February 11, 2009 | Barb Carr

Root Cause Analysis Tip: You didn’t Change anything in the XYZ Process when it failed… or did you?

200902092318 When analyzing defects/incidents using DMAIC that just seem to appear for no apparent reason per the operators and managers, what do you do? Using a technique called “Change Analysis”, taught in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, you may be surprised as to the results.

While pulling stock from the shelf, worker A grabbed the wrong material type. Is this a problem of common variation or did someone introduce a change or difference into the process? First we must determine key performance factors that may have a major impact on material selection for this process.

So how do we determine the critical factors? We could use these tools just to mention a few…..

– CHAP (Critical Human Action Profile) to determine critical steps where an error could occur and then compare successful material procurements with this current unsuccessful attempt.

– The Root Cause Dictionary and Laminated Root Cause Tree to review key steps where errors in Procedures, Communication and Human Engineering could occur between previous successful procurements and this failed procurement.

Next we must…… to determine significant differences. To learn the rest of the process join the others who have successfully used “Change Analysis” to solve repeatable process issues by taking our 5-Day Course.

If there was no significant difference in the process and this was due to common variation of a process, you will be interested in the next quality process improvement Root Cause Analysis Tip coming soon.

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