Corrective Action And Root Cause Analysis

Corrective Action and Root Cause Analysis

By Sam Lines, Concrete Sealants

Agenda Overview

• Nonconformances• Corrective Action Process• Root Cause Analysis• Cost of qualityValue

Opener

LEAKING JOINT

Opener

PROBLEM SOLVED! RIGHT?

NONCONFORMANCES

Nonconformances

• What are non-conformances?– Product does not match specification

• Discovered by inspection– Pre-pour– Post pour– Final

• Discovered by an external source– NPCA Plant Certification Audit– DOT Inspector

• Discovered by the customer

– Product’s form, fit, or function has been altered

Bad Forms = Bad Product

Enough Steel?

Leaking at Honeycomb

Poor Consolidation?

Insufficient Cover

Rebar

Where’s My Hammer?

Nonconformances

• Formwork• Concrete• Blockouts and cast in items• Drawings• Sales Order• Other?

Nonconformances

• Material from supplier– Incoming inspection– Setup and installation– Mill Certificates

• Traceability Question: What products might contain material from nonconforming lot? Do you know?

Nonconformances

• Where is the product?• Is the product quarantined?• Are any other products affected?• Are bad products still being produced?• Were nonconforming products shipped?

Don’t spend your time determiningwho was at fault.

Now, let’s solve the problem.

Traditional Problem Solving

Don’t Mess With It!

YES NO

YESYOU IDIOT!

NO

Look The Other Way

Anyone ElseKnows?

You’re SCREWED!YES

NO

Hide ItCan You Blame Someone Else?

NO

NO PROBLEM!

Yes

Is It Working?

Did You Mess With It?

The Traditional Way

Event(Problem)Form Team

Identify ProblemGather DataAnalyze Data

Determine CausesDetermine Corrective Action

Implement(fix It)

A Better Way:

The Corrective Action Process

Corrective Action Process

• What is it?• Why is it needed?• When is it used?• Who performs it?• How is it performed?• What documentation is needed?• Correction vs. Corrective Action

THE STEPS WITHIN THE PROCESS

Corrective Action Process

Corrective Action Process

• Problem Identification– Who, what, where, when, why, and how– Is the problem isolated?

• Problems with significant risk need corrective action

– Has this happened before? Recently?• Reoccurring problems need corrective action

– Use statistics to evaluate trends• Trends will show a process which is out of control where

corrective action is needed

• Document the corrective action on a form.• Assign responsibility for the activity.• Track corrective actions using a master list.

ST

EP

1

Document the Problem

Corrective Action Process

• Short term remedy (immediate fix)– Repair product– Quarantine bad product(s)– Stop producing bad product– Evaluate extent of problem– Has any bad product been shipped?– Notify customers as necessary

ST

EP

2

Corrective Action Process

• Root Cause Analysis– A process of determining what

underlying cause or causes are responsible

– Tools:• Fishbone Diagram• 5 Whys• Flowchart• Pareto Diagram

– Document the Analysis

ST

EP

3 We will learn more about how to perform a root cause analysis in

later slides.

Corrective Action Process

• Implementation of the action– Eliminate root cause

• Training• Procedures• Work instructions• Visual indicators• Mistake proof

– Document actions taken– Evaluate the effectiveness of the actions

ST

EP

4

ROOT CAUSE ANALYSISCorrective Action Process

Definition

• What is root cause analysis?

“Root cause analysis is the process of defining all of the major and minor causation factors, and then determining the one or ones that, if eliminated, would prevent a future nonconformance.”

The Problem Solving Funnel

Tools

• Cause and Effect Diagram, Ishikawa Diagram, Fishbone Diagram

Why is my toast burnt?

• Effect: Burnt Toast• Main Cause

Categories:– People– Equipment– Methods– Materials

People

• I don’t usually make the toast– My wife is out of town– I was not trained on this toaster

• My wife assumed I was smarter than the toaster– Assumptions are bad!

Equipment

• The toaster is old– The toaster is full of bread crumbs

• The toaster is not maintained– I didn’t know it mattered– My wife wasn’t complaining about it

» She knows what she’s doing

• The settings were changed– A different material was used last time– There are no instructions

Methods

• There are no work instructions– I thought it seemed easy

• I am smarter than a toaster– Re-evaluate my self worth

• I didn’t adjust the settings– Don’t know what setting it

should be• Lack of instructions

Materials

• The bread is stale.– Didn’t use it fast enough

• Not home for breakfast– Leave early for work

» Working on a special project

• The bread is thinner than usual– We change brands

• Save money

Cause and Effect: Burnt Toast

BurntToast

PeopleEquipment

Methods Materials

I don’t usually make the toast

I was not trained on this toaster

My wife assumed I was smarter than the toaster

Bad assumption

The toaster is old

The settings were changed

The toaster is full of bread crumbs

I didn’t know it mattered

My wife hadn’t complained

She knows what she’s doing

Material is different

No instructions

No instructionsDidn’t change the settings

Don’t know what setting to use

No instructions

Thought it was easy

Lack of knowledge

Need training

Thinner bread

Changed brand

Save money

Stale bread

Didn’t use it fast enough

Not home for breakfast

Leave early for work

Special project

5 Why’s

• Ask “Why” 5 times• Best used when people are involved• Great for auditing a process to gain

understanding• Can be 4 or 6 why’s Why?

5 Why’s

Problem Statement: You are on your way home from work

and your engine dies.

1. Why did your engine die?

  - Because your car ran out of gas.

2. Why did your car run out of gas?

  - Because I didn't buy any gas on my way to work.

3. Why didn't you buy any gas this morning?

  - Because I didn't have any money.

4. Why didn't you have any money?

  - Because I lost it all last night in a poker game.

5. Why did you lose your money in last night's poker game?

  - Because I'm not very good at "bluffing“.

Solution

• Good solution: Stop bluffing

• Better solution: Set a dollar limit

• Best solution: Stop playing poker for

money

Other Problem Solving Tools

• 8D Method– Developed by Ford in the 80’s

• A3 Format– Uses A3 Size paper (11” x 17”)– Used extensively by Toyota

• Process Cause and Effect– Follows the process to find out where

mistakes can happen.

Example of an A3

Example of Process Cause and Effect

Inputs Process Outputs

What can go wrong

What can go wrong

What can go wrong

What can go wrong

What can go wrong

What can go wrong

Eliminate the Root Cause

• Implement action based on root cause analysis– Creation of instruction– Training of operator(s)

• Verify effectiveness– Increase inspection (temporary or long term)– Create a metric for evaluation– Audit the process in 1, 3, and 6 months

Mistake Proofing

– Poka yoke: the Japanese work for mistake proofing• Go / no-go gauge• Warning lights• Color coding

– Proportionate to the risk and/or cost of a future failure

Examples of Poka-Yoke

Lights and gauges

Tethers and holders

Posted Signs and Instructions

• Stop lights• Spell Cheker• “Lights on” warning buzzer• “Auto-off” on coffee maker• Pictures and signs• Color coded bins and instructions

Poka Yoke Rules

THE VALUE OF QUALITYCorrective Action Process

“Quality is free. It’s not a gift, but it is free. What costs money are the unquality things – all the actions that involve not doing the job right the first time.”

Phillip Crosby

Defect Escalation Cost

Order En-try

Design Pre-pour Inspection

Post-pour Inspection

Delivery $-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$1 $10 $100

$1,000

COSTS

COSTS

Cost of Quality

Prevention Costs Appraisal Costs+ Failure Costs

Total Quality Costs

Cost of Quality

Prevention Costs: The costs of all activities specifically designed to prevent poor quality in products or services.

Examples: – New product review – Quality planning – Supplier capability surveys – Process capability evaluations – Quality improvement team activities – Quality improvement projects – Quality education and training

Cost of Quality

Appraisal Costs: The costs associated with measuring, evaluating or auditing products or services to assure conformance to quality standards and performance requirements.

Examples: – Incoming and source inspection/test of purchased material – In-process and final inspection/test – Product, process or service audits – Calibration of measuring and test equipment – Associated supplies and materials

Cost of Quality

Failure Costs: The costs resulting from products or services not conforming to requirements or customer/user needs.

• Internal Failure Costs: Failure costs occurring prior to delivery or shipment of the product, or the furnishing of a service, to the customer. Examples:

– Scrap

– Rework

– Re-inspection

– Re-testing

– Material review

– Downgrading

Cost of Quality

• External Failure Costs: Failure costs occurring after delivery or shipment of the product; and during or after furnishing of a service to the customer. Examples:

– Processing customer complaints

– Customer returns

– Warranty claims

– Product recalls

Cost of Quality - Optimized

Optimum Level of Service Quality

Low High

Low

High

Quality

Cost

Total Cost of Quality

Cost of Quality Management

Minimum Cost of Quality

Cost of Service Defects

Where you want to be

Cost of Quality – Trifecta

Investment in a quality strategy will yield:– Lower defects– Reduce cycle time to delivery– Improve customer satisfaction– Higher employee morale

Value of Quality

• Save 10% (or more) from:– Reduction of waste, scrap, and repairs– Less variability in processes– Less time fixing, more time producing– Reduced incoming material problems– Reduced overtime– Reduced warranty and service calls

Conclusion

• A corrective action program is simple to implement and easy to use.

• Eliminating the root cause is essential in preventing future nonconformances.

• Preventing problems saves money.

Questions