Root Cause Analysis Tutorial
Root cause analysis tutorial is designed by TONEX to help you self-educate yourself on the concepts, definition, tools, methods, application, and process of root cause analysis (RCA). Let us start with understanding what we exactly mean by root cause analysis.
Root Cause Analysis Definition
Root cause analysis is the process of investigating a failure, problem, or accident in order to discover the real reason caused such undesirable, harmful, and often dangerous situation. We start with studying the surface symptom(s) of the problem and then will get deep to the bottom of the problem at the roots to find out the underlying cause(s) of the problem, eliminate them, and make sure they will never happen again in the future. You might now notice that you do this for many of the problems that occur in your routine life and never had thought about the name and meaning of it as root cause analysis. As simple as it sounds, the RCA process often becomes very challenging for more complex cases where there are more than one underlying cause associated with a problem, including latent ones difficult to identify. Such multiple, tangled underlying causes usually have impacts on each other and on the entire system, which make them challenging to eliminate and to develop corrective and preventive actions plan for them.
Root cause analysis helps you save time and money because when you identify the real problem and eliminate it, you will save the maintenance time and labor costs in the future, plus your warranty claim costs will go down, along with the extra costs you would pay to attract your customers’ satisfaction after they became upset due to the poor quality of your products. In fact, root cause analysis significantly improves the quality of your products, processes and services, too.
Root Cause Analysis Major Tools
There are several tools and techniques used in root cause analysis projects, which vary by the nature of the problem and industry the RCA is applied in. Below are some of the essential tools and techniques of RCA:
- 5 Why’s, aka Gemba Gembutsu
- Pareto Analysis
- Fishbone Diagrams, aka cause-and-effect or Ishikawa Diagrams
- Flowcharting and Cause Mapping
- Fault Tree Analysis
- Check Sheets
- Control Charts
- Quality Planning
- Failure Mode and Effect Analysis (FMEA)
- Barrier Analysis
- Change Analysis
- Causal Factor Tree Analysis
- Statistical Methods such as t and NOVA tests
Some of the tips you should take into consideration:
- The correctness and effectiveness of root cause analysis fully depends on the type of data you collect and how you do it
- Not knowing can significantly harm the root cause analysis project
- Explore and discover exactly what and how the targeted problem or incident happened
- In case of using interviews, develop effective and useful questionnaires
- Know that human-source errors and problems can not be fixed with punishment, they require patience, training and careful leadership. And even with these, they will always happen even if everybody is being cautious and careful
- Train your eyes to really “see” effective corrective actions after identifying the root causes (your employees often don’t)
Root Cause Analysis Procedure
- Step I- Identify the problem
- Step II- Assess the importance and severity of the problem
- Step III- Research and collect data
- Step IV- Evaluate and analyze the collected data
- Step V- Identify the underlying cause(s)
- Step VI- Come up with possible solutions
- Step VII- Develop a corrective and preventive actions plan
- Step VIII- Implement the plan
- Step IX- Monitor the effectiveness of the plan
- Step X- Document the process for the future references
Case Study: Deepwater Horizon Oil Spill
|What||Well blowout, explosion|
|When||April 20, 2010|
|Unusual||Confusing pressure test results|
|Where||Gulf of Mexico|
|Unit, Area||Deepwater horizon rig|
|Task performed||Final stage drilling of exploratory well|
Impact to the Goals:
|Safety||11 fatalities, 17 injured|
|Environment||~4.9 M barrels oil spilled|
|Customer Service||Negative publicity and loss of value share|
|Regulatory||All new drillings stopped in Gulf of Mexico|
|Production Status||Production stopped|
|Losses||Total loss of the oil rig|
|Labor, Time||Cleanup, response|
Recommended Solutions (Corrective Actions Plans)
- Applying functionality inside the blowout preventer (BOP) that had failed to seal the well
- Installing a cofferdam over the leak and distract the spilled oil to a surface ship
- Using a Riser Insertion Tube Tool (RITT) that would tap some of the flow from the end of the riser and send it to a surface ship for collection.
- Ending the flow from the leaking well by stuffing heavy mud and cement directly into the well itself.
- Seizing all the flow by using a 3-ram capping stack, or “sealing cap”.
- Drilling of relief wells, pumping mud, then cement, down into the leaking reservoir, a permanent fix to the spill (known as a “static kill”). This plan was finally selected to implement.
How Can You Learn More about Root Cause Analysis?
TONEX offers multiple training courses suitable for different group of audiences. Search through the following list and find what serves you the best:
Root Cause Analysis Tutorial