Root Cause and Corrective Action Tutorial

1. Root Cause and Corrective Action Tutorial • January 21, 2014

2. Course Overview • This presentation is an introduction to performing Root Cause and Corrective Action (RCCA). • The RCCA process includes: • Clearly defining and analyzing a defect • Identifying solutions • Carrying out solutions • Validating the effectiveness of applied corrections to eliminate a defect.

3. Application • RCCA applies to the activities associated with correcting and preventing defects related to: • all phases of production from raw material to finished product • production processes • all aspects of your company’s business • RCCA can be beneficially applied to all departments and functions in a company.

4. Goals • The Goals of this presentation are: • To provide a working understanding of the roles, responsibilities & activities associated with RCCA; • To assist our suppliers in performing this important function when responding to a SCAR; • To provide tools to our suppliers that may help in identifying and addressing defects before they are delivered to Marvin Engineering.

5. Hands on Experience • This afternoon we will provide an opportunity to apply the concepts provided in this presentation to: • Conduct a problem investigation (fact finding). • Determine the Root Causes (causal analysis) • Define actions to eliminate the problems (identify solutions)

6. Root Cause Analysis • Root cause analysis is an approach to identify the underlying causes of why an incident occurred so that the most effective solutions can be identified and implemented • RCCA comes down to three basic questions:  • What's the problem? • What allowed it to happen? • What will prevent it in the future?  • The word root, in root cause analysis, refers • to the underlying causes, not the one cause.

7. Root Cause Definition • Root Cause:A condition or action thatbegins a chain that ends in a defect • There are multiple root causes that can result in the same problem • Addressing only 1 of many causes won’t eliminate the defect. If effective RCCA is not performed, the problem will reoccur.

8. Symptom vs. Root Causes Old New • “Errors are often a result of worker carelessness.” • “We need to train and motivate workers to be more careful.” • “We don’t have the time or resources to really get to the bottom of this problem.” Symptom Approach Root Cause Approach • “Errors are the result of defects in the system. People are only part of the process.” • “We need to find out why this is happening, and mistake-proof it so it won’t happen again.” • “This is critical. We need to fix it for good, or it will come back and burn us.”

9. The RCCA Process Simplified

10. The RCCA Process Detailed • Define and confirm the problem • Capture (contain) all affected items • Restore (rework) the discrepant items to compliance • Find the causes of the problem • Develop an action plan prevent a recurrence • Implement the plan • Evaluate the effectiveness of the solutions • Provide Objective Evidence of the implemented solutions

11. When to initiate RCCA • Corrective Action triggers: • Customer SCAR issued • A Supplier Notification • Recurring nonconformity • Audit finding • Sub-tier supplier defect found

12. Phase 1: Investigation Define the Problem • A well-written problem statement answers four simple questions: • What is the specific problem? • Where did it happen? • When did it happen? • How many or how much is involved?

13. Phase 1: Investigation Problem Statement • The statement of a documented problem (from a Marvin Engineering SCAR) • S/B .219 +.002/-.001 Dia. Hole,B/P sheet 3, zone C-4, section A-A • IS O/S to .228

14. Phase 1: Investigation Restate the Problem • Problem Restated: • PN 1534AS1234 has an oversized hole: S/B .219 +.002/-.001 dia.;IS O/S to .228;B/P : sheet 3, zone C-4, section A-A. • Work orders: 216, 178 and 230 • Machines: Drill Presses #2 and #9 • Qty. = 121 pcs. on SCAR, 78 pcs. In work

15. Containment Action • Phase 1: Investigation • Search to find all items affected by the problem. Isolate them to ensure they are not processed further, or shipped to the customer. Investigate all areas inside and outside the company: • Work in process • Open P.O.s • At outside suppliers, e.g. plating, heat treat • Shipped to customer

16. Determine the Root Causes Phase 2: Analysis • Do not sit at a desk, read the problem statement, and then “solve” the issue alone. • Instead, involve others who have knowledge to offer: • The Purchasing Agent • The Machine Operator • The QualityInspector

17. Escapes Work Cell or Facility • An escape is movement ofa defect to the next work area, or to the customer Escape Process B Process A Escape PLUG THE HOLE! Process C MarvinEngineering Escape Something Must Change if an Escape Occurs

18. Why Perform RCCA? Defects eat your profit.The later they are found,the more they cost Design Component Level Assembly Test or Inspection By Customer ? Eliminate the defect as far up the stream as possible. At the source.

19. Corrective Actions: Fix the nonconformity and prevent its recurrence Defect orunwanted event Short Term Corrective Actionsfix the Defect Containment Restore affected itemsto compliance Root Causes Long Term Corrective Actions fix Root Causes and Prevent Recurrence Corrective Actions

20. Corrective Action • Short Term Corrective Action(s) fix the immediate problem(s) • Long Term Corrective Action(s) fix the systemic problems at the root cause level • Generate no additional problems Phase 3: Decision IMPORTANT

21. Not All Corrective Actions are Created Equal • Corrections that are systemic in nature, like automatic checks or gates are significantly better than just cautioning an employee to be more careful Corrective Action Continuum weak STRONG Employee Counseled Formal Training Warning on/ in tools, instruction, work area Mandatory checks & reviews Design, tooling, kitting, shadow boxes, automated checking Control of process inputs, resulting in controlled outputs

22. Mistake Proofing When to use Mistake Proofing: • Human error can cause mistakes or defects to occur • The customer can make an error which affects the output • At a hand-off step in a process • Consequences are expensive or dangerous Elevator Phase 3: Decision “..mistakes will not turn into defects if errors are discovered and eliminated..” Shingo

23. Verification & Validation • Verification & Validation • Verification • Did we do what we said we were going to do? • Validation • Were the actions effective in eliminating the problem and preventing it from recurring? • Were other problems created because of the changes?

24. Objective Evidence Each SCAR response requires that evidence of the changes made are provided to Marvin Engineering along with the SCAR Examples: • Training sign-in sheets for employee training on a new or changed procedure • A copy of the new or changed procedure • The inspection data validating the First Article Inspection part from a changed CNC program • A copy of a revised inspection sheet adding a previously skipped characteristic

25. Summary • The fundamental Root Cause & Corrective Action (RCCA) process involves • Containment, Correction, Root Cause Analysis, Corrective Action, Verification, Validation • Effective RCCA depends upon: • A well written problem description - define the requirement being violated • A robust causal analysis - use quality tools • A diligent validation - with data showing elimination of the root cause Without these the defect cycle will repeat