5 Whys Root Cause Analysis
5 Whys Root Cause Analysis
1. Problem Statement
On August 15th, 2050, at 10:30 AM, the primary production line in Plant A experienced an unexpected shutdown. The incident resulted in a 4-hour halt in operations, which delayed the production schedule by one day and led to an estimated financial loss of $50,000 due to missed shipment deadlines and overtime pay for recovery. The issue affected a high-demand product, exacerbating the impact on customer satisfaction.
2. Why Analysis
Why 1:
Question: Why did the production line shut down?
Answer: The main conveyor belt suddenly stopped moving, bringing the entire production process to a halt.
Why 2:
Question: Why did the main conveyor belt stop moving?
Answer: The motor that drives the conveyor belt failed and ceased operation.
Why 3:
Question: Why did the motor fail?
Answer: The motor overheated and subsequently burnt out, causing it to stop functioning.
Why 4:
Question: Why did the motor overheat?
Answer: The motor’s cooling fan was not operational, leading to excessive heat buildup.
Why 5:
Question: Why was the cooling fan not operational?
Answer: The cooling fan was clogged with dust and debris, preventing it from functioning correctly. The clogging occurred because the fan had not been cleaned or inspected for several months, as it was not included in the regular maintenance schedule.
3. Root Cause
The root cause of the production line shutdown was inadequate maintenance procedures. Specifically, the omission of regular cleaning and inspection of the motor's cooling fan led to a buildup of dust and debris, causing the fan to fail, which in turn led to motor overheating and eventual burnout.
4. Corrective Actions
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Action 1: Revise the existing maintenance schedule to include routine cleaning and inspection of all motor cooling fans in the production facility. This update should ensure that fans are checked and cleaned at least once a month.
1. Responsible: Maintenance Team Lead
2. Timeline: To be implemented by August 22nd, 2050, with the first round of inspections to be completed by September 1st, 2050. -
Action 2: Introduce a preventive maintenance software system that tracks the status of all critical machinery components, including cooling fans, and alerts the maintenance team when inspections are due.
1. Responsible: IT and Maintenance Teams
2. Timeline: Software selection and implementation to be completed by September 15th, 2050. -
Action 3: Provide comprehensive training to the maintenance staff on the importance of cooling fan maintenance, the risks associated with overheating, and the correct procedures for cleaning and inspecting fans. Include this training as part of the onboarding process for new staff.
1. Responsible: Training Coordinator
2. Timeline: Initial training session to be conducted by August 25th, 2050, with ongoing training sessions every quarter. -
Action 4: Install high-efficiency dust filters on all motors to minimize the accumulation of dust and debris on cooling fans. These filters should be easy to clean and replace, reducing maintenance time and improving motor longevity.
1. Responsible: Engineering Team
2. Timeline: Filters are to be designed and installed by September 10th, 2050, with a replacement plan in place by October 1st, 2050. -
Action 5: Conduct a root cause review meeting with all relevant departments to discuss the findings of this analysis, ensuring that lessons learned are shared across the organization and similar issues are prevented in other plants.
1. Responsible: Operations Manager
2. Timeline: The meeting is to be held on August 20th, 2050.
5. Conclusion:
The production line shutdown on August 15th, 2050, was traced back to a failure in the maintenance process, specifically the neglect of routine cleaning and inspection of the motor cooling fan. This led to the motor overheating and shutting down the line, resulting in significant operational and financial impacts. The corrective actions proposed include revising the maintenance schedule, implementing preventive maintenance software, providing targeted training, installing dust filters, and ensuring organizational learning from the incident. These measures aim to prevent similar occurrences in the future, thereby enhancing the reliability of the production process and safeguarding the company’s reputation for timely delivery.
