Root Cause Analysis For Beginners

50
I
JULY 2004
I
www.asq.org
QUALITY BASICS
Root Cause Map
FIGURE 2
Section one
1
2
Start here with each causal factor.
1
6
Equipment
reliability program
problem
7
Installation/
fabrication
8
Equipment
misuse
2
Equipment difficulty
Corrective maintenance
LTA
• Troubleshooting/corrective
action LTA
• Repair implementation
LTA
Preventive maintenance
LTA
• Frequency LTA
• Scope LTA
• Activity implementation
LTA
Predictive maintenance
LTA
• Detection LTA
• Monitoring LTA
• Troubleshooting/
corrective action LTA
• Activity implementation
LTA
29
32
36
30
31
33
34
35
37
38
39
40
Proactive maintenance
LTA
• Event specification
LTA
• Monitoring LTA
• Scope LTA
• Activity implementation
LTA
Failure finding maintenance
LTA
• Frequency LTA
• Scope LTA
• Troubleshooting/
corrective action LTA
• Repair implementation
Routine equipment
rounds LTA
• Frequency LTA
• Scope LTA
• Activity implementation
LTA
41
42
43
44
45
47
48
49
50
52
53
54
46
51
Equipment reliability
program implementation
LTA
28
Procedures
111
No program
Program LTA
• Analysis/design
procedure LTA
• Inappropriate type
of maintenance
assigned
• Risk acceptance
criteria LTA
• Allocation of
resources LTA
22
23
24
25
26
27
Equipment reliability
program design
less than adequate (LTA)
21
16
Design input
LTA
Design output
LTA
17
Design input/
output
15
Equipment
design records
LTA
Equipment
operating/
maintenance
history LTA
19
20
Equipment
records
18
Administrative/
management
systems
55
Note: Node numbers correspond to matching page in Appendix A of the
Root Cause Analysis Handbook.
Customer
interface/
services
• Customer
requirements
not identified
• Customer needs
not addressed
• Implementation
LTA
106
108
109
110
Document and
configuration
control
• Change not
identified
• Verification of design/
field changes LTA
(no PSSR*)
• Documentation
content not kept
up to date
• Control of official
documents LTA
100
102
103
104
105
Procurement
control
• Purchasing
specifications LTA
• Control of changes
to procurement
specifications LTA
• Material acceptance
requirements LTA
• Material inspections
LTA
• Contractor selection
LTA
93
95
96
97
98
99
Product/material
control
• Handling LTA
• Storage LTA
• Packaging/
shipping LTA
• Unauthorized material
substitution
• Product acceptance
criteria LTA
• Product inspections
LTA
85
87
88
89
90
91
92
Safety/hazard/
risk review
• Review LTA or
not performed
• Recommendations not
yet implemented
• Risk acceptance
criteria LTA
• Review procedure
LTA
72
74
75
76
77
Standards,
policies or
administrative
controls (SPACs)
LTA
• No SPACs
• Not strict
enough
• Confusing,
contradictory or
incomplete
• Technical error
• Responsibility
for item/activity
not adequately
defined
• Planning, scheduling
or tracking of work
activities LTA
• Rewards/incentives
LTA
• Employee screening/
hiring LTA
57
59
60
61
62
63
64
65
66
SPACs not used
• Communication of
SPACs LTA
• Recently changed
• Enforcement LTA
67
69
70
71
Problem
identification
control
• Problem reporting
LTA
• Problem analysis
LTA
• Audits LTA
• Corrective action
LTA
• Corrective actions not
yet implemented
78
80
81
82
83
84
Not used
• Not available or
inconvenient to
obtain
• Procedure difficult
to use
• Use not required
but should be
• No procedure for
task
112
113
114
115
116
Misleading/confusing
• Format confusing or
LTA
• More than one action
per step
• No checkoff space
provided but should be
• Inadequate checklist
• Graphics LTA
• Ambiguous or confusing
instructions/
requirements
• Data/computations
wrong/incomplete
• Insufficient or excessive
references
• Identification of revised
steps LTA
• Level of detail LTA
• Difficult to identify
118
117
120
121
122
123
124
125
126
127
128
129
Wrong/incomplete
• Typographical error
• Sequence wrong
• Facts wrong/
requirements not
correct
• Wrong revision or
expired procedure
revision used
• Inconsistency
between
requirements
• Incomplete/situation
not covered
• Overlap or gaps
between
procedures
130
131
132
133
134
135
136
137
5
Equipment
design problem
Figure 2 continued on next page
Page 6/9
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