A Summary of Apollo Root Cause Problem Solving

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A Summary of Apollo Root Cause Problem Solving

• Holly Duckworth
• Master Black Belt
• TRW Automotive
• 4/16/2008

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Method Credited to
Based upon the book Apollo Root Cause
Analysis, Dean L. Gano, 2nd ed., Apollonian
Publications, Yakima, Washington, 2003.
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Problem Solving Techniques

• Problem Resolution -- to help identify and
  rectify an identified problem a special cause
  situation
• 8-D problem solving
• Process Improvement -- to identify and implement
  improvements proactively a common cause
  situation
• Six Sigma process improvement
• 8-D Problems solving can be used within a six
  sigma project to solve special cause issues

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PDCA
Plan Plan for a change needed to solve the
problem/improve the process
Act Implement the change, if appropriate. Make
all needed systems changes to formalize
Plan
Act
Do
Check
Do Test change on a small scale. Collect data.
Check Check the impacts of the proposed change.
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8-D Problem Solving
The Eight Disciplines (8-D) are

• Team Formation
• Problem Description
• Interim Corrective Action
• Root Cause Identification
• Choosing/Verifying Permanent Corrective Action
• Implementing Permanent Corrective Action
• Preventing Problem Recurrence
• Recognizing the Team

Generally attributed to Ford Motor Company
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Root Cause Identification

• We always start with understanding the EFFECT
• However, in each problem there is usually a
  series of effects and causes
• Example

Effect Cause Injury Fall Fall Wet
Floor Wet Floor Mopping Mopping Mud in
Aisle Mud in Aisle No mat at door
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Root Cause Identification

• What we also find is that every EFFECT is caused
  by a combination of CONDITIONS and ACTIONS
• Conditions Causes that exist prior to an action
• Actions Momentary causes that bring the
  condition and effect together

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Defect and Systemic Root Cause

• The effect is an employee slips and falls
• The defect root cause is the employee walking
  across a wet floor
• The condition is the wet floor
• The action is the employee walking on the wet
  floor
• The systemic root cause is the employee choosing
  the at-risk behavior and/or the janitor not
  marking the wet floor

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Cause and Effect Diagrams

• We might use a fish bone diagram, but only to
  brainstorm possible causes (conditions and
  actions)

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Cause and Effect Diagrams

• But the important tool in Apollo Root Cause
  Problem Solving is the Condition/Action Chart

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Condition/Action Analysis

• Lets walk through an example

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Condition/Action Analysis

• We must now VERIFY each condition and action with
  EVIDENCE

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Condition/Action Analysis

• Next, we analyze the next layer

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Condition/Action Analysis

• Can we take these causes any further?

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Condition/Action Analysis
Condition Lowest cost objective
Condition Battery beyond warranty life
Condition Battery is dead
Action New battery purchase delayed
Action Battery not replaced
Effect Car doesnt start
Condition Car is out of gas

• These are the defect root causes

• These are the systemic root causes

Condition Starter is defective
Condition No voltage to starter
Action Ignition switch does not start the car
Action Repeated trial of ignition switch
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Condition/Action Analysis

• How do you know when to stop?
• Answers are nonsense or repeated
• Condition/Action Charting is an iterative process
• Once a draft chart is finished, start at the
  beginning and refine
• All Actions and Conditions should be verified
  with evidence
• This may take some time

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Solutions

• The best solutions address CONDITIONS
• If we can remove conditions, then it doesnt
  matter what actions happen
• There may be multiple root causes with multiple
  conditions
• It may be too costly to address CONDITIONS, then
  ACTIONS should be addressed

Systemic Corrective Action on CONDITIONS will
prevent recurrence
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Apollo Root Cause Problem Solving

• Condition/Action Charting and Analysis
• Another tool in the tool box

• Now youll try an example.