12 | Mar/Apr 2016 | ME Root Cause Analysis – a business imperative ROOT CAUSE ANALYSIS I f you do not react properly to equipment failures, you will continue to suffer with evermore deteriorating performance results, says Peter Jackson, a senior consultant with the MCP Consulting Group. Introduction MCP has learned from working with clients that are keen to improve their performance that, all too often, the historical reaction to failure has been hasty and superficial, in order to deal quickly with a problem, because we need to rush to the next crisis. If this sounds familiar, and your practices do not drive out the true sources of a problem, it is time to act. Understanding the need for, and application of, a robust process that eliminates (or mitigates) failures from future performance as a key to reliable equipment performance, is limited in many businesses. However, it is high in the agenda for a world-class company. Root Cause Analysis Root Cause Analysis (RCA) is a well known technique. Having, within it, a robust methodology that ensures root causes of problems are identified, resolved and valued is essential. Although claimed to be adequate by many managements, all too often the process is weak at driving down to the root of a problem. Safety RCA for accident investigation Production RCA for quality control non-compliances Process RCA for business process step deviations Equipment Failure RCA for engineering / maintenance failures System RCA for high level service performance issues The overall principles remain the same despite the application: 1. Always investigate each event 2. Work with facts associated with the event 3. Involve the people closest to the problem 4. Perform to a systematic process 5. Ensure sufficient analysis to determine root causes 6. Implement the solution 7. Evaluate the outcome and report the value Although some limitations should be recognised: o Accuracy of data o Capability of those involved o Study time pressure o Leadership support for the process o Recognition for the outcome Problem solving The key to the RCA process is the structured analysis leading identifying root causes. If a solution is immediately obvious, then a ‘Just-do- it’ (JDI) action may be appropriate. This should be a first challenge concerning what to do next in the decision making process. If no JDI is available, then the underlying causes can be determined using a cause-effect diagram (Figure 1) to structure the thinking involved. Before using a case study to highlight the value of the process, a brief summary of the RCA technique may be appropriate. The simple picture above helps us to remember that: Effects are the tangible evidence that something is wrong. The analysis of the root causes are the solvable issues that need to be eliminated. RCA should apply to any failure that is an unexpected event in a business. Sometimes this is referred to as having a ‘zero tolerance’ approach when dealing with, and resolving, issues. It is vital that there is no blame attached!! RCA is a flexible arrangement that can be applied as the best and most appropriate way to deal with situations: First introduced in 1968 by Kaoru Ishikawa in Japan, the 6 major causal elements that could contribute to an effect are collected in the diagram before failure analysis is conducted. The analysis is good at ensuring that all avenues have been explored. There can be several potential causes and each one needs to be investigated more closely to dig down to the root of the problem. For each cause identified, the proven 5Whys technique is often sufficient to uncover the root of the problem – see Figure 2. Childish? Too simple? Superficial? Not according to world-class companies who us ethos initial discipline before referring to more complex techniques such as Figure 1 Problem Solving Continued on page 14
Transcript
12 | Mar/Apr 2016 | ME
Root Cause Analysis – a business imperative
R O O T C A U S E A N A LY S I S
If you do not react properly to equipment failures, you will continue to suffer with evermore deteriorating performance results, says Peter Jackson, a senior consultant with the MCP Consulting Group.
IntroductionMCP has learned from working with clients that are
keen to improve their performance that, all too often, the historical reaction to failure has been hasty and superfi cial, in order to deal quickly with a problem, because we need to rush to the next crisis. If this sounds familiar, and your practices do not drive out the true sources of a problem, it is time to act.
Understanding the need for, and application of, a robust process that eliminates (or mitigates) failures from future performance as a key to reliable equipment performance, is limited in many businesses. However, it is high in the agenda for a world-class company.
Root Cause AnalysisRoot Cause Analysis (RCA) is a well known technique. Having, within it, a robust methodology that ensures root causes of problems are identifi ed, resolved and valued is essential. Although claimed to be adequate by many managements, all too often the process is weak at driving down to the root of a problem.
� Safety RCA for accident investigation� Production RCA for quality control non-compliances� Process RCA for business process step deviations� Equipment Failure RCA for engineering / maintenance
failures� System RCA for high level service performance issues
The overall principles remain the same despite the application:1. Always investigate each event2. Work with facts associated with the event3. Involve the people closest to the problem4. Perform to a systematic process5. Ensure suffi cient analysis to determine root causes6. Implement the solution7. Evaluate the outcome and report the value
Although some limitations should be recognised:o Accuracy of datao Capability of those involvedo Study time pressureo Leadership support for the processo Recognition for the outcome
Problem solvingThe key to the RCA process is the structured analysis leading identifying root causes.
If a solution is immediately obvious, then a ‘Just-do-it’ (JDI) action may be appropriate. This should be a fi rst challenge concerning what to do next in the decision making process.
If no JDI is available, then the underlying causes can be determined using a cause-effect diagram (Figure 1) to structure the thinking involved.
Before using a case study to highlight the value of the process, a brief summary of the RCA technique may be appropriate. The simple picture above helps us to remember that:
� Effects are the tangible evidence that something is wrong.� The analysis of the root causes are the solvable issues
that need to be eliminated.
RCA should apply to any failure that is an unexpected event in a business. Sometimes this is referred to as having a ‘zero tolerance’ approach when dealing with, and resolving, issues. It is vital that there is no blame attached!!
RCA is a fl exible arrangement that can be applied as the best and most appropriate way to deal with situations:
First introduced in 1968 by Kaoru Ishikawa in Japan, the 6 major causal elements that could contribute to an effect are collected in the diagram before failure analysis is conducted. The analysis is good at ensuring that all avenues have been explored.
There can be several potential causes and each one needs to be investigated more closely to dig down to the root of the problem.
For each cause identifi ed, the proven 5Whys technique is often suffi cient to uncover the root of the problem – see Figure 2.
Childish? Too simple? Superfi cial? Not according to world-class companies who us ethos initial discipline before referring to more complex techniques such as
Figure 1 Problem Solving
Continued on page 14 �
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14 | Mar/Apr 2016 | ME
Kepner-Tregoe, 6Sigma and others.Increasingly, a combination of cause and effect,
and 5Whys, has emerged as a process called ‘Cause Mapping’ – see Figure 3.
Note the reversal of the direction of thinking from the Ishikawa cause-and-affect diagram. It is because the Japanese write from right to left and it easier for westerners to think left to right.
Case exampleThere is no better way to confi rm that the RCA process works than to look at an actual result from the analysis of a problem at a UK manufacturing plant – a faulty Festo dump valve, where contamination and a blocked fi lter were causing it to stick.
Each problem is addressed following an agreed process that indicates the expected timeline for a solution, who should be involved and when decisions or analysis are required. This is expressed as a fl ow diagram as follows – see Figure 4.
R O O T C A U S E A N A LY S I S
Figure 3 Cause mapping
Figure 2
Continued on page 16 �
� Continued from page 12
Figure 4 The overall RCA process
Effect Causes
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R O O T C A U S E A N A LY S I S
XXX.123.56789
Line Technician
Problem(s) Faulty Dump Valve on Capper - Lack of air supply
Frequency of incident / failure Experienced twice per year £1,200 240
SAP Order No 2
RCA Reference Number:
SAP Order No 1
Define the Problem and Provide the Data
RCA Owner/Manager
What?
When?
Consequences Arising
30498548
Figure 5 RCA of a Festo dump valve – Cause Map
Table 1 Defi ne the problem, provide the data and consider the consequences arising
RCA of Festo Dump Valve - Cause Map
and / or
and / or
Diag 5
No air to capper - line stop
Festo dump valve stuck
Valve contaminated
Filter Blocked Filter not checked for 12 months
Inadequate filtration
No PM task scheduled
Rust in Line Utilities problems -
water in air
Filter too coarse
� Continued from page 14
Continued on page 18 �
Next, the problem must be defi ned:
Using the following templates, the problem is thoroughly and formally defi ned. Deeper explanation can be provided when necessary. The template requires only the absolute minimum information. Additional details are not provided here, as it is the process that is important – see Table 1.
(MCP Comment. It would be wise to refl ect on the outcome from the ‘Cause Map’ and ensure the fi nal cause has been identifi ed. Where the simple problem solving tools prove to be inadequate, an escalation step should be allowed for passing the problem to those better qualifi ed to use more precise tools such as Kepner Tregoe or 6Sigma approaches.)
The cause map is best conducted by a small team who have intimate knowledge of the equipment, the impact of the problem and experience in problem solving where the consequences need to be considered.
Then the ‘Cause Map’ can be developed – see Figure 5
18 | Mar/Apr 2016 | ME
Solutions (RCA Template)
No. Action Item Cause SAP No.: Owner Due Date Status Completed
1 Replace filter - fit 5 micron element Blocked filter - inadequate filtration 90491348 I Potts 11/01/12 Planned 18/01/2012
3Filter PM schedule required - ammended SAP plan Blocked filter Plans Created Mk/Ms 31/01/12 Planned
4
5
6
Failure effect on OEEApprox. 0.1%
Corrective Actions to be taken that address the root cause of the problem
NOTE: Since solutions control specific causes, every action item (solution) should correspond to a cause from the Cause Map. This provides continuity in the analysis. Every cause on the Cause Map does not need to be solved. Only those causes with action items (solutions) are listed in this table.
Summary� World-Class companies establish a zero tolerance
approach to dealing with all unexpected failures.� Operations and Maintenance personnel should jointly be
involved in the RCA process� A pro-active continuous improvement culture is essential
and can only be created by inspirational leadership.� The RCA process must be formal and accountability for
process adherence clearly assigned.� The ‘value’ to the business must be communicated and
Added value to the businessThis is too often a weakness in many businesses where there appears to be some kind of uncertainty about putting a value to the improvement. For example, where a ‘more safe’ situation is an outcome, it is always a challenge to agree what value to assign. Some creativity and an estimate of what average cost can be put on each safety incident should be agreed with the business. Similarly, the cost of a lost hour due to equipment failure also needs to be clear. Where the business can sell all it can make the cost could be the cost of the lost sales value per production hour. These values may be diffi cult for the accountant to appreciate on paper, but they are indicative of the scale of issues in the common business language of ‘cost’. It is the best way to show the value being extracted for each separate improvement.
One problem. Imagine the annual impact when every failure can be addressed.
[Note: Since solutions control specifi c causes, every action item (solution) should correspond to a cause from the Cause Map. This provides continuity in the analysis. Every cause on the Cause Map does not need to be solved. Only those causes with action items (solutions) are listed in Table 2.]
From the ‘Cause Map’ the solutions are documented – see Table 2
And fi nally the value to the business can be calculated – see Table 3
Description of Solution
Implemented
Filter replacment
Benefi ts AcievedExpected increased MTBF of valve leading to less downtime and reduced replacement cost
KPI Improvement
Effect on Reliability: Line MTBF increased from 4 to 6 mths Increased customer satisfaction = £ ?
Effect on OEE: D/T reduced by 4 hours per year £10440/hr
Effect on Quality/Yield: Improved yield £ ?
Effect on Cost: Spares reduction for 2 failure per year £600/failure
Effect on Safety: N/A
Value to Business (£10440 X 4) + (£600 X 2) = £ 42 960
