Professional Documents
Culture Documents
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Root Cause Analysis Proposals
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Root Cause Analysis (RCA) Objectives
• Describe RCA
• Applying RCA
– Develop mitigation activities
– Create corrective action plan
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RCA
Description of Root Cause Analysis
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RCA
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RCA
Applying Root Cause Analysis
• Major accidents
• Everyday incidents
• Near-misses
• Human errors
• Maintenance problems
• Medical mistakes
• Productivity issues
• Development of corrective actions and mitigation plans
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RCA Process
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Common Root Cause Mistakes
• Equipment Failure
• Human Error
• Procedure Not Followed
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Look Beyond the Obvious
• Inadequate training
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Human Error
• Collaborative Effort
• Inter-disciplinary Process
• Requires participation (buy-in) by the
leadership of the organization
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Using the RCA Process
Investigation
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Basic steps of the RCA process...
Step two—Analysis
• 5 Whys
• Causal factor charting
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Analysis Tool: 5 Whys
Sakichi Toyoda:
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Analysis Tool: 5 Whys
Where do we start?
Write down the specific problem
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Analysis Tool: 5 Whys Example
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Analysis Tool: 5 Whys Example
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Basic steps of the RCA process...
Step two —
Fishbone Cause and Effect
Step Three—
Root cause identification
Step Three—
Root cause identification
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Basic steps of the RCA process...
• Human Error
• Mistake
• Distraction
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Basic steps of the RCA process...
Step 4 –
Recommendations and implementation
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Corrective Action
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Corrective Action
• Reminded employees
• Retraining
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Basic steps of the RCA process...
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Follow Up Monitoring
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McDonald’s Spilled Coffee Case
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McDonald’s Spilled Coffee Case
The Investigation
The Investigation
• She was wearing sweat pants that held the hot
liquid against her skin for over 90 seconds
The Investigation
• McDonald's defended its policy of serving coffee
at a temperature of 180 degrees or greater
Cause Map
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McDonald’s Spilled Coffee Case
5 Whys Analysis
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McDonald’s Spilled Coffee Case
Answer: E – A, B, C, D
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McDonald’s Spilled Coffee Case
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McDonald’s Spilled Coffee Case
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Summary
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Summary
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Questions
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Contact Information
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