Root cause analysis apr 2010
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The document outlines a workshop on root cause analysis led by Michael Sahota, focusing on techniques such as the '5 Whys' and the fishbone diagram to identify and mitigate problems. It emphasizes a 'no blame' policy and the importance of systems thinking, encouraging participants to ensure a culture of safety and trust. Additionally, the document stresses continuous improvement and the necessity of shared goals for achieving sustainable success in quality and efficiency.
Root cause analysis apr 2010
- 1. Root Cause Analysis Workshop Michael Sahota
- 2. Overview Stop the line quality, speed Root cause thinking Tool #1: ask “Why?” 5 times Tool #2: fishbone diagram Additional considerations make this work
- 4. Stop the Line to improve quality, reduce waste and go faster When there is a problem No problem is a problem! Image by http://www.exchange3d.com
- 5. Find the root cause and invent countermeasures to mitigate it Surface problems are only symptoms “ Putting out the fire” will only mask the problem Every problem has one or more root causes Find countermeasures for these so that they do not recur
- 6. Caution: countermeasures obey the law of unintended consequences Not helpful to think about “fixing problems” Not permanent; a step in working towards perfection Think of countermeasures that mitigate problems Be open to multiple possibilities Everything we do has consequences, so we may be introducing our next problem Examples: rabbits in Australia, Streisand effect
- 7. Goal is to identify the problem and find countermeasures - not to blame people “ No blame” policy “ Everyone is doing the best they can with the resources they have” Systems thinking is a good model How has the system functioned to bring about this result? For this to work, people need to feel safe and trust one another
- 8. Tool #1: ask “Why?” 5 times to uncover details Start with the problem and ask “Why” 5 times Sounds simple and takes practice Requires creative thinking Use beginners mind to avoid the expert trap
- 9. Example of Jeff Bezos – CEO at Amazon.com asking “Why?” to find the root cause Why did the associate damage his thumb? Because his thumb got caught in the conveyor. Why did his thumb get caught in the conveyor? Because he was chasing his bag, which was on a running conveyor. Why did he chase his bag? Because he placed his bag on the conveyor, but it then turned-on by surprise Why was his bag on the conveyor? Because he used the conveyor as a table http://www.shmula.com/987/jeff-bezos-5-why-exercise-root-cause-analysis-cause-and-effect-ishikawa-lean-thinking-six-sigma
- 10. Countermeasures identified at Amazon Provide portable, light tables Greater focus on safety training Look into accident prevention as standard work http://www.shmula.com/987/jeff-bezos-5-why-exercise-root-cause-analysis-cause-and-effect-ishikawa-lean-thinking-six-sigma
- 11. Exercise: Find a partner, pick a problem and ask why 5 times
- 12. Tool #2: fishbone (Ishikawa) diagram facilitates looking at the big picture
- 13. Demo: Fishbone with Amazon Example
- 15. Additional considerations to make this work…
- 16. Go and see (Genchi Genbutsu) – Go to the source to see the facts for yourself Often when performing root cause analysis you will not know the answer Beware of data someone else has prepared Get the Facts! – Go and see for yourself Look, See, Understand Think for yourself
- 17. Kaizen – continuous improvement in the pursuit of perfection "A journey of a thousand miles must begin with the first step.“ - Lao Tzu Ask small questions Take small actions Solve small problems Constraints: Spend no Money Add no People Add no Steps http://www.shmula.com/1112/the-atomic-rules-of-kaizen
- 18. Everyone needs to work towards shared goals of quality for this to be successful 1 person @ 100% will not have sustained success Toyota has proven 100 people @ 1% works Successful companies build people Culture of empowerment Ownership of problems and countermeasures
- 20. What questions do you have?