ASQ Pocket Guide to Root Cause Analysis

Tom Fagerhaug, Bjorn Andersen

Description

All organizations experience unintended variation and its consequences. Such problems exist within a broad range of scope, persistence, and severity across different industries. Some problems cause minor nuisances, others leads to loss of customers or money, others yet can be a matter of life and death.
The purpose of this pocket guide is to provide you with easily accessible knowledge about the art of problem solving, with a specific focus on identifying and eliminating root causes of problems.
Root cause analysis is a skill that absolutely everybody should master, irrespective of which sector you work in, what educational background you have, and which position in the organization you hold. The content in this little pocket guide can contribute to disseminating this skill a little further in the world.

Sujets

• Business
• Qualité, hygiène, sécurité, environnement
• Techniques
• Automatisation et Contrôle
• Problem Solving
• Decision-Making
• Gestion et management
• Economics
• ASQ

Informations

• Publié par: ASQ Quality Press
• Date de parution: 18 octobre 2013
• Nombre de lectures: 0
• EAN13: 9781951058937
• Langue: English
• Poids de l'ouvrage: 2 Mo

Extrait

ASQ Pocket Guide to Root Cause Analysis

Aso avaiabe from ASQ Quaity Press: Root Cause Analysîs: Sîmplîfîed Tools and Technîques, Second Edîtîon Bjørn Andersen and Tom Natand Fagerhaug Root Cause Analysîs and Improvement în the Healthcare Sector: A Step-by-Step Guîde Bjørn Andersen, Tom Natand Fagerhaug, and Marti Betz Busîness Process Improvement Toolbox, Second Edîtîon Bjørn Andersen Mappîng Work Processes, Second Edîtîon Bjørn Andersen, Tom Natand Fagerhaug, Bjørnar Henriksen, and Lars E. Onsøyen The ASQ Qualîty Improvement Pocket Guîde: Basîc Hîstory, Concepts, Tools, and Relatîonshîps Grace L. Duffy, editor The Qualîty Toolbox, Second Edîtîon Nancy R. Tague Root Cause Analysîs: The Core of Problem Solvîng and Correctîve Actîon Duke Okes The ASQ Pocket Guîde for the Certîfîed Sîx Sîgma Black Belt T.M. Kubiak The Qualîty Improvement Handbook, Second Edîtîon ASQ Quaity Management Division and John E. Bauer, Grace L. Duffy, Russe T. Westcott, editors Process Improvement Usîng Sîx Sîgma: A DMAIC Guîde Rama Shankar The Certîfîed Manager of Qualîty/Organîzatîonal Excellence Handbook, Fourth Edîtîon Russe T. Westcott, editor Faîlure Mode and Effect Analysîs: FMEA From Theory to Executîon, Second Edîtîon D. H. Stamatis

To request a compimentary cataog of ASQ Quaity Press pubications, ca 800-248-1946, or visit our Web site at http://quaitypress.asq.org.

ASQ Pocket Guide to Root Cause Analysis

Bjørn Andersen and Tom Natland Fagerhaug

ASQ Quality Press Milwaukee, Wisconsin

American Society for Quality, Quality Press, Milwaukee, WI 53203 © 2014 by ASQ All rights reserved. Published 2013. Printed in the United States of America.

18 17 16 15 14 13 5 4 3 2 1 Library of Congress CataloginginPublication Data

Andersen, Bjørn. ASQ pocket guide to root cause analysis / Bjørn Andersen and Tom Natland Fagerhaug.  pages cm ISBN 9780873898638 (pocket guide: alk. paper) 1. Total quality management. 2. Problem solving. 3. Quality control. I. Fagerhaug, Tom, 1968 II. Title. HD62.15.A528 2013 658.4’013—dc23  2013034268

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To place orders or to request ASQ membership information, call 8002481946. Visit our Web site at www.asq.org/qualitypress.

Printed on acidfree paper

Contents

Lîst of Fîgures and Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introductîon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Root Cause Anaysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  The Root Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Root Cause Eimination . . . . . . . . . . . . . . . . . . . . . . . .  The RCA Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Root Cause Anaysis Steps . . . . . . . . . . . . . . . . . . . . .  The Logistics of a Root Cause Anaysis . . . . . . . . . . . .

Section II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Step 1: Define the Event. . . . . . . . . . . . . . . . . . . . . . . . . .  Purpose of Step 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Substeps in Step 1 . . . . . . . . . . . . . . . . . . . . . . . . . . .  Checkist for Step 1 . . . . . . . . . . . . . . . . . . . . . . . . . .  Step 2: Find Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Purpose of Step 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Substeps in Step 2 . . . . . . . . . . . . . . . . . . . . . . . . . . .  Checkist for Step 2 . . . . . . . . . . . . . . . . . . . . . . . . . .

v

vîî îx 1 1 3 5 6 6 12

15 15 15 16 30 30 30 31 42

vi Contents

 Step 3: Find the Root Cause . . . . . . . . . . . . . . . . . . . . . . . 43  Purpose of Step 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43  Substeps in Step 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 44  Checkist for Step 3 . . . . . . . . . . . . . . . . . . . . . . . . . . 65  Step 4: Find the Soution(s). . . . . . . . . . . . . . . . . . . . . . . . 66  Purpose of Step 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66  Substeps in Step 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . 67  Checkist for Step 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 77  Step 5: Take Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78  Purpose of Step 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78  Substeps in Step 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . 79  Checkist for Step 5 . . . . . . . . . . . . . . . . . . . . . . . . . . 91  Step 6: Measure and Assess . . . . . . . . . . . . . . . . . . . . . . 92  Purpose of Step 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92  Substeps in Step 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . 92  Checkist for Step 6 . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Section III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 99RCA Exampe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99  Define the Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101  Find Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101  Attempt 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102  Find the Root Cause . . . . . . . . . . . . . . . . . . . . . . . 102  Find Soutions . . . . . . . . . . . . . . . . . . . . . . . . . . . 110  Take Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110  Measure and Assess . . . . . . . . . . . . . . . . . . . . . . 110  Attempt 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111  Find the Root Cause . . . . . . . . . . . . . . . . . . . . . . . 111  Find Soutions . . . . . . . . . . . . . . . . . . . . . . . . . . . 113  Take Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114  Measure and Assess . . . . . . . . . . . . . . . . . . . . . . 114 Conclusîon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Figure 1 Figure 2 Tabe 1 Figure 3 Tabe 2 Tabe 3 Tabe 4 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Tabe 5

List of Figures and Tables

Cause eves . . . . . . . . . . . . . . . . . . . . . . . . . . . Root cause anaysis steps . . . . . . . . . . . . . . . . . Root cause anaysis steps . . . . . . . . . . . . . . . . . RCA team mandate tempate . . . . . . . . . . . . . . . RCA team composition tempate . . . . . . . . . . . . Gantt chart exampe . . . . . . . . . . . . . . . . . . . . . Gantt chart tempate . . . . . . . . . . . . . . . . . . . . . Precise description of event . . . . . . . . . . . . . . . . Customer satisfaction survey. . . . . . . . . . . . . . . Mapping eves . . . . . . . . . . . . . . . . . . . . . . . . . Fow chart symbos . . . . . . . . . . . . . . . . . . . . . . Fow chart exampe . . . . . . . . . . . . . . . . . . . . . . Fishbone diagram exampe . . . . . . . . . . . . . . . . Fishbone diagram tempate . . . . . . . . . . . . . . . . Cause-and-effect tree exampe . . . . . . . . . . . . . Five Whys exampe . . . . . . . . . . . . . . . . . . . . . . Faut tree exampe . . . . . . . . . . . . . . . . . . . . . . . Cat studio data . . . . . . . . . . . . . . . . . . . . . . . . .

vii

4 7 9 19 20 23 24 26 29 32 34 35 40 41 47 51 54 55

viii Lîst of Fîgures and Tables

Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Tabe 6 Tabe 7 Figure 21 Figure 22 Figure 23 Figure 24 Figure 25 Figure 26 Figure 27 Tabe 8 Tabe 9 Figure 28 Figure 29 Figure 30 Figure 31

Pareto chart exampe. . . . . . . . . . . . . . . . . . . . . 56 Pareto chart tempate . . . . . . . . . . . . . . . . . . . . 57 Scatter chart exampe . . . . . . . . . . . . . . . . . . . . 59 Scatter chart tempate . . . . . . . . . . . . . . . . . . . . 60 Histogram exampe . . . . . . . . . . . . . . . . . . . . . . 62 Histogram tempate . . . . . . . . . . . . . . . . . . . . . . 62 Probem concentration diagram exampe . . . . . . 64 “Why Not” principes exampe . . . . . . . . . . . . . . 75 “Why Not” principes tempate . . . . . . . . . . . . . . 76 Impact effort matrix tempate. . . . . . . . . . . . . . . 81 Impact effort matrix exampe . . . . . . . . . . . . . . . 83 Force fied anaysis exampe . . . . . . . . . . . . . . . 85 Force fied anaysis tempate . . . . . . . . . . . . . . . 85 Impementation pan/project proposa exampe . 88 Process ayout diagram . . . . . . . . . . . . . . . . . . . 102 Data coection. . . . . . . . . . . . . . . . . . . . . . . . . . 104 Simpified samping check sheet . . . . . . . . . . . . 105 Weighted data for samping check sheet . . . . . . 105 Fim strip histogram. . . . . . . . . . . . . . . . . . . . . . 107 CMHSB extruder pictures. . . . . . . . . . . . . . . . . . 109 Conversion ine Five Whys anaysis . . . . . . . . . . 111 Geometry of extrusion too . . . . . . . . . . . . . . . . . 112

Introduction

ecome to the pocket guide to root cause anaysis! W The purpose of this guide is to provide you with easiy accessibe knowedge about the art of probem soving, with a specific focus on identifying and eiminating root causes of probems. This is a ski that absoutey everybody shoud master, irrespective of which sector you work in, what educationa background you have, and which position in the organization you hod. We hope this pocket guide can contribute to disseminating this ski a itte further in the word. We have previousy pubished two traditiona books on the subject of root cause anaysis. One, an introduction to RCA, is in its second edition. The other deas with RCA in the heathcare sector specificay. Both were designed to provide practica instruction and advice on how to undertake rea-ife root cause anayses. It seems ogica to take the next step and provide a pocket guide that buids on these books. The strengths of a pocket guide are severa: compact presentation of the materia, a handy format, and easy access to tempates for toos, to name just a few. Readers who are famiiar

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