 8D, TRIZ, SIPOC, RCA, Shainin Methods...' started by Chris Glover, Feb 14, 2017.

  1. Chris Glover

    Chris Glover Member

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    I have been tasked with reviewing and analyzing our corrective actions and root causes.
    One of my thoughts is to develop "categories" the "wordy" root causes can be fit into.
    Examples:
    Failure Mode not defined on PFMEA
    Failure Mode defined on PFMEA - Inadequate Controls

    I would like to come up with a list of 10 or so categories so moving forward we can assign them to one category. We would then be able to more effectively determine where our system is weak and where to best allocate resources.

    Does this approach make sense?
    if so, what other categories could be added?
     
  2. Miner

    Miner Moderator Staff Member

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    What you are describing sounds like the Taproot Root Cause Tree approach. It is a legitimate approach (as are many others). As with many approaches, don't get locked into the idea that there is only one single root cause. Even the 8D methodology has acknowledged that there are at least three root causes (i.e., problem, escape, systemic). I recommend using the best aspects of each approach.
     
  3. Chris Glover

    Chris Glover Member

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    For sure..we do identify a "Why Made" and "Why Shipped" root cause
     
  4. Bev D

    Bev D Moderator Staff Member

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    Let's first separate human behavior from physics. Chris are you mostly dealing with recurring physics sourced problems as opposed to problems that result from human behavior (mistakes and errors). the effectiveness of this 'cause categorization scheme varies greatly between the two types of problems. Tap Root and Apollo were developed to deal with the latter (safety and human behavior) In this case categorization can be helpful IF good root cause analysis is performed for each incident AND the systemic causes are sufficiently detailed. Tap Root has done a good job at this and the tap root guys will tell you that these "categorizations" were the result of a deep understanding of the causal mechanisms of unique incidents. I can say that "Failure mode not defined on PFMEA" is not a root cause, nor is "Failure Mode defined on PFMEA - Inadequate Controls"; the lack of a solution is never a cause. These may be enabling factors or contributing factors but they are not the physical causal mechanism of what happened.

    Secondly, I understand the desire to do this - but in my experience it is rarely valuable. The drive to come up with categories too often over rides the effort to get at the true causal mechanisms that will prevent specific problems from recurring. Second the categorization becomes an attempt to over simplify the complex. Ten or so categories is over simplification. Understanding systemic causes is complex and really can't be 'quantified' in a simplistic fashion.

    In my experience, good problem solving and holding lessons learned sessions will highlight the systemic causes - there is no need to try to define them ahead of time. (this is a very biased exercise if you think about)

    As examples we've come up with improvements to our change assessment and V&V processes, instituted the use of truly crossfunctional teams for Problem Solving with frequent leadership review, etc. these have been highly successful in reducing our excursion rates and we just 'knew' what to do because we were intimately involved in solving Problems and reviewing what happened. we never had to actually count them...
     
  5. ncwalker

    ncwalker Well-Known Member

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    I agree. Once you make categories, you then have to feed the monster. Training on what the categories mean. Scrubbing the data for erroneous entries. Here is ncwalker's crazy thought.... assuming you have these root causes electronically in a database or Excel sheets, I think it would be interesting to take them all, or a subset for a period of time, or both, and run them through that word cloud software. Where the most used words are bigger. That would give your graphs AND make the categories at the same time. Never seen it done before, but it would be interesting.
     
  6. Chris Glover

    Chris Glover Member

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    I see what you all are saying..and one of our glaring weaknesses is our very poor job of RCA...
    I am just trying to find a way to meet a request from on high...
     

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