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Lesson 5C - Tools For RCA Presentation
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Lesson 5C - Tools For RCA Presentation
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What Is a Process? A process is generally defined as a series of steps or actions performed to achieve a specific purpose. The components of a process, including a control process are: ° Input * Transformation * Output INPUT 1¢) mAs TRANSFORMATION OUTPUTTool: The 5 Whys © The 5 Whys is a questions-asking technique used to explore the cause/effect relationships underlying a particular problem, with the goal of determining a root cause of a defect or problem. By repeating why five times, the nature of the problem as wells its solution usually becomes clear. Ask "why" and identify the causes associated with each sequential step towards the defined problem or event. "Why" is taken to mean "What were the factors that directly resulted in the effect?"The 5 Whys — Questions-Asking Method The following examples demonstrates the basic process of the 5 Whys: The vehicle will not start. (the problem) reer ead ceeea ee errr! pipers Coton eometan) Aird yp The worker fell. (the problem) eons ood eta fete oer) renee rid tyTool: Pareto Chart The Pareto Chart illustrates the Pareto principle, frequently referred to as “The 80/20 Rule,” which holds that 20 percent of the population accounts for 80 percent of the situation. The purpose of the Pareto chart is to highlight the most important set of factors or activities that most contribute to a problem or opportunity. PRINGIPLE vl ggPareto Chart A Pareto Chart can be a useful measurement tool for the audit team in an RCA effort. It can focus their attention in the direction of the most important cause or causes to resolve in orderto reduce or eliminate the problem. Thisiis particularly helpful when the teamis: Analyzing data about potential root causes or the frequency of problems. Pareto Cart Type of ror_| Dealing with many different problems and causes but wants to focus on the most significant ones. waa Analyzing wide-reaching causes by zeroing in on their individual componentsSteps for Creating a Pareto Chart 1. Choose the problem and causes that will be compared/rank-ordered by brainstorming, using a fishbone diagram. 2. Choose the time period for the analysis. 6 3. Collect the data 4 Decide on appropriate measurement for your data, e.g, frequency, quantity, cost, time, etc Devise an appropriate scale for your measurements. Decide onthe categories that will be used to group your data items. the far left, descending to the smallest on the far right. 5: 6. 7. Create abarfor each category and add appropriate labels for each, placing the tallest on 8. Calculate the subtotal of each category's measurements. 9: Beginning at the top of the first category bar, draw a line showing the cumulative percentage total reached with the addition of each cause category. . Draw alline at 80% on the y-axis running parallel to the x-axis. Then drop the line at the point of intersection with the curve on the x-axis. This point on the x-axis separates the important causes onthe left from the less important causes on the right.Tool: Fault Tree Analysis Fol ent Frotlnd cae Sod eda ae farted Fhe naeSteps for Performing a Fault Tree Analysis 1. Begin constructing the Fault Tree by stating the problem/issue/undesired event, placing it in the first box, and labeling it the Failure Event. 2. The audit team brainstorms the immediate causes of the problem/issue/undesired event and determines whether an OR gate or AND gate should be applied. 3. Evidence is gathered by the audit team to confirm the paths to follow for OR gates and continue to build out the tree, along with AND gate paths as well. 4. The above process continues down through each level until all relevant causes are identified the root cause(s) are reached. The audit team evaluates the Fault Tree and developsaction plans corresponding to the root cause(s) determined.Tool: Scatter Diagram Ascatter diagram is a type of diagram that displays pairs of data, with one variable on each axis, to look for a relationship between them.Tool: Scatter Diagram Degrees of correlation:.. Brainstorm potential causes and effects for the problem using a fishbone diagram 6 . Identify all potential pairs of cause and effect variables associated . Use existing data or collect new data regarding to what extent Steps for Creating a Scatter Diagram with the problem. causes contribute to the problem Select the most likely pairs of cause and effect variables to verify. Draw a graph with the independent variable on the horizontal axis and the dependent variable on the vertical axis. Select the scales for the xand y axes. Plot the data by putting a dot for each pair of data where the x-axis value intersects the y-axis value. Determine if there is a relationship between the cause and effect, noting whether the points clearly form a line ora curve.Cause Cause is the reason for the difference between the expected and actual conditions. The cause answers the question: “Why?”Identify Causes *° Ask “Why do the conditions exist?” * Identify proximate, intermediate, and root levels of cause. ® Identify which level of cause is actionable.
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