Root Cause Analysis – LCI Congress 2014.pdf Cause... · Root Cause Analysis - LCI Congress 2014 10/8/14 (c) ... Participants will learn how to move from root causes to mitigation
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3 Credit(s) earned on completion of this course will be reported to AIA CES for AIA members. Certificates of Completion for both AIA members and non-AIA members are available upon request.
This course is registered with AIA CES for continuing professional education. As such, it does not include content that may be deemed or construed to be an approval or endorsement by the AIA of any material of construction or any method or manner of handling, using, distributing, or dealing in any material or product. _______________________________________ Questions related to specific materials, methods, and services will be addressed at the conclusion of this presentation.
"5 Why" is a common tool in problem solving, but "5 Why only gets to one root cause - often there are multiple root causes to a project organization problem. For this we need a more robust methodology: Root Cause Analysis. This session will help participants learn deep problem solving skills. Participants will get hands on experience doing a Root Cause Analysis on a real problem in their professional life.
1. Participants will learn how to define a significant project or organization problem by describing the current condition. Participants will learn the general principles of Root Cause Analysis (RCA) as practiced by Toyota and reported by Stephen Spears in "High Velocity Edge.“ 2. Participants will learn how to combine active facilitation, the Fishbone (Ishikawa) Diagram and "5 Why" questioning to achieve identification and evaluation of multiple root causes. 3. Participants will learn how to move from root causes to mitigation measures (without jumping to "solutions" too early). 4. Participants will learn how RCA can move owner-designer-contractor-trades teams to friendly collaboration through hearing a first person account case history of how an RCA resolved a significant issue on a state museum project in Alaska.
At the end of the this course, participants will be able to:
• The objecDve of this session is to teach you how to: – quickly idenDfy a problem, – quickly solve the problem using 5 Why, or – immediately swarm it using Root Cause Analysis,
• and devise and test countermeasures to achieve a Target CondiDon.
• Know how to disDnguish between a problem that can be quickly resolved and one that requires deeper analysis
• Know how beLer to clearly define and state “the problem” • Know how to employ a method called “5 Why” • Understand how to employ methods to dig deeper beyond
the problem’s symptoms to discover true causes • Know how to develop and test miDgaDon measures to
solve defined problems • Know how to employ a method called “Root Cause
At Alcoa, Capability 1: – “If you do not see a problem when and where it occurs and swarm it to inves.gate it, much of the informa.on needed to understand it will perish, spoil, fade and dissipate.
• Once that happens, it becomes impossible to re-‐create the problem, nail down what caused it, and take correc.ve measures that will prevent its recurrence.”
• “By seeing problems and solving them in an accelerated fashion, Alcoa was building process knowledge that was not only hard won, but also scarce and proprietary – unavailable to outsiders who did not make the same efforts.”
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Seeing Problems
“Seeing problems was the prerequisite for the highspeed kaizen (‘conDnuous improvement’) for which Toyota came to be so highly regarded.”
“It’s not that I’m so smart, it’s just that I stay with problems longer…. One should look for what is, and not for what one thinks should be.” – Albert Einstein
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• Problem Solving Template – Background – Current CondiDon – Root-‐Cause Analysis(Diagnosis)
– Countermeasure Treatments
– Target CondiDon – Actual Outcomes – Gap Analysis
• RCA’s iniDal needs: – EffecDve problem statements and event descripDons (as failures, for example)
– sequence of events or Dmeline • to understand the relaDonships between contributory (causal) factors, root cause(s) and the defined problem or event to prevent in the future.
1 Define the problem (describe the event) 2 Gather data and evidence 3 5 Whys 4 Classify causes into causal factors 5 Reveal mulDple root causes 6 IdenDfy all harmful factors (might be causes) 7 IdenDfy correcDve acDons & soluDons 8 Implement them – PDCA
• Classify causes into causal factors that relate to an event in the sequence, and root causes, that if applied can be agreed to have interrupted that step of the sequence chain.
5 – Reveal MulDple Root Causes • If there are mulDple root causes, which is ofen the case,
reveal those clearly for later opDmum selecDon. • IdenDfy all other harmful factors that have equal or beLer
claim to be called "root causes."
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RCA Process Steps 1 Define the problem (describe the event) 2 Gather data and evidence 3 5 Whys 4 Classify causes into causal factors 5 Reveal mulDple root causes
Process Root Cause - 5Whys Analysis With Countermeasures
Analysis Title:
________________________________________________
Date:
Sheet ______ of ______
Categories of Variance 1. Bad Planning 2. Prerequisite Work 3. Design Issue 4. Failed Inspection 5. Labor not Available 6. Materials not Available 7. Equipment not Available 8. Contracts/CO’s/FCO’s 9. SubmiLals 10. Weather 11. I Forgot 12. No Update 13. Unforeseen Conditions 14. Other
RFI on design Issue, conflict W/ Rebar & inserts in IB78
WWP scheduled placement without RFI resolved
IB78 not inspect by structural team in time
Supervision has push culture
Last planner committed to an unsound assignment
WWP process not conducted
Supervision under pressure by owner
Inspection need not communicated to structural team before it was issued
IB78 issued just before scheduled placement
Look-ahead process did not trigger inspection 6 weeks out
Supervision under pressure by owner
Supervision lacks pull plan training or buy-in
Supervision not bought into process
No process to identify sub work impacted by ongoing changes Changes are not
collaboratively designed with subs
Supervision has a push culture
WWP team needs more training
Design coordination not complete in advance of work
Pull Planning not pulling design coordination/information
Look-ahead process not conducted
Look-ahead process only has 2 week window
1
2
1
Owner does not understand Pull Planning and impact of push
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Common Cause (see handout) CombinaDon of 2 or 3 levels using numbers and leLers.
• B1n – Design/SpecificaDon of the Rebar was Ambiguous
• B4o – Design/SpecificaDon of the concrete pour plarorm was not not safe
• Problem Solving Template – Background – Current CondiDon – Root-‐Cause Analysis(Diagnosis)
– Countermeasure Treatments
– Target CondiDon – Actual Outcomes – Gap Analysis
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RCA Process Steps
1 Define the problem (describe the event) 2 Gather data and evidence 3 5 Whys 4 Classify causes into causal factors 5 Reveal mulDple root causes 6 IdenDfy all harmful factors (might be causes) 7 Iden.fy correc.ve ac.ons & solu.ons 8 Implement them – PDCA
• The purpose of idenDfying all soluDons to a problem is to prevent recurrence at lowest cost in the simplest way. If there are alternaDves that are equally effecDve, then the simplest or lowest cost approach is preferred.
• Root cause analysis can help to transform a reac.ve culture (that reacts to problems) into a forward-‐looking culture that solves problems before they occur or escalate.
• More importantly, it reduces the frequency of problems occurring over Dme within the environment where the RCA process is used.
• RCA is a threat to many cultures and environments. Threats to cultures o6en meet with resistance.
• There may be other forms of management support required to achieve RCA effecDveness and success. For example, a "non-‐puniDve" policy towards problem idenDfiers may be required.