Tactics for Root Cause Analysis

toniriazor

Involved In Discussions
#1
Hello

From a long time I was thinking to open this thread. The idea is to exchange knowledge for different ways when it comes to root cause analysis and problem solving.

Most of us here work in environments where we encounter issues every day and have to solve them following certain approaches. Learning is endless.

Long time ago I found a post here in the forum where it was written that a Japanese professor used to gather team of 5 people and send them for an hour to observe a mfg. process. Afterwards everyone had to write what he/she had seen during this one hour of time. At the end all 5 people had seen different things. I really liked this method and understood how many different approaches actually one can use to find a problem and what we all see is different.

I will share some of the methods I use and hope you guys can share too your way of handling issues. So I most often rely on:

1 ) observing at least 10 full cycles of mfg. line or a process, because people tend to return to their habits shortly after I appear on the line to investigate. Then I can often see what really is wrong and where is the problem.
2 ) Always try to have friendly talks with operators on the line and most of the time they are the key to finding the root cause.
3 ) Another method I use from time to time is to check cameras ( I really don't like this one ) but I often see how careless people could be especially on night shifts when management is out of factory. Then I can use what I had seen on the cameras to ask proper questions the operators which worked and skip key process steps.
4 ) Trying to manufacture a product by myself with current standard (often see so many gaps) including process design issues and product design issues as well.

Thank you.
 
Elsmar Forum Sponsor
#2
Hi, I share with you the Number 1, 2 and 3. I think 4 is a good one since I always look how to not depend to human to do the things right, correctly or as expected.

To find a root cause to a certain level, I always look how to not depend to operator.

Currently, we have issues with wrong-incorrect parameters set up to machine. Units were processed with wrong parameters and line clearance approved. So, anyone does not detected it at the beginning of the work order, it was detected later. So instead of be a failure of employee to set up a parameter, why does the machine does not stop by a change on their output? Is there a possibility to have alarm limits so robust enough to detect a wrong parameter?. So I think that Root Cause that units were processed with other parameters is because limits are not robust enough. This is not a final decision, I am working on it to decide if took it as RCA or keep it looking.

The previous was an example.
 

toniriazor

Involved In Discussions
#4
Hi, I share with you the Number 1, 2 and 3. I think 4 is a good one since I always look how to not depend to human to do the things right, correctly or as expected.

To find a root cause to a certain level, I always look how to not depend to operator.

Currently, we have issues with wrong-incorrect parameters set up to machine. Units were processed with wrong parameters and line clearance approved. So, anyone does not detected it at the beginning of the work order, it was detected later. So instead of be a failure of employee to set up a parameter, why does the machine does not stop by a change on their output? Is there a possibility to have alarm limits so robust enough to detect a wrong parameter?. So I think that Root Cause that units were processed with other parameters is because limits are not robust enough. This is not a final decision, I am working on it to decide if took it as RCA or keep it looking.

The previous was an example.
Hello, try to modify software of machine or contact machine manufacturer so you could have as a job-starter option the OK values of the product. Meaning operator has to carry out certain checks and measurements and input them in the software as OK and NOK. If NOK machine will not start. Include this in your control plan and operation standard. Negative side of it is that when they learn the values by heart they just put them without doing the measurements and checks, but this discipline issue can be improved by frontman or leader of the production line with continuous work with the people on the machines.
 

outdoorsNW

Quite Involved in Discussions
#5
If the problem is two or more parts that won't fit together correctly, make sure you check out both sides. Sometimes people jump to the conclusion that one of the two parts is the problem when actually the mating part is the problem. You also need to check any fasteners.

People often jump to the conclusion the mass produced part is not defective and focus on custom or low volume items. While a mass produced part is typically less likely to be the problem, mass produced parts can have defects.
 
Thread starter Similar threads Forum Replies Date
P Tactics to work with Design Engineering on CAR Nonconformance and Corrective Action 3
P Tactics to get cooperation from Contract Manufactuers Manufacturing and Related Processes 6
N Scouting Potential Suppliers - Strategy and Tactics Supplier Quality Assurance and other Supplier Issues 7
H Getting Things Started ? QM, Tactics, Strategy, Acceptance vs. Gridlock, Enthusiasm Quality Manager and Management Related Issues 3
ScottK Political Smear Tactics - how do they affect you? Coffee Break and Water Cooler Discussions 4
M Root cause General Auditing Discussions 6
J NADCAP Root Cause - Misinterpretation of Checklist Requirement Various Other Specifications, Standards, and related Requirements 5
B NADCAP Rejection Response to Root Cause Analysis and Corrective Action. Nonconformance and Corrective Action 1
Lee Taylor Indentifying human error as a root cause Human Factors and Ergonomics in Engineering 34
K HR concerns with listing human factors as root cause Problem Solving, Root Cause Fault and Failure Analysis 11
qualprod What is exactly the root cause? Nonconformance and Corrective Action 9
M Test failure Root cause not found Customer Complaints 10
Tagin You're Gonna Need a Bigger Root Cause Coffee Break and Water Cooler Discussions 12
Q IATF audit - Root Cause Analysis results IATF 16949 - Automotive Quality Systems Standard 5
S Knee Implant (Femoral -Cobalt chrome)-Sub chronic toxicity test (ISO 10993-11)choice of root Medical Device and FDA Regulations and Standards News 2
qualprod D5 of 8D clarification, how to verify root cause Problem Solving, Root Cause Fault and Failure Analysis 26
W Misinterpretation of requirement acceptable as root cause? Problem Solving, Root Cause Fault and Failure Analysis 19
T Root Cause Failure Analysis - Not following Customer packaging Specification Problem Solving, Root Cause Fault and Failure Analysis 9
D Root Cause for Missed Audits Misc. Quality Assurance and Business Systems Related Topics 1
qualprod Always one root cause? ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 35
I Root Cause Analysis as Training ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 10
F Struggling with a root cause analysis - Customer Returns - Escape issue Problem Solving, Root Cause Fault and Failure Analysis 15
G Working on a Root Cause Problem Solving, Root Cause Fault and Failure Analysis 11
I Root Cause Analysis when someone simply stops performing a task? ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 16
C Neglect or legitimate deferral? Is excessive workload or lack of resources in a department or a team a valid root cause for a non-conformance? Problem Solving, Root Cause Fault and Failure Analysis 12
E CAR (Corrective Action Report) with questionable Root Cause ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 16
S Root cause analysis - The system of developing a work instruction is not effective Problem Solving, Root Cause Fault and Failure Analysis 1
I What if your root cause analysis is -- they just didn't do it?" Nonconformance and Corrective Action 3
T Root causes - operator's actions Problem Solving, Root Cause Fault and Failure Analysis 17
Ed Panek Root Cause CAPAs from internal audit ISO 13485:2016 - Medical Device Quality Management Systems 16
A Interesting Discussion Human Factors as Root Cause AS9100, IAQG, NADCAP and Aerospace related Standards and Requirements 13
D Root Cause on Non-Conformity Against Quality Manual Problem Solving, Root Cause Fault and Failure Analysis 9
A CAR from 3rd party AS9100D auditor - Root cause dilemma AS9100, IAQG, NADCAP and Aerospace related Standards and Requirements 45
P Examples of Nonconformance, Corrective Action Requests, and Root Cause Analysis Nonconformance and Corrective Action 2
N The known set of all root causes Nonconformance and Corrective Action 11
Q Loss of Personnel - Root Cause Analysis ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 8
P Root Cause for a Process Validation Batch Failure 21 CFR Part 820 - US FDA Quality System Regulations (QSR) 2
H How to define Root Cause when some points are out of control chart Statistical Analysis Tools, Techniques and SPC 6
K What is supposed to happen when a CA cannot be closed out or the root cause... General Auditing Discussions 1
T Human Error vs Technique Root Cause (Categories) Human Factors and Ergonomics in Engineering 9
Q Several Nonconformances with same Root Cause with just one CA ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 15
D Customer Audit - Root Cause Help - ISO 9001:2008 Cl. 7.5.3 ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 10
Q Risk Tools in ISO 31010 - Root Cause Analysis vs. Cause-and-effect Analysis ISO 9000, ISO 9001, and ISO 9004 Quality Management Systems Standards 1
E Root Cause Analysis - Is Insufficient Understanding an acceptable Root Cause? General Auditing Discussions 9
N Root Cause Challenge: The guy at the top ... Problem Solving, Root Cause Fault and Failure Analysis 4
V Root Cause help needed - Sheet metal breaking at press Problem Solving, Root Cause Fault and Failure Analysis 9
W Root Cause Analysis Requirements per TS 16949:2009 Problem Solving, Root Cause Fault and Failure Analysis 8
S Preparing a Root Cause Report - Possible Root Causes Document Control Systems, Procedures, Forms and Templates 11
Marc Stem Cell stimulation to end tooth Root Canals World News 0
J Required on-site training on writing deviations & root-cause analysis Training - Internal, External, Online and Distance Learning 3

Similar threads

Top Bottom