RCA 101
The issue that caused a nonconformance and should be eliminated through process improvement
What is Root Cause?
"The machine keeps stopping.”
Symptom
RCA is not found here.
Instead of “Who?”, what is one word that helps find the real cause?
What is "WHY"?
The tool that asks “Why?” repeatedly
What is "5 Why's"?
Why are we getting sporadic wrinkled labels coming from labeler?
Any of the following:
The overall purpose of Root Cause Analysis.
What is preventing the problem from happening again
“The sensor was wired incorrectly.”
What is a Root Cause?
This meeting at Niagara helps validate widespread issues and provides long-term corrective actions.
What are "Alignment Meetings"?
The tool shaped like a fish skeleton for organizing potential causes
What is Fishbone Diagram?
We have a high kick-out rate on blow molder. Considering RCA, what is the first step?
What is
A sign or indication of a root cause but it is not, by itself, a cause.
What is a Symptom?
Team members are frustrated.
What is a Symptom?
RCA is not found here.
RCA avoids focusing on blaming this.
Who is "who" (a person)?
The chart that highlights the “vital few” causes.
What is Pareto Chart?
Finished goods reconciliation delayed due to incorrect lot being received at time of delivery and overruns in Oracle and Manhattan.
This principle means doing the right thing, the right way, every time—even under pressure.
What is Operational Discipline?
“Preventive maintenance was not scheduled.”
What is a Root Cause?
These meetings at Niagara are designed for shift-level issue containment and quick RCA.
What is "SIC Meetings"?
A tool used to capture answers from the group, without diving into them – throwing ideas out there.
What is Brainstorming?
During a safety walk, the manager notices pre-forms scattered on the floor, standing water under machines, and team members with untucked shirts. Cleaning supplies are missing, and PPE compliance is unclear. This is not the first time.
Name at least one thing that can get in the way of an effective RCA
What is
Blame
Ignoring knowledge and experience from team members or subject matter experts
Involving all relevant people
Jumping to conclusions
Jumping to solutions
Poorly defined problem statement
Lack of root cause validation
Not sticking to the root cause
Selecting lack of training, support or money as a root cause
Assuming problems have a single root cause
“Production fell behind schedule.”
What is a Symptom?
RCA is not found here.
We typically use RCA as a way to diagnose problems, where else can RCA be an effective tool?
What is "When we have Success"?
A tool that visually maps process steps.
What is Flow Chart?
You have been experiencing infeed jams at L1 Packer throughout the shift. You have temporarily corrected with your team. It’s 9:50am, what is a way that you could approach eliminating the symptom?
What is,
RCA Tools - such as; 5 Why/Fishbone/Brainstorm
"I would address in the SIC Meeting to brainstorm to get to root cause. This issue could include other departments and other input and perspectives would help us get to RCA"
Escalate to Supervisor