scholarly journals ROOT CAUSE ANALYSIS AND OVERALL EQUIPMENT EFFECTIVENESS OF PRESS MACHINE IN LINE H AND HIRAC AT PT. XYZ

2020 ◽  
Vol 4 (2) ◽  
pp. 285
Author(s):  
Lina Gozali ◽  
Frans Yusuf Daywin ◽  
Carla Olyvia Doaly
Keyword(s):  
Risk Assessment ◽  
Root Cause Analysis ◽  
Analysis Tool ◽  
Production Lines ◽  
Automotive Manufacturing ◽  
Cause Analysis ◽  
Root Cause ◽  
Machine Maintenance ◽  
Assessment Sheet ◽  
And Performance

ABSTRAKLine H pada PT. XYZ Press Production di perusahaan manufaktur otomotif menggunakan mesin press semi otomatis yang bekerja dua shift per hari. Oleh karena itu, mesin harus dijaga agar ketersediaan dan performanya tetap terjaga, serta kualitas dan kuantitas produksinya. Makalah ini bertujuan untuk menganalisis departemen perawatan mesin dengan menggunakan Root Cause Analysis (RCA), Overall Equipment Effectiveness (OEE), dan HIRAC. Dalam penelitian ini RCA digunakan sebagai alat analisis atau metode pemecahan masalah untuk mengidentifikasi akar penyebab dari kesalahan atau masalah. Dari hasil analisis, PT. XYZ menggunakan lembar catatan penghentian jalur sebagai alat untuk mengidentifikasi akar penyebab penghentian jalur yang terjadi di setiap jalur produksi. Lini produksi kritis adalah Line H. Kemudian, ditentukan ketersediaan, kinerja, dan kualitas mulai bulan Agustus 2018 hingga Januari 2019 di Line H untuk mendapatkan OEE. Bulan Oktober 2018 memiliki Overall Equipment Effectiveness (OEE) terendah di antara periode lainnya. Juga, kami menganalisis HIRAC pada PT. XYZ menggunakan WRAS (Work Risk Assessment Sheet). Hasil analisis data menunjukkan bahwa perusahaan harus melakukan pemeliharaan preventif secara konsisten untuk mengurangi penghentian jalur di Line H. Kata kunci: Analisis Akar Penyebab; Efektivitas Peralatan Keseluruhan; HIRAC; perawatan mesin.ABSTRACT Line H at PT. XYZ Press Production in automotive manufacturing company used semi-automated press machines which work for two shift per day. Therefore, the machines should be maintained to keep the availability and performance of the machines, also to keep the quality and quantity of production. The aim of this paper is to analyze the machine maintenance department that are using Root Cause Analysis (RCA), Overall Equipment Effectiveness (OEE), and HIRAC. In this research, RCA is used as an analysis tool or method of problem solving, used for identifying the root causes of faults or problems. From the analysis, PT. XYZ used line stop record sheet as the tool for identifying the root causes of line stops that happened in every production lines. The critical production line is Line H. Then, determined the availability, performance and quality start from August 2018 to January 2019 in Line H to get OEE. October 2018 has the lowest OEE (Overall Equipment Effectiveness) among the other period. Also, we analyze HIRAC. PT. XYZ used WRAS (Work Risk Assessment Sheet). The results of data analysis show that the company should do the preventive maintenance consistently to reduce line stops in Line H

Root Cause Analysis by Shainin Approach in Automotive Manufacturing Sector: A Case Study

2021 ◽  
pp. 247-256
Author(s):  
Kartik Thakur ◽  
Akhilesh Kumar ◽  
Sushanta Jashwara ◽  
Kamaljeet Singh ◽  
Kulwinder Singh
Keyword(s):  
Manufacturing Sector ◽  
Root Cause Analysis ◽  
Automotive Manufacturing ◽  
Cause Analysis ◽  
Root Cause

Outcomes From Root Cause Analysis of Hospital-Associated Thrombosis Over Twelve Months: A Single Centre Experience

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 675-675
Author(s):  
Lara N Roberts ◽  
Raj K Patel ◽  
Lynda Bonner ◽  
Roopen Arya
Keyword(s):  
Risk Assessment ◽  
High Risk ◽  
Cause Of Death ◽  
Conflicts Of Interest ◽  
Bleeding Risk ◽  
Root Cause Analysis ◽  
Medical Patients ◽  
Advanced Malignancy ◽  
Cause Analysis ◽  
Root Cause

Abstract Abstract 675 The national Venous Thromboembolism (VTE) Prevention Programme in England incorporates standardised guidance on risk assessment (RA) and thromboprophylaxis (TP) with a requirement for root cause analysis of all episodes of hospital associated thrombosis (HAT), defined as any VTE occurring whilst an inpatient or within 90 days of discharge. We report findings from audit of root cause analysis of HAT over 12 months at King's, a major London tertiary centre with 900 beds and an estimated 53 000 admissions per annum. 239 episodes of HAT were identified associated with surgical, medical and obstetric admission accounting for 101 (42.3%), 133 (55.6%) and 5 (2.1%) cases respectively. The estimated incidence of HAT is 4.5 per 1000 admissions. The mean age of patients with HAT was 62.7 (+/− 16.8) years, with males accounting for 53.6% of the cohort. HAT manifested as deep vein thrombosis in 121 (50.6%) and pulmonary embolism in 128 (49.6%). The median time to diagnosis of HAT following admission was 16 days (IQR 7–30). 171 (67.4%) of HAT occurred prior to discharge. Of the 78 (31.7%) events occurring post discharge, 60 (76.9%) required readmission for management of HAT and 2 (2.6%) represented with fatal events. HAT was associated with mortality in 51 cases (21.3%), with death directly attributable to PE in 16 (6.7%). The estimated incidence of HAT associated with fatal PE is 0.3 per 1000 admissions. Of note, autopsy was undertaken in 12/51 with PE identified as the primary cause of death in 11/12 (2/12 had known/suspected VTE prior to death). The five remaining patients with PE as the primary cause of death had the diagnosis made on clinical suspicion alone in four cases and radiological imaging in one case. The remaining deaths were attributed to other causes in 25, with 15 having unknown cause of death as certification occurred in the community (10 with known advanced malignancy at discharge). Root cause analysis has been completed for 149 (62.3%) of HAT episodes. Of these, 43.9% had RA undertaken on admission to hospital. Retrospective RA revealed 91.0% of patients were at high risk for VTE with 33.1% also at high risk of bleeding. 72% were prescribed anticoagulant TP. Anticoagulant prophylaxis was prescribed for 30/49 (61.2%) medical, 33/36 (91.7%) surgical and 3/4 (75%) obstetric HAT cases with a high VTE risk and low bleeding risk. Of those with a high bleeding risk, 8/23 (34.8%) and 15/27 (55.6%) medical and surgical patients respectively received anticoagulant TP for part of their admission. Mechanical TP was prescribed for 41/63 (65.1%) surgical, all obstetric (4) HAT cases and 5/15 (33.3%) medical patients in whom mechanical TP was indicated and appropriate. HAT was attributed to inadequate TP in 51 (32.5%), contraindication to chemical TP in 23 (14.6%), contraindication to all TP in 11 (7.0), TP failure in 43 (27.4%), line associated in 20 (12.7%), and was considered unexpected in 9 (5.7%) patients without any risk factors for VTE. Inadequate TP resulted from failure to prescribe in 17 (33.3%), unexplained delay in initiation in 8 (15.7%), unexplained missed doses in 7 (13.7%), inadequate duration of TP in 5 (9.8%) or inferior agent or dose in 9 (17.6%) cases with a combination of the above in 5 (9.8%) cases. Mortality associated with inadequate TP was 21.6% with death directly attributable to PE of 5.9%. TP remains underused in cases of HAT, with lowest rates associated with medical admission. At our centre, improved RA and TP could reduce the annual incidence of HAT by an estimated 21%. Further research is required to improve risk assessment and thromboprophylactic strategies to address unexpected events and those arising despite optimal TP. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Leadership Root Cause Analysis: Using a Formal Analysis Tool to Dissect and Promote Intrusive Leadership in a U.S. Naval Hospital

2021 ◽  
Author(s):  
David A Paz ◽  
Jean A Thurber ◽  
Cynthia L Judy ◽  
Timothy M Quast
Keyword(s):  
Formal Analysis ◽  
Root Cause Analysis ◽  
Analysis Tool ◽  
Cause Analysis ◽  
Root Cause ◽  
Potential Problems ◽  
Naval Hospital

ABSTRACT Intrusive leadership is a method that looks for signs that might indicate a problem within or outside of the workplace that can affect a member’s performance and, subsequently, the mission. Our scenario demonstrates how intrusive leadership can identify potential problems which, when coupled with accountability, can prevent more significant complications.

scholarly journals PERBAIKAN PADA FISHBONE DIAGRAM SEBAGAI ROOT CAUSE ANALYSIS TOOL

2013 ◽  
Vol 3 (3) ◽  
Author(s):  
Hari Agung Yuniarto ◽  
Annisa Dewi Akbari ◽  
Nur Aini Masruroh
Keyword(s):  
Bayesian Network ◽  
Root Cause Analysis ◽  
Quality Characteristics ◽  
Analysis Tool ◽  
Machine Method ◽  
Cause Analysis ◽  
Common Cause ◽  
Root Cause ◽  
Fishbone Diagram

<p>Diagram Fishbone (tulang ikan), atau biasa pula disebut ishikawa diagram ataupun cause effect<br />diagram, adalah salah satu dari root cause analysis tools yang paling populer di kalangan praktisi industri<br />untuk melakukan quality improvement mendasarkan pada usaha mengenali akar penyebab terjadinya variasi<br />pada quality characteristics tertentu yang ingin dicapai. Meski telah banyak dipakai di dunia industri,<br />disayangkan tool ini menderita kelemahan karena tidak memfasilitasi analisa korelasi antar potential root<br />causes dari masing-masing kategori yang ada (5M1E - man machine method measurement material<br />environment), selain tentu saja penyajian datanya yang hanya kualitatif. Kelemahan ini diyakini menjadi<br />kontributor utama penyebab kegagalan fishbone diagram dalam mengenali root causes yang berupa sumber<br />variasi common cause dan hanya mampu mengenali yang berasal dari sumber variasi special cause. Bertolak<br />belakang dengan karakteristik special cause variations, common cause variations adalah variasi yang terjadi<br />pada quality characteristics tertentu yang ingin dicapai di mana kemunculannya tidak mudah teridentifikasi<br />dan jikapun berhasil dikenali akan sulit dihilangkan karena sifatnya yang seolah adalah merupakan bagian<br />dari sistem (embedded in a system), cenderung berakar penyebab berupa soft factors serta kemunculannya yang<br />tidak random namun tersamar dalam pola tertentu.<br />Penelitian ini bertujuan melakukan improvement pada kelemahan yang terdapat di fishbone diagram<br />dengan mengadopsi kelebihan yang dimiliki oleh bayesian network agar mampu mengenali root causes yang<br />merupakan common cause variations. Kelebihan bayesian network mengatasi kekurangan fishbone diagram,<br />demikian pula sebaliknya. Oleh karena itu, analisa dilakukan terhadap fishbone diagram dan bayesian network<br />untuk mengenali characteristics dan kelebihan/kekurangannya. Hasil dari analisa tersebut mengarahkan pada<br />sifat-sifat komplementer dari keduanya yang diyakini mampu mengisi gap pada fishbone diagram.<br />Mendasarkan padanya, dikembangkan sebuah model untuk mengintegrasikan konsep serta sifat komplementer<br />yang dimiliki bayesian network dan fishbone diagram. Model ini merepresentasikan metodologi baru dalam<br />root cause analysis, bayes-fishbone. Metodologi yang dikembangkan ini kemudian diujikan ke sebuah case<br />study company untuk melihat applicability-nya.<br />Hasil dari penelitian ini menunjukkan bahwa metodologi bayes-fishbone yang dikembangkan terbukti<br />telah valid mampu merepresentasikan kondisi probabilitas produk cacat sebenarnya pada case study company<br />dengan prosentase perbedaan nilai yang ditunjukkan antara model yang dikembangkan dengan kondisi aktual<br />yang besarnya tidak signifikan yaitu kurang dari 1 % (0,9597%). Dengan menerapkan metode contructive<br />research approach, terbukti pula bahwa metodologi bayes-fishbone berhasil lolos weak-market test yang<br />menunjukkan bahwa metodologi yang dikembangkan applicable pada case study company atau perusahaan lain<br />yang sejenis characteristics dan production process-nya.</p>

scholarly journals ANALISIS RISIKO KESELAMATAN KERJA PADA PROYEK PENGEMBANGAN BANDARA INTERNASIONAL JUANDA TERMINAL 2 SURABAYA

IKESMA ◽  
2017 ◽  
Vol 13 (2) ◽  
Author(s):  
Reny Indrayani
Keyword(s):  
Risk Assessment ◽  
Root Cause Analysis ◽  
Risk Identification ◽  
Occupational Accidents ◽  
Observational Research ◽  
Cross Sectional ◽  
Cause Analysis ◽  
Safety Issues ◽  
Overtime Work ◽  
Root Cause

The construction sector played an important role in development and was the biggest contributor of work accident rate in Indonesia. The aim of the research were to analyze human, methods, machines, materials, and environment element as cause of occupational accidents. This was a cross-sectional observational research conducted in October 2012 to March 2013. This research was carried out with several integrates stages which include risk identification, risk assessment and priorities formulation, root cause analysis, and ended by recommendations for controlling risk and hazard. Risk identificationshowed that there were 100 risks that couldthreaten the workers. The following categories were: 4% low risk categories, 48% moderate risk, 39% high risk, and 9% extreme risk. Through the Q sort technique obtained five priority safety issues: workers falling from height, electric shock, workers stung by material lifted, fires or explosions, and the scaffolding collapsed. Based on root cause analysis, it showed that the most likely root cause of the problems was dominated by the human factor such as: fatigue due to overtime work, lack of experience and understanding of the procedure, lack of awareness of the importance of the ocupational safety and health. Keywords: construstion,risk assessment, root cause.

Comprehensive Venous Thromboembolism Prevention Programme Incorporating Mandatory Electronic Risk Assessment Reduces the Incidence of Hospital-Associated Thrombosis: A Single Centre Experience

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 363-363
Author(s):  
Lara N Roberts ◽  
Gayle Porter ◽  
Raj K Patel ◽  
Lynda Bonner ◽  
Roopen Arya
Keyword(s):  
Risk Assessment ◽  
Venous Thromboembolism ◽  
Bleeding Risk ◽  
Root Cause Analysis ◽  
Prevention Programme ◽  
Cause Analysis ◽  
Root Cause ◽  
Significant Difference ◽  
Analysis Programme ◽  
Anticoagulant Prophylaxis

Abstract Abstract 363 The national Venous Thromboembolism (VTE) Prevention Programme in England incorporates standardised guidance on risk assessment (RA) and thromboprophylaxis (TP) with a requirement for root cause analysis of all episodes of hospital associated thrombosis (HAT), defined as any VTE occurring whilst an inpatient or within 90 days of discharge. We previously reported findings of root cause analysis for HAT from 2010. We present updated findings from combined census of VTE RA and the root cause analysis programme at King's College Hospital, London over a 24 month period. A principal change in VTE RA process was the phased introduction of prompted electronic RA in 2011. Census data collection of RA identified a significantly higher median monthly RA rate in 2011 of 93.9% (IQR 92.3 – 94.5) compared to 85.8% (IQR 72.0–90.4; P=0.001) in 2010. The root cause analysis programme for HAT identified 192 episodes in 2011 compared to 236 events in 2010. The median number of events per month was significantly lower at 1.2 per 1000 admissions (IQR 0.8 to 1.4) in 2011 compared to 1.5 per 1000 admissions (IQR 1.3 – 1.8; P=0.023) in 2010. There was no significant difference in type of admission preceding HAT between 2010 and 2011 (medical 55.5% vs 47.4%, surgical 42.4% vs 49.5% and obstetric 2.1% vs 3.1% respectively). The proportion of HAT presenting as PE was lower in 2011 (36.7%) compared to 2010 (46.7%, P=0.07). The proportion of fatal PE was non-significantly lower in 2011 at 6.2% (n=12) compared to 2010 (7.3%, n=17). There was no significant difference in 90 day mortality between 2010 and 2011 (21.2% vs 19.3%). Root cause analysis was completed for 65.3% and 89.0% of HATs in 2010 and 2011 respectively. Of investigated episodes, RA was completed for 85.4% in 2011 compared to 43.9% (P<0.001) in 2010. RA rates in HAT were significantly lower than hospital wide rates of RA in 2010 (P=0.008) and 2011 (P=0.002). There was no difference in VTE risk between those who developed HAT in 2010 compared to 2011 (high VTE risk 93.3% vs 96.5% with concomitant high bleeding risk in 36.7% and 36.8% respectively). However, risk profile of those with HAT was significantly different to that identified in hospital wide TP audit of electronic patient records, where high VTE risk was identified in 86.1% (P<0.001) with concomitant bleeding risk in 22.5% (P<0.001). Of those with high VTE and low bleeding risk, significantly more patients with HAT received anticoagulant prophylaxis in 2011 (91.0%) compared to 2010 (72.1%, P=0.001). Of those with both high VTE and bleeding risk, there was no difference in the use of mechanical thromboprophylaxis between 2010 and 2011. The profile of underlying root cause was significantly different in 2011 with less HAT attributable to inadequate thromboprophylaxis (21.1% vs 30.7%, P=0.058), more events associated with a contraindication to anticoagulant prophylaxis (27.5% vs 18.1%, P=0.057) and significantly more events due to TP failure (40.9% vs 28.3%, P=0.024) compared to 2010. Electronic solutions to support VTE prevention combined with dedicated VTE training led to improved overall RA with a significant reduction in HAT of almost 20% over a two year period. A comprehensive VTE prevention programme significantly reduces preventable patient harm. Disclosures: No relevant conflicts of interest to declare.

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