Root Cause Analysis emergency - Historical problems return to plague us!

[Toolbox]

Hey guys,

I work in a fast paced manufacturing gross environment. Lately we have started to see a lot of historical problems return to plague us stemming from poor PM, poor management decisions etc. When we first had these problems, steps were taken to document the corrections made with proper PM schedules, etc. However I am afraid that several important facts may have been omitted and relied upon as hand-down knowledge.

To cut a long story short, I need to implement a large scale root cause analysis program, teaching my managers how to conduct and properly utilize different root cause tools. Right now I am leaning towards a 5-Why approach but really do need something with faster turnaround. The end result will be easy to follow forms that can guide my managers through the different aspects of EVERY problem, not just ones that they feel deserve a comprehensive investigation. People, Process, Management would be 3 fair groups to address.

If you guys could provide some thoughts, ideas or materials to get the ball rolling, I would appreciate it. Also, if there are any RCA implementation stories I may be able to learn from, please do share

Thanks guys,
the cove rocks!

 

[Marc]

Start out going through https://Elsmar.com/8D/

Scroll down the index on that page - There are a number of places it focuses on Root Cause.

 

[Bill Pflanz]

Hey guys,

To cut a long story short, I need to implement a large scale root cause analysis program, teaching my managers how to conduct and properly utilize different root cause tools. Right now I am leaning towards a 5-Why approach but really do need something with faster turnaround. The end result will be easy to follow forms that can guide my managers through the different aspects of EVERY problem, not just ones that they feel deserve a comprehensive investigation. People, Process, Management would be 3 fair groups to address.

The problem I have always had with root cause analysis methods whether it is fishbone diagrams, 5 why or any other brainstorming type technique is that it is only providing opinions on the causes. Since the people providing the causes are generally closest to the problem, I assume that they must be correct and therefore there must be data or it can be collected to support their opinions.

Many times I have been able to prove which was the most likely cause but sometimes I was able to show that what they thought was the cause really wasn't it all. Collecting data will take longer but it will likely lead to a better long term solution.

Bill Pflanz

 

[Wes Bucey]

The problem I have always had with root cause analysis methods whether it is fishbone diagrams, 5 why or any other brainstorming type technique is that it is only providing opinions on the causes. Since the people providing the causes are generally closest to the problem, I assume that they must be correct and therefore there must be data or it can be collected to support their opinions.

Many times I have been able to prove which was the most likely cause but sometimes I was able to show that what they thought was the cause really wasn't it all. Collecting data will take longer but it will likely lead to a better long term solution.

Bill Pflanz

There's a fellow who wrote in the Quality Progress Forum of the ASQ Discussion Forums recently about his Apollo method of Root Cause Investigation. His primary thesis (he wrote a book on his view) seems to be the Root Cause Investigation must be extended to hypothesizing and incorporating methods to eliminate or ameliorate the root cause, then evaluating them for effectiveness. If you're interested in further discourse, I'll invite him to join the Cove.

 

[gpainter]

Sounds like someone reverted. I know most of us follow-up on CA to verify, but we probably need to do it more to keep success syndrome (reversion) down.

 

[Steve Prevette]

Personal opinion is that most folks who spend a great deal of effort trying to find the "root cause" and train up large amounts of folks to do "root cause analysis" are weak implementers. Even the most perfect root cause identification will do no good if the resulting information is generates no actions and nothing is implemented. And then, yes, there is the "reversion" issue. Especially if you are in a hurry to get results, I would first try to make use of the information you have on hand, and identify your leading problems and then work on those. Be aware of common cause versus special cause issues. "Fixing" a root cause on an individual event may in fact only be tampering (aka The Funnel Experiment).

 

[Bill Ryan - 2007]

FWIW - Right or Wrong, I have always been taught that if you can't turn it on and off - you may not have found the root cause. It is something we try to hammer on around here due to all the interactions in a die casting process.