How I Was Pushed Into RCA

[JimCubb - 2005]

I lost my job with the County after ten years and went back to the temp agency. I am now working as the data freak in the machine shop of a company that is ISO certified.

On 19 April the Machine Shop was audited by one of the Quality Engineers. There were three findings and a note.

The machine shop supervisor knows that I can write (I am the only person in his department for whom English is not a second language. Many of the Hispanics are not able to write in Spanish properly.) so I was charged with answering the findings.

I sent multiple drafts to the Engineer. On 11 May he sent me the form that was to be used to answer findings. We continued to go back and forth until the Engineer wrote that I was providing containment details, not a Root Cause, and offered to spend some time with me that the Machine Shop Supervisor to explain the process of determining Root Cause.

The Machine Shop Supervisor was on vacation that day and the two days that followed. Finally a meeting was held at 10 a.m. on Friday, June 3.

The Engineer talked us through some examples and gave us a printed document that he said would be extremely helpful. It was the PowerPoint Presentation of Refresher Training in the Tashiro method. When I read it I was almost completely confused.

I went to my computer and did a search on the Tashiro method. None of the hits were of any help in determining Root Cause. I started searching for Root Cause Analysis. I found many interesting references and printed the ones that made any sense but I was no closer to being able to determine a relevant Root Cause than I had been the day before. (It was during this process that I found this site. I had to register to be allowed to see the relevant documents and I do not register for anything on a work computer.) Nevertheless, I brought all the material home so that I could study it over the weekend.

Saturday morning I woke at 2:40 and tried reading everything again. I was still confused. By Sunday evening I was ready to concede failure.

Monday morning I tried another search. I found an article, "Root Cause Analysis For Beginners" that had not been there last week. I read it and printed it. If the article were correct, I had been doing things the hard way. It must be more difficult than the article made it appear. I did some normal work for the rest of the day and resolved to do a search the next morning to see what new resource had floated to the top.

Tuesday I found another article that reinforced my perception of the first. I wrote a complete response at 9:42 am. The Engineer brought me his suggestions for correction (two were valid, one was not. Neither was in the area of Root Cause.). I made the changes, submitted the new response and the matter was closed at 10:16.

I still do not know much about Root Cause Analysis and I understand less than half of what I know.

I have since registered and contributed to this site. I did it at home.

 

[Jen Kirley]

Welcome, Jim, if you have not been thus greeted already.

Few to none of us started out saying, "I want to be a quality professional." I made my fateful switch when swapping places with a fellow metal working Navy person. Since then the trip has been positively one worth comparing with the Wizard of Oz tale.

You may eventually find, as I did, that upon researching and absorbing wisdom it may be hard to let it go--that can be vexing depending on the situation and our personalities. That can make us interesting members of industry, ranging perhaps from reluctant riders to something like the Baron Munchausen character.

I think the best advice I can give is to not take things so seriously that they affect your sense of wellness and/or worth. We offer advice, give data and measurements, but in the end our advice is just that.

Be well!

 

[Jim Wynne]

If you could give an example of one of the auditor's findings we could point you in the right direction, and there's a good chance that the explanation will go further in helping you to understand RCA than anything you've read so far.

 

[WALLACE]

Welcome Jim.
https://www.systems-thinking.org/rca/rootca.htm
The above URL may enlighten you in a relaxing manner.

I must say, I have found RCA to be the most invigorating part of Business. Being a very visual communicator, I have found presenting pictorial facts after a walk through of process, always gets the attention of the recipients of an NC related to RCA.
If you get the chance, walk the process in question and gather data that would allow you to either measure the capability of three (3) main elements:
1. Personnel
2. Technology
3. Process
You can dig as deep as you want, and yes you'll find other "Causes" that tend to drag you off course. Keep focused, and never loose sight of the product.
Wallace.

 

[JimCubb - 2005]

In The Interest of Completeness

The Audit concerned the Preventive Maintenance of machines in the Machine Shop. The two newest machines were put into service at the beginning of this year. They had not been entered into the Maintenance Log and their schedules of Preventive Maintenance had not been prepared. There were two reasons for this.

One of the machines was dysfunctional when it arrived and still requires some tweaking at the beginning of the shift. Everyone's attention was directed towards getting this machine up and operating properly.

These were the first new machines to be introduced into the system in FIVE years.

The article that I found on Monday, "Root Cause Analysis for Beginners" included a massive decision tree. Once I got to the right branch of the tree, the Root Cause became obvious. "Knowledge of the procedure was less than adequate." After five years, everyone who was involved had forgotten what to do when a new machine was installed. I was deeply concerned that this answer was too simplistic.

When I found the second article on Tuesday, I do not remember its title, but a couple of its points grabbed me. The first point was that the Root Cause had to be expressed simply. The second point was that the Root Cause had to be something that MANAGEMENT could fix. (In my experience the two points are related. MANAGEMENT has a very short attention span and most members of that class can barely get through the Executive Summary without losing focus.)