The document provides an overview of root cause analysis (RCA) used to identify and address problems. It discusses why RCA is performed, the typical steps which include identifying the problem, collecting data, identifying causal factors and the root cause, and recommending solutions. Several tools used in RCA are also outlined, such as fishbone diagrams, 5 whys, fault tree analysis, and failure mode and effects analysis (FMEA). The document provides examples of how these tools can be applied to identify root causes and prevent future issues.
1. ROOT CAUSE ANALYSIS
RCA
PREPARED BY:ENG.: WALEED EL
SAYED
“Failure is the opportunity to begin again more
intelligently”
Henry Ford (1863-1947)
CHIEF ENGINEER
MBA
7. 3: IDENTIFY CAUSAL FACTORS
• Involve all again.
• Be neutral again.
• Ishikawa diagram.
• 5 Why’s?
• Identify possible cause.
•What sequence of events leads to the problem?
•What conditions allow the problem to occur?
•What other problems surround the occurrence of the central
problem?
Immediate event/condition that
caused accident
Direct
Cause
Event/condition that increased
probability or severity of the
accident.
Contributi
ng Cause
Event/condition that, if corrected,
will prevent recurrence.
Root
Cause
8. 4: IDENTIFY THE ROOT CAUSE
• Validate & differentiate.
• May be multiple.
• Ask? & Answer!!
9. 5: RECOMMEND & IMPLEMENT SOLUTIONS
• Set a clear (SMART) steps
for the solution.
• Assign responsibility.
• Go through solution
assessment.
• Improve again & again.
10. Corrective
Action
• Is designed to eliminate the
reoccurrence of a non-
conformity.
Preventive
Action
• Is designed to eliminate the
occurrence.
16. 5 WHY’S?
• Why won’t the car start?
The engine won’t turn over.
• Why the engine won’t turn
over?
The battery is dead.• Why the battery is dead?
The alternator is not
functioning.• Why the alternator is not
functioning?
The belt is broken.• Why the belt is broken?
The belt was not replaced according to the manufacture’s
maintenance schedule.
17. FAULT TREE ANALYSIS
• Top down analysis.
• Start with the system failure &
work down to the root cause.
• Uses common logic symbols.
20. A STRUCTURED APPROACH TO:
• IDENTIFYING THE WAYS IN WHICH A PRODUCT OR PROCESS
CAN FAIL.
• ESTIMATING RISK ASSOCIATED WITH SPECIFIC CAUSES.
• PRIORITIZING THE ACTIONS THAT SHOULD BE TAKEN TO
REDUCE RISK.
• EVALUATING DESIGN VALIDATION PLAN (DESIGN FMEA) OR
CURRENT CONTROL PLAN (PROCESS FMEA).
• FIRST USED IN THE 1960’S IN THE AEROSPACE
INDUSTRY DURING THE APOLLO MISSIONS
• IN THE LATE 1970’S, THE AUTOMOTIVE INDUSTRY
WAS DRIVEN BY LIABILITY COSTS TO USE FMEA
• LATER, THE AUTOMOTIVE INDUSTRY SAW THE
ADVANTAGES OF USING THIS TOOL TO REDUCE RISKS
RELATED TO POOR QUALITY
21. SEVERITY, OCCURRENCE,
AND DETECTION
• SEVERITY
• IMPORTANCE OF THE EFFECT ON CUSTOMER REQUIREMENTS.
• OCCURRENCE
• FREQUENCY WITH WHICH A GIVEN CAUSE OCCURS AND
CREATES FAILURE MODES (OBTAIN FROM PAST DATA IF POSSIBLE).
• DETECTION
• THE ABILITY OF THE CURRENT CONTROL SCHEME TO DETECT
(THEN PREVENT) A GIVEN CAUSE (MAY BE DIFFICULT TO ESTIMATE EARLY IN
PROCESS OPERATIONS).
22. RATING SCALES
• SEVERITY
• 1 = NOT SEVERE, 10 = VERY SEVERE
• OCCURRENCE
• 1 = NOT LIKELY, 10 = VERY LIKELY
• DETECTION
• 1 = EASY TO DETECT, 10 = NOT EASY TO DETECT
RISK PRIORITY NUMBER (RPN)
Severity Occurrence Detection RPNX X =
23. Identify failure modes and their
effects
Identify causes of the failure
modes
and controls
Prioritize
Determine and assess actions