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Root Cause Analysis - Solving the Production Machine Breakdown Issue

Posted on January 21, 2013 in Case Studies

In an effective Root Cause Analysis (RCA), it is imperative that problem solvers be able to find the root cause(s) of the problem. With this we will be able to arrive to a best possible actions or solutions that will mitigate the risk & to prevent the problem occurrence. Similarly this has been clearly stated as a requirement for most quality management standard for organisation’s continual improvement effort, such as that stated in ISO 9001 standard, Clause 8.5.3.

A problem arises in a manufacturing company where in recent weeks high machine breakdown were reported in the production floor – accumulating on average 15% of unscheduled downtime. Neville Clarke was asked to train & equip their employees with Root Cause Analysis problem solving methodology as part of the company’s continuous improvement effort to resolve process issues and improve productivity. Post training, the management tasked the Engineering and the Maintenance team to identify the possible causes to the breakdown issue. With a multi-disciplinary cross functional team being formed, the team of 6 members were able to look into various angles of the issue. Using the Why-Why Analysis and in conjunction with the Tree Diagram (part of a set of tool-kits in Root Cause Analysis) that were being taught in the training, the following result was reported out by the team:

Root Cause Analysis - Tree Diagram

From Figure 1, the team found a commonality in one of their final ‘leaf’ causes – Inadequate training program. Upon further deliberation, the team decided to implement 2 improvement actions:
1.    Review their current new recruit operator On-Job-Training training program and revamp the content and
2.    Work with the Production Planner to improve on the Production Planning process and the availability of
        timely information to avoid the too frequent changes.

People often do not achieve real success using this Root Cause Analysis method because they stop too soon in identifying the root cause. The other common pitfall is focusing blame on people who do the job. Instead, team should look into the system or process issue underlying the problem – which the team have correctly mapped out in Figure 1.

People always thought that Root Cause Analysis is a tricky methodology to use. In reality it is the opposite. Through this initiative, the problem solving mindset of the team have become more mature & structure. As a result of this, the company is able to bring down the machine breakdown rate to 3% of unscheduled downtime - all because they able to get to bottom of the issue.

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