Root Cause Analysis and Corrective Action Workshop

1. Module 1 Welcome to the Root Cause Analysis and Corrective Action Workshop

2. Introduction LetterPW page 3 Points to remember about RCA: - It is a complete process, ready to be used as a powerful tool. - It can be used everywhere, home and work. - ISO 9001/SQM requires a strong corrective action process in place.

3. Module 1 - Introduction Class structure Workbook review Applications Module 2 - Collection Forming teams Gathering Data Exercises Module 3 - Analysis Why-Why Method Causes Cause Chains Exercises & More Exercises Module 4 - Solution Corrective Action Types Testing Exercises Module 5 - Assessment Followup Effectiveness Lessons Learned Exercises Module 6 - Reporting Formats Fan Exercise Course Evaluation Workshop Agenda(The Process) PW - 4

4. Root Cause Analysis and Corrective Action Process Definition: An effective process for finding the cause of an event, facilitating effective corrective actions, and preventing recurrence. Remember - If you don’t know what caused the problem you can’t fix it!! PW - 5

5. Participate Actively! Act on Fact! Have Fun!

6. Module 2 Collection

7. Event Definition:An all inclusive term for any of the following: Product Failure Out of control process Audit finding Accident Customer complaint Pleasant surprises

8. Natural Team Definition:A group of people having vested ownership of the problem to be solved.

9. Importance of The Natural Team • Team members bring different: • - Ideas • - Needs • - Experiences • - Procedural Requirements Team Members experience affects: - Areas Investigated - Methods of collection - How corrective action is identified

10. Pick Team Names Rattlers Mavericks Bulls Screaming Eagles Barnstormers

11. Qualified Team Definition:The Natural Team, including other individuals, who can provide necessary resources to understand the problem, or can help in the root cause analysis and corrective action process.

12. State The Problem! The process starts here First you must understand the problem Then you must find out if more than one problem exists PW-5

13. Remember! “If you cannot say it simply, you do not understand the problem.”

14. Is: Short Simple Concise Focused on one problem A question (Why…?) Does not: Tell what caused the event State what to do next Explain the event Event Question pw-6

15. Remember! Everything should be made as simple as possible but no simpler. PW 6

16. Exercise PW 7Write an event questionIdentify natural team membersIdentify qualified team members Team reports in 10 minutes.

17. Capture the Scene! Take Pictures Preserve the Evidence Talk to People

18. You can’t tell which way the train went by looking at the tracks!

19. Gathering DataUsea Check list: Location Names Date and Time Operational Conditions Environmental Conditions Communications Sequence of Events Equipment Physical Evidence Recent Changes Training Other Events PW-9

20. Exercise: pw-10Write the event Question from the event, and identifythe data that you might want to collect for each event. Each team needs to have a member report decisions made by their team.

21. Check for Accuracy Data Verification Use a second source Note conflicting information Verify That Data!

22. DON’T BE AFRAID TO BACK UP! Your data may often show you that multiple problems exist.This may require a parking lot. The data may also lead you to rewrite your event question.

23. Mill Fire Event Exercise Using Mill Fire worksheet 1, Blue sheet under tab10: -Write an event question -Select team members (natural and qualified) Note: Is there more than one problem? Who are the customers of the report?

24. Mill Fire Scene

25. Burned Gloves Found at Fire Scene

26. Why did the fire start? (first problem) Why was she burned? (second problem) Mill Fire Event The fire came first, but the burns make the event more serious.

27. Review • Who makes up the team? • What do you start the analysis with? • What does the event question begin with?