5 why training 4-27-04

landscape Powerpoint Template*
Understanding of 5-Why
Critique Sheet
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As indicated previously, 5-Why is the prescribed tool to determine the root cause.
Global Supply Management - April 27, 2004
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5-WHY
After a supplier has submitted an initial response and containment plan (Step # 2 in the PRR process), a detailed investigation is necessary to determine what caused the problem. Step # 4 (Supplier determines the root cause) requires a 5-Why analysis to help in identifying the root cause of the problem.
Going back to one of the elements within the Purpose of a PRR “to facilitate problem resolution”, 5-Why is the prescribed tool for determining the root cause of the problem to facilitate problem resolution.
Where does it fit within the PRR process?
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Mention how the effective use of this tool can create the discipline needed in the process with Delphi and its supplier base.
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Who are the best at asking questions to solve problems?
…because they keep asking objective, open-ended questions until the answer is simple and clear
Children!
Why?
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When working with people to solve a problem,
it is not enough to tell them what the solution is. They need to find out and understand the solution for themselves. You help them do this by asking open-ended , thought provoking questions.
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by one word, often “yes” or “no”. Usually
gives a predetermined answer.
Example: “Did the lack of standardization cause the incorrect setup?”
Open-Ended:
person answering which draws out more
thought or research.
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Avoids predetermined answers
In many circumstances, it is not only the answer itself,
but the process by which the answer was determined
that is important when asking an Open-Ended question
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(Open-Ended, probing question forces the person to think about all
possibilities, not just PM)
“Would improving material flow help reduce lead times?”
(Good question but it’s still Close-Ended, focuses the person on material
flow as a means to reduce lead time. Is this the best improvement?)
“Did the lack of a PM system cause this tool to break?”
(Close-Ended question, can be answered by a “yes” or “no”, gives the
person a predetermined answer that PM is to blame)
“What are some options on improving lead time?
(Open-Ended, triggering more thought and research on all variables
impacting lead time.)
“Is equipment capability causing the variation in your process?
(Close-Ended, can be answered by a “yes” or “no”, focuses the person on
equipment being the source of variation)
“What could potentially cause variation in your process?
(Open-Ended, triggering more thought and research, opens up possibilities
of variation with man, material & method, not just machine)
More Examples
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Problem not detected:
System failure:
Why did our system allow it to occur?
Once the problem has been defined (as the customer sees it) a cause/effect relationship investigation for each path will help in determining the root cause.
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WHY?
Therefore
Use this path to investigate why the problem was not detected.
WHY?
Therefore
WHY?
Therefore
B
WHY?
Therefore
WHY?
Therefore
A
Use this path to investigate the systemic root cause (Quality System Failures)
WHY?
Therefore
WHY?
Therefore
C
WHY?
Therefore
WHY?
Therefore
B
Implement System Change Date:
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Part I – Grasp the Situation
Step 1: Identify the Problem
In the first step of the process, you become aware of a problem that may be large, vague, or complicated. You have some information, but do not have detailed facts. Ask:
What do I know?
Step 2: Clarify the Problem
The next step in the process is to clarify the problem. To gain a more clear understanding, ask:
What is actually happening?
What should be happening?
Step 3: Break Down the Problem
At this point, break the problem down into smaller, individual elements, if necessary.
What else do I know about the problem?
Are there other sub-problems?
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Step 4: Locate the Point of Cause (PoC)
Now, the focus is on locating the actual point of cause of the problem. You need to track back to see the point of cause first-hand. Ask:
Where do I need to go?
What do I need to see?
Who might have information about the problem?
Step 5: Grasp the Tendency of the Problem
To grasp the tendency of the problem, ask:
Who?
Which?
When?
It is important to ask these questions before asking “Why?”
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Is the problem statement clear & accurate?
Is the analysis on the problem as the customer sees it?
Step 2: Three Paths
Can you ask one, two, or three more Whys?
Is there a cause-and-effect relationship in each path?
Can the problem be turned “on” and “off”?
Does the path make sense when read in reverse?
Do the whys relate to the actual error?
Does the non-conformance path tie to design, operations, dimensional issues, etc.?
Does the detection path tie to the customer, control plans, etc.?
Does the systemic path tie to management issues or quality system failures?
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Is it possible to implement each corrective action?
Do corrective actions require Customer approval? If so, how will they be communicated to the Customer?
Is there evidence to support the validity of corrective actions?
Are corrective actions irreversible?If not, do actions address ongoing containment?
Is there a plan to standardize lessons learned across products, departments, etc?
Step 4: Lessons Learned
How will information be implemented?
On the line or in the plant?
At the point of detection?
Cross functionally at the Supplier?
Other products/plants?
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Are there things missed or not documented?
Do corrective actions address actions the Supplier owns?
How many iterations of 5 Why Analysis have there been?
Who prepared the 5 Why Analysis?
One person?
Sales representative ?
Clerk?

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The problem is stated through the eyes of the customer
Problem
Etc.
can demonstrate:
Why?
Therefore
Etc.
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chicken eggs
Root Cause
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lead times of all PPAP elements
Root Cause
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Root Cause
Did not react to the target submittal date
Why?
Therefore
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(Non-conformance)
Did not meet the annual business plan goal of a 10% increase in sales
Problem
“how” the goal would be reached
Root Cause
Did not thoroughly evaluate
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(Detection)
Did not meet the annual business plan goal of a 10% increase in sales
Problem
the status of reaching the goal
Root Cause
going to be met
(monthly, quarterly, etc.)
the goal until December
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At 7:00 a.m. this morning, Jake received a call from Janet, CSE at the Winding River Assembly Plant. Janet informed him that the customer had found five defective stabilizing brackets on second shift last night. She checked the remaining inventory and there were no defects in the remaining 326 pieces. The manufacturing sticker on the back of the brackets indicated that they were made by the second shift operator. Normally, the stabilizing bracket is fastened to the regulator motor with three rivets. The five defective brackets had only two rivets in them. The lower set of rivets on all five brackets was missing a rivet. This was the first time that the problem occurred.
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Jake set-up containment procedures at the plant warehouse to sort for discrepant materials. As of this morning, two more defective brackets had been found in the remaining 2019 pieces of inventory at Flex.
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Cause Investigation
Jake went out to the floor to talk with the team leader of the two rivet lines (East and West) and the area quality assurance auditor. He informed Sam (the team leader) of the quality problem and asked him to identify the line which runs the stabilizing bracket assembly. Sam directed Jake to the East line which runs Winding River assembly brackets only.
At the East Line, he spoke with Judy (the QA Auditor for the area) and asked to see the quality log sheets. Jake and Judy reviewed the Nov. 11th log sheet and could not find anything out of the ordinary. He asked her to set-up in-house containment procedures to sort for any discrepant material in the finished goods area.
Next, Jake tried to locate the second shift operator whose clock number was on the defective parts. Since that operator was gone, Jake spoke with the current machine operator (Ben). He asked Ben about any recent difficulties with the rivet machine. Ben said that he hadn’t noticed anything out of the ordinary. Ben also mentioned, however, that there had never been any quality bulletins posted in the two years that this particular part has been running.
Jake decided to stay in the area to watch the machine run for a while. After about 15 minutes, he watched Ben dump rivets into the feeder bowl to prepare for the next run.
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Cause Investigation
Shortly after restarting rivet operations, Ben walked over to another riveter and came back with a steel rod. Ben poked around the rivet chute and then continued working. Jake approached Ben and asked him about the steel rod. Ben replied that from time to time the chute gets jammed and he has to clear it out. This happens two or three times during a shift. He didn’t mention this in his earlier conversation with Jake because the problem has existed ever since he started working with this machine. The previous operator showed him how to clear the chute. All the rivet machines are like this.
Jake called the Machine Repair Department and asked that someone look at the rivet track. A slight gap in the track was found and removed, and Ben continued to work.
Two hours later, Jake got a call from Ben saying that the track was still jamming. As far as Jake could see, only rivets were in the bowl. Next, Jake looked into the rivet supplier containers. There was some foreign material in the blue container, but none in the red container. The label on the blue container showed that it was from Ajax Rivet, Inc., and the label on the red container indicated that it was from Frank’s Fasteners. Obviously, the foreign material was entering the rivet feeder bowl and jamming the track.
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Cause Investigation
Jake called Maintenance and requested that the bowl be cleaned. He also added the cleaning operation to the preventive maintenance schedule on the equipment. He then called both Ajax Rivet, Inc. and Frank’s Fasteners. He asked about the cleaning procedures on the returnable containers. Frank’s did a full container purge and clean. Ajax just re-introduced the containers back into their system. When Jake asked why Ajax did not clean their containers, he was told that Ajax was not aware that such a policy was needed.
Upon further investigation, Jake learned that Frank’s Fasteners supplies other major automotive companies. Since these companies require that all returnable containers be cleaned, Frank’s instituted the purge as part of its practice for all customers. Ajax Rivet, however, depends primarily on Flex as its major customer. No such policy has ever been required of them.
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Cause Investigation
Jake called the Material Control Department and requested that a container maintenance policy be drafted which would apply to all their suppliers. He also asked that a machine modification be developed to sense for the presence of rivets. Hopefully, this would error-roof the process.
Key Players
Ben Machine Operator
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WHY?
WHY?
WHY?
WHY?
Operator did not return
No standard rework procedures exist
Why did they
have to rework?
& needs to be addressed,
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WHY?
WHY?
WHY?
WHY?
Sensor was damaged
No system to
assure sensors are
& needs to be addressed,
of the lack of detection.
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A good 5-Why will answer “Yes” to the five PDCA questions:
PLAN
DO
CHECK
ACT
CLEAR and ACCURATE?
to verify the
to STANDARDIZE and take
all lessons learned across
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A
Burrs on the thread
PM intervals
dies after every run, minimum
1 x / day, to collect history
(L. Burg)
for all dies based on history
& mfg recommendations
(B. Clark)
monitor PM improvement
(M. Mendoeous)
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The plant received a PR/R from a customer. (We use 5-Why Analysis to answer every PR/R.)
The PR/R states that the customer received “Regular Cola in the right container (same for both products) with the Diet Cola label”. The order called for Regular Cola.
The plant has two identical lines that are capable of running either of our two products. The lines are located immediately beside each other. The only differences in the products are the syrup and the labels.
The plant runs both lines 24 hours per day. There are three shifts that run 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m.
The date code indicates that the defective product was manufactured at 3:03 p.m.
Defective product has been contained and sorted.
Generic Information for 5-Why Example: Regular Cola Soft Drink vs. Diet Cola
Objective: To use the 5-Why Problem-Solving Process in conjunction with brainstorming to investigate, solve, and report corrective actions in a problem-solving activity.
- Use only the information provided. The purpose of this activity is to use the 5-Why analysis chart to build a chain of cause/effect relationships that lead to the root cause, corrective actions and lessons learned.
- After the first attempt in using the 5-Why tool, reference the 5-Why Critique Sheet that follows to help you evaluate your work.
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INSPECT
LIDS
B
O
T
T
L
I
N
G
WATER
BOTTLES
SYRUP
LABELS
Graphical representation of the 5-Why sample exercise as a group.
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The plant received a PR/R from a customer. (We use 5-Why Analysis to answer every PR/R.)
The PR/R states that the customer received “Mixed/Foreign Material in Shipment”.
The supplied part is an “O” Ring seal for oil filter.
A cutting operation produces the part to specified size. As the raw material (cylindrical component) goes through the cutting operation, the irregular end-cuts are removed from the station.
Generic Information for 5-Why Real Example: “O” Ring Seal
Cutting Station
Mat’l Flow
Second example describing, in general terms, an actual quality situation at one of Delphi’s divisions.
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5-Why Critique Sheet
General Guidelines: A.) Don’t jump to conclusions!; B.) Be absolutely objective. C.) Don’t assume the answer is obvious. D.) If you are not thoroughly familiar with the process yourself, assemble a cross-functional team to complete the analysis.
Step 1: Problem Statement
Is the analysis being reported on the problem as the Customer sees it?
Step 2: Three Paths (Dimensional, Detection, Systemic)
-Are there any leaps in logic?
-Is this as far as the Whys lead? Can you still ask one, two, three more why’s)?
-Is there a true cause-and-effect path from beginning to end of each path? Is there statistical data/evidence to prove it? ---Can the problem be turned off and on?
-Does the path make sense when read in reverse from cause to cause? (e.g.—We did this, so this happened, so this happened, and so on, which resulted in the original problem.)
-Do the why’s go back to the actual error?
-Does the systemic path tie back to management systems/issues?
-Does the dimensional path ties back to issues such as design, operational, tier-n management, etc…?
-Does the detection path ties back to issues such as protect the customer, control plans, etc…?
For reviewing suppliers’ 5-Why as part of the PRR root cause analysis.
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5-Why Critique Sheet (cont)
Step 3: Corrective Actions
-Does each corrective action address the root cause from a path?
-Is there a separate corrective action for each root cause? If not, does it make sense that the corrective action applies to more than one root cause?
-Is each corrective action possible to implement?
-Are there corrective actions that affect the Customer or require customer approval? How will they be communicated to the Customer?
-Is there evidence and documentation to support the validity of the corrective actions?
-Are the corrective actions irreversible? If not, are there corrective actions in place that address containment?
Step 4: Lessons Learned
-How will this information be implemented:
a.) on the line or in the plant?
b.) at the point of detection?
c.) cross-functionally at the Supplier?
d.) other product/plants?
Step 5: Overall
-Do there seem to be big holes where ideas, causes,
corrective actions, or lessons learned are being avoided?
-Where things are missed or not documented?
-Do the corrective actions address what are the actions the supplier owns?
-How many iterations has the supplier gone through so far in preparing
this 5-why (It doesn’t happen on the first try!)
-Who prepared the 5-why?
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5-Why Analysis: Green, Yellow, Red
G: Can follow logic and flow of all 3 legs of 5 why's. The legs all differentiate "What is the problem, why wasn't it detected, and what happened systemically."
Y: All 3 legs filled out, some leaps of logic, needs minor corrections to improve.
R: 1 or 2 legs missing, Leg 1 repeated as leg 2 or 3, not understanding what the different legs mean--typically missing what the systemic leg is. Poor answers on 2 or more legs.
Corrective Action
with Responsibility
Implement System Change Date:

5 why training 4-27-04

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