77 lewis root cause -77 mors

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)1

http://www.mors.org/events/78thsym.aspx�

http://www.almc.army.mil/index.asp�



Solving Tomorrow’s Problems Today …And Resolving Yesterday’s Problems As Well.





Tutorial Presentation for the 78th MILITARY OPERATIONS RESEARCH SOCIETY Symposium

21 – 24 June 2010Marine Corps University,

Quantico, Virginia

Presented by Kenneth W. Lewis, Ph.D., 23 June 2010 @ 1215 Hours

US Army Logistics University Fort Lee, VA




78th MORS Symposium (MORSS)

PREMISE:All human beings look forward to achieving goals.

Goals might be Big or Small,Tangible or Intangible,Physical, Mental, Emotional,Career Oriented, Status Oriented, Finance Oriented,Military Oriented, Politically Oriented,Or Otherwise.

Regardless, all human beings look forward to achieving goals.

Goals are easier to grasp if they are SMART GOALS.

4





SMART Goals are

Specific Who? – What? – Which? – Where? – Why?are answerable.

Measureable How much? How many? How often?Attainable You can plan your steps to actually achieve

that goal.Realistic You have the will and the ability to work

towards achieving that goal.Timely That goal is Grounded within a timeframe.





So let us consider the GOAL …

… as the desired end state of some plan, process or procedure

Some carefully executed plan …Some ingeniously produced widget …Some thoughtfully offered service …Some successful emergency response …

6





That plan might be … “Operation Eagle Claw” – April 1980

That Product or Widget might be … the V-22 Osprey Tilt-Rotor Aircraft – 1984 to Present

That Program might be … Space Shuttles Challenger January 1986 or

Columbia February 2003

That Service might be … the JCIDS or CBA process – March 2002

That Emergency Response might be …The BP Gulf Coast Oil Spill Disaster of 2010

They all represent some military related examples of plans, products, procedures, which have been executed, produced, implemented with some desired outcome or GOAL.

7





Recent Problems:

•Haiti Earthquake Disaster and Recovery Capability Gap•British Petroleum Oil Disaster and Recovery Capability Gap in the Gulf Coast•US Army Velcro Capability Gap

8

BP oil leak: now partner company says firm was "reckless" as public relations disaster gets worse Photo: EPA/US COAST GUARD



http://www.khurak.net/haiti-earthquake-facts-0012609/haiti-earthquake-facts/�

http://www.telegraph.co.uk/finance/newsbysector/energy/oilandgas/7842322/BP-oil-spill-could-be-nearly-double-original-estimates-internal-document-shows.html�





http://www.telegraph.co.uk/news/worldnews/asia/afghanistan/7831702/Casualty-of-war-US-army-dumps-Velcro-for-buttons.html�



History of the previous slide recallsthat the actual outcomes did not align with the desired or expected outcomes.

There was Discrepancy – Discord – Separation between the actual and desired end state or goal.

What you see is what you get. – Flip Wilson, ComedianWhat you get is not what you expected. – Discrepancy What did you expect?

There was VARIABILITY!- Behavior Not True to Type – Aberrant – Subject to Change (Merriam-Webster)

9





The Inquisitive OR Analyst will look at the actual outcome, compare it to the desired outcome or goal, and then begin to ask

WHY? WHY? WHY? WHY? WHY?

The answer to “WHY?” lies in the Root Cause that led to that variability of the GOAL.

So we begin the journey of finding the WHY by conducting a Root Cause Analysis –

A part of the Six Sigma process that seeks to identify problematic causes of operational failures so that a solution can be put in

place which will solve that problem and/or prevent reoccurrence of that problem.

10





Abstract:

Variability = Descrepancy between Observed and Desired Outcomes.Variability in plans, products, services is inevitable.

Variability is problematic when•variability is not explainable.•variability results in an unsatisfactory outcome.

Identification of root causes of variability allows us to• minimize variability associated with outcomes,• maximize likelihood of achieving satisfactory outcomes, • create and implement action plans to maintain desired outcomes.

Review of Six Sigma Tools will help• Identify root causes of variability,• Provide remedies to potential problems due to variability,• Improve quality of desired outcomes of plans, products, or services.• Prevent future incidents –Source: Walker (2000)IELD DEMONSTRATION WORKSHOP ON ROOT CAUSE ANALYSIS FOR MARINE CASUALTIES AND ENVIRONMENTAL INCIDENTS

11



http://www.uscg.mil/hq/cg5/cg5211/docs/RBDM_Files/PDF/RBDM_Guidelines/Volume 4-Resources/Example Root Cause Analysis.doc.�



Brief Overview of Six Sigma

Question: What is the Six Sigma Foundation?

Answer: To improve business or enterprise processes by using theDMAIC approach to problem solving.

Process Steps:

1) Defining Opportunities (What is Important?)2) Measuring Performance (How are we doing?)3) Analyzing Opportunity (What is Wrong or What is currently happening?)4) Improving Performance (What needs to be done?)5) Controlling Performance (How do we sustain performance?)





Brief Overview of Six Sigma Tools

Improvement teams use the DMAIC methodology to root out and eliminate the causes of defects:

D - Define a problem or improvementopportunity.

M - Measure process performance.A - Analyze the process to determine the

root causes of poor performance;determine whether the process canbe improved or should be redesigned.

I - Improve the process by attacking rootcauses.

C - Control the improved process to holdthe gains.

Source: http://www.asq.org/learn-about-quality/six-sigma/overview/dmaic.html

The DMAIC Methodology

Measure

Modify Design? Redesign

Control

Analyze

Improve

Define



http://www.asq.org/learn-about-quality/six-sigma/overview/dmaic.html�









Brief Overview of Lean Six Sigma

Lean Six Sigma is distinguished from other quality systems by several themes:

• Focus on the customer rather than process, inputs, or outputs. • Data- and fact-driven management:

with an emphasis on measurement of quantitative data.• Process is the key vehicle of success. – monitoring the input, throughput, and output• Proactive management.

Implementing Six Sigma in an organization requires a high level of management buy-in. The work is delegated, but accountability is not.

• Emphasis on root causes:digging down beyond proximal causes to find what is really going on.

• Creating sustained changes, with control mechanisms in place to ensure changes aresustained over the long term.

Source: What is Six Sigma?, Pete Pande and Larry Holpp, McGraw-Hill, 2002.





Definitions:

Root Cause Analysis (RCA)A structured evaluation method that identifies the root causes for an undesired outcome (event) and the actions adequate to prevent recurrence.

Event or the ProblemA real-time occurrence describing one discrete action, typically an error, failure, or malfunction.Examples: pipe broke, power lost, lightning struck, person opened valve, etc…

Cause (Causal Factor)Root cause analysis should continue until organizational factors have been identified, or until data are exhausted. The antecedent behavior that led to the observed final behavior.

Source: www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf



http://www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf�



Definitions:

Proximate Cause(s)The event(s) that occurred, including any condition(s) that, existed immediately before theundesired outcome, directly resulted in its occurrence and, if eliminated or modified, would haveprevented the undesired outcome. Also known as the direct cause(s).

Root Cause(s)One of multiple factors (events, conditions or organizational factors) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated, or modified would have prevented the undesired outcome. Typically multiple root causes contribute to an undesired outcome.

ConditionAny as-found state, whether or not resulting from an event, that may have safety, health, quality,security, operational, or environmental implications.







Definitions:

Organizational FactorsAny operational or management structural entity that exerts control over the system at any stage inits life cycle, including but not limited to the system’s concept development, design, fabrication,test, maintenance, operation, and disposal. Examples: resource management (budget, staff,training); policy (content, implementation, verification); and management decisions.

Contributing Factor(s)An event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence.

BarrierA physical device or an administrative control used to reduce risk of the undesired outcome to anacceptable level. Barriers can provide physical intervention (e.g., a guardrail) or procedural separation in time and space (e.g., lock-out-tag-out procedure).







• Clearly define the undesired outcome.• Conduct “5 Whys” analysis to identify root causes.• Create an event and causal factor tree.• Gather data, including a list of all potential causes.• Check your logic and eliminate items that are not

causes.• Generate solutions that address both proximate

causes and root causes.Source: www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf

Overview of Steps in Root Cause Analysis






Root Cause Analysis Techniques for this Presentation

• Identify the Problem• Identify the Key Performance Parameters or Indicators• Apply the “5 Whys” Technique• Apply the Ishikawa Fishbone Cause and Effect Chart Technique• Apply the Pareto Chart Technique• Apply the Failure Modes and Effects Analysis Technique• Apply the Control Plan or Action Plan

+ 8 Tutorial Assignments





Assignment #1

Identify a recurring military problem related to:1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis





Assignment #2

Identify those key performance parameters or indicators used to measure success or failure of the plan, product or service related to that recurring military problem related to:1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis





Assignment #3

Use the “5 Whys?” technique to Identify the root cause of that recurring military problem related to:1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis





The 5 Why's Root Cause Analysis Technique

By repeatedly asking the question "Why" at least five times, you can peel away the layers of symptoms which can lead to the root cause of a problem.

Why? Why? Why? Why? Why?

Source: http://www.emsstrategies.com/dd020106article.html



http://www.emsstrategies.com/dd020106article.html�



“Five Whys?” Chain of Causation Example

Problem: Injuries occur with great frequency.

Effects Causes

Injury Caused by Fall

Fall Caused by Wet Surface

Wet Surface Caused by Leaky Valve

Leaky Valve Caused by Seal Failure

Seal Failure Caused by Poor Maintenance

Source: Quality Progress: October 2008





Effects Causes

Loss of Kingdom Caused by Loss of Battle

Loss of Battle Caused by Loss of Rider

Loss of Rider Caused by Loss of Horse

Loss of Horse Caused by Loss of Shoe

Loss of Shoe Caused by Loss of Nail

Loss of Nail Caused by ?????????

“Five Whys?” Chain of Causation ExampleProblem: The Kingdom of Liberty and Freedom was lost.

Can you do this with the Army Velcro Problem?





5-Why’s Exercise - Jefferson Memorial, Washington, DC - True Story

Problem:Excessive amounts of seagull droppings were requiring the monument to be pressure washed much more frequently than other memorials, causing erosion and deterioration of the granite.

Inquiry:How Might We Stop the Seagulls from Swarming around the Jefferson Memorial?

Source: Terry Madden (2005)http://74.125.93.132/search?q=cache:jjmZJ8xd3z0J:www.irmi.com/conferences/crc/handouts/crc25/workshops/cuttingedgesafetyapplyinglean.pdf+root+cause+analysis+jefferson+memorial&cd=6&hl=en&ct=clnk&gl=us



http://74.125.93.132/search?q=cache:jjmZJ8xd3z0J:www.irmi.com/conferences/crc/handouts/crc25/workshops/cuttingedgesafetyapplyinglean.pdf+root+cause+analysis+jefferson+memorial&cd=6&hl=en&ct=clnk&gl=us�






5-Why’s Exercise - Jefferson Memorial, Washington, DC - True Story

Possible Solutions:• Elaborate system of spikes and nets (high- cost solution)• Loud noises to chase off the birds (and tourists)• Kill the birds• Or, let’s ask “why?” several times...

Source: Terry Madden (2005)http://74.125.93.132/search?q=cache:jjmZJ8xd3z0J:www.irmi.com/conferences/crc/handouts/crc25/workshops/cuttingedgesafetyapplyinglean.pdf+root+cause+analysis+jefferson+memorial&cd=6&hl=en&ct=clnk&gl=us









5-Why’s Exercise - Jefferson Memorial, Washington, DC –True Story (cont.) Source: Terry Madden (2005)

• The Jefferson Memorial is requiring excessive power washes. Why?• Because seagulls are swarming to the monument and depositing large

amounts of droppings. Why?• Because they are feeding on an unusually large amount of spiders living

under the roof line. Why?• Because the spiders are feeding on an unusually high number of midge

flies as they hatch throughout the day. Why?• Because midge fly larva is literally caked under the roof line of the

memorial. Why? ………






Root Cause...As it turns out, the lights that illuminate the memorial were set to come on automatically 20 minutes before dusk. This twilight condition created a ideal condition for midge flies to mate.






Solution: The automatic lights were reset to reduce the twilight condition

Result:– Fewer midge flies– Fewer spiders– Fewer seagulls– Less droppings– Fewer power washings– Slower Deterioration of the Jefferson Memorial





http://www.slideshare.net/gibsonjunkie/jefferson-memorial

Jefferson Memorial Slide Show



http://www.slideshare.net/gibsonjunkie/jefferson-memorial�





Assignment #4

Identify those categories of causation that contribute to the variability in outcome of the plan, product or service of that recurring military problem related to:

1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis





Causal Categories:


Categories Categories Categories

Man Machine Equipment

Machine Method Process

Material Measurement People

Method Material Material

Measurement People Management

Mother Nature Environment Environment






Other Causal Categories:


Categories Categories Categories

Method Doctrine Political Element

Machine Organization Military Element

Material Training Economic Element

Management Materiel Social Element

Manpower Leadership and Education

Information Element

Personnel Infrastructure Element

Facilities Physical Environment Element

Time Element






CONTEMPORARY OPERATIONAL ENVIRONMENT VARIABLES (PMESII-PT)

Political. Describes the distribution of responsibility and power at all levels of governance or cooperation.

Military. Explores the military capabilities of all relevant actors in a given operational environment.

Economic. Encompasses individual behaviors and aggregate phenomena related to the production, distribution, and consumption of resources.

Social. Describes the cultural, religious, and ethnic makeup within an operational environment.

https://rdl.train.army.mil/soldierPortal/atia/adlsc/view/public/10536-1/FM/2-0/chap1.htm;jsessionid=hGfGJ2qZ3C3hghQGGP88HvSSXhcKsc3pYQ1KB62r1TLw7b1yy9vb!467865



https://rdl.train.army.mil/soldierPortal/atia/adlsc/view/public/10536-1/FM/2-0/chap1.htm;jsessionid=hGfGJ2qZ3C3hghQGGP88HvSSXhcKsc3pYQ1KB62r1TLw7b1yy9vb!467865�




CONTEMPORARY OPERATIONAL ENVIRONMENT VARIABLES (PMESII-PT)

Information. Describes the nature, scope, characteristics, and effects of individuals, organizations, and systems that collect, process, disseminate, or act on information.

Infrastructure. Is composed of the basic facilities, services, and installations needed for the functioning of a community or society.

Physical Environment. Defines the physical circumstances and conditions that influence the execution of operations throughout the domains of air, land, sea, and space.

Time. Influences military operations within an operational environment in terms of the decision cycles, operational tempo, and planning horizons. (FM 3-0)

https://rdl.train.army.mil/soldierPortal/atia/adlsc/view/public/10536-1/FM/2-0/chap1.htm;jsessionid=hGfGJ2qZ3C3hghQGGP88HvSSXhcKsc3pYQ1KB62r1TLw7b1yy9vb!467865







The Fishbone Diagram Root Cause Analysis Technique:

•Causal Categories resemble the skeleton of a fish. •The failure event or problem is stated in the box to the right. •Major causes are usually summarized as Methods, Measurements, Machines,Materials, and People.

Under each category, identify potential causes for the problem relating to the category.

For example: Incorrect parts being delivered to the assembly area is a potential cause for the “Materials” category.







Ishikawa Fishbone Diagram - Wikipedia



http://upload.wikimedia.org/wikipedia/commons/5/52/Ishikawa_Fishbone_Diagram.svg�



Fishbone Diagram Example





The nail was lost.





Operation Eagle Claw RememberedOperation Eagle Claw rememberedthe members from the 8th Special Operations Squadron who died in the fatal accident during Operation Eagle Claw were (from left to right) Capt. Richard Bakke, Tech. Sgt. Joel Mayo, Capt. Lyn McIntosh, Capt. Hal Lewis and Capt. Charles McMillan. (Courtesy photo)

The wreckage that was left after the RH-53 Sea Stallion Helicopter and MC-130 Aircraft collided in the desert during Operation Eagle Claw April 25, 1980. (Courtesy photo)Source: http://www.hurlburt.af.mil/news/story_media.asp?id=123095779



http://www.hurlburt.af.mil/news/story_media.asp?id=123095779�

http://www.hurlburt.af.mil/news/story_media.asp?id=123095779�



Recent Problems:

•Haiti Earthquake Disaster and Recovery Capability Gap•British Petroleum Oil Disaster and Recovery Capability Gap in the Gulf Coast•US Army Velcro Capability Gap

42

BP oil leak: now partner company says firm was "reckless" as public relations disaster gets worse Photo: EPA/US COAST GUARD



http://www.khurak.net/haiti-earthquake-facts-0012609/haiti-earthquake-facts/�






http://www.telegraph.co.uk/news/worldnews/asia/afghanistan/7831702/Casualty-of-war-US-army-dumps-Velcro-for-buttons.html�



People

British Petroleum Oil Spill Disaster 2010

ProcessEquipment

Management MaterialEnvironment

The BPBlowout PreventerDevice Failed





Assignment #5

Use your chosen categories of causation to construct a Fishbone Cause and Effect Diagram for that recurring military problem related to:1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis





Creating A Cause-and-Effect DiagramPlace the problem in the square to the right and construct a fish vertibrae with 5, 6, or 7 extensions. The 6 basic categories are easily remembered from the anagram "5 ME". Source: http://thequalityweb.com/cause.html

MAN - Does the operator have the proper training, experience, and ability to perform the function?

METHOD - Are the work instructions available and up-to-date? Do they reflect the best method to perform the task? Are the proper tools available? Are the process parameters specified clearly?

MACHINE - Does the machine have the capability to produce the product as specified? Does the machine have the ability to produce the product on a consistent basis? Are there regular routine maintenance and preventative maintenance tasks? Are they performed according to schedule?

MATERIAL - Are the correct materials available for the process? What is the quality of the material used in the process? Is there more than one supplier and does quality vary with different suppliers? What types of material problems could exist?

MEASUREMENT - Are the measurement instruments adequate for the process? Are they maintained correctly and regularly calibrated? Are the measurement instruments affected by environmental conditions such as temperature, vibration, dirt, etc.?

ENVIRONMENT - Is the manufacturing environment affected by temperature, humidity, dust and dirt, power fluctuations or seasonal differences?



http://thequalityweb.com/cause.html�



People Machines Measurements

Methods Materials

Incorrectly Assembled Parts

CommunicationTraining

Standard Work Charts

incorrect

Incorrectparts

delivered to line

FixturesAble to

assemble

incorrectly - no

poke-a-yoke

Not verified at

process

Inexperienced

operators not

trained as well

as others.

Lack of

communication

between

testers and

assemblers.







The Pareto Chart Analysis Technique Source: http://www.schools.utah.gov/sars/servicesinfo/module4/04pchart.pdf

Pareto Chart - Named after Vilfredo Pareto, a 19th century economist who postulated that a large share of wealth is owned by a small percentage of the population.

The descending bar chart is used to separate the “vital few” from the “trivial many”.

Based on the Pareto Principle which states that 80 percent of the problems come from 20 percent of the causes.

A Pareto Chart can answer the following questions: o What are the largest issues facing our team or business? o What 20% of sources are causing 80% of the problems? o Where should we focus our efforts to achieve the greatest improvements?



http://www.schools.utah.gov/sars/servicesinfo/module4/04pchart.pdf�




When is the Pareto Chart useful?The Pareto analysis technique is used primarily to identify and evaluate nonconformities

Pareto Charts convey information in a way that enables you to see clearly the choices that should be made, they can be used to set priorities for many practical applications. Some examples are:

o Process improvement efforts for increased unit readiness o Skills you want your division to have o Customer needs o Suppliers o Investment opportunities

-







Consider the following example:Your business was investigating the delay associated with processing credit card applications. You could group the data into the following categories and their frequencies of occurrence.

Category Frequency No address 9 Illegible 22 Current customer

15

No signature 40 Other 8 Total 94

Category Frequency No signature 40 Illegible 22 Current customer

15

No address 9 Other 8 Total 94

Step 1Construct a Frequency Chart

Step 2 Order the categories according to descending frequency.






Category Frequency Percentage Cumulative Percentage

No signature 40 43% 43% Illegible 22 23% 66% Current customer 15 16% 82% No address 9 10% 92% Other 8 8% 100%

Step 3 and Step 4Compute Relative Frequencies and Cumulative Relative Frequencies







Step 5 Draw the descending bar chart and the cumulative line graph together

Frequency 40 22 15 9 8Percent 42.6 23.4 16.0 9.6 8.5Cum % 42.6 66.0 81.9 91.5 100.0

CategoryOthe

r

No Add

ress

Curren

t Cus

tomer

Illegib

le

No Sign

ature

90

80

70

60

50

40

30

20

10

0

100

80

60

40

20

0

Freq

uenc

y

Perc

ent

Pareto Chart of Category







Things to look for on your Pareto Chart: In most cases, two or three categories will tower above the others. These few categories which account for the bulk of the problem will be the high-impact points on which to focus. If in doubt, follow these guidelines:

1. Look for a break point in the cumulative percentage line. This point occurs where the slop of the line begins to flatten out. The factors under the steepest part of the curve are the most important.

2. If there is not a fairly clear change in the slope of the line, look for the factors that make up at least 60% of the problem. You can always improve these few, redo the Pareto analysis, and discover the factors that have risen to the top now that the biggest ones have been improved.

3. If the bars are all similar sizes or more than half of the categories are needed to make up the needed 60%, try a different breakdown of categories that might be more appropriate.







Assignment #6

Using your chosen categories of causation and associated frequencies of occurrences construct a Pareto Chart for that recurring military problem related to:






The District 11 Southern Region (SR) Auxiliary Strategic Plan for 2007-2008:The District 11 of the Southern Region (SR) reviewed its Strategic Plan of 2005-6:Issues of review included:

- With the Management tools of SWOT Analysis (Strengths – Weaknesses – Opportunities – Threats)- Balanced Score Card- Pareto Chart Analysis

Problems IssuesUnavailable fuel for Patrols Operations IssuesCoast Guard Training to serve the Sector needs

Human Resource Issues

AUX Structure Alignment Organizational Management IssuesCommunication Technology IssuesAUX Officer Training Facilities Issues

Source: DISTRICT 11 (SR) AUXILIARY STRATEGIC PLAN 2007-2008





Pareto Chart Analysis Findings:Weaknesses in Coast Guard Operations1. New Boat Crew requalification requirements2. Poor bottom to top chain of communications3. Old, poorly maintained facility equipment4. Poor direction for MOM (Marinetime Observation Mission) patrols5. Members on limited income find it hard to participate6. Limited planning and goals






Pareto Chart Analysis FindingsWeaknesses in Coast Guard Human Resources1. Average age of the member is over 502. Low membership participation (80/20 rule)3. Poor emphasis on member retention4. Poor mentoring5. AP status requires too much time6. Members don’t follow chain of leadership7. Poor recruitment of youth8. No plan in flotillas for new members9. Need more emphasis on Elected Officer training at flotilla and Division10. Need more qualified coxswains11. Too much paperwork12. Too many levels in the organization






Pareto Chart Analysis FindingsWeaknesses in Coast Guard Organizational Management1. Poor communication by leaders2. Staff officers are not effective3. Flotillas struggle to survive with poor focus on increasing membership4. Poor inter-flotilla communications5. Members get positions based on popularity not ability6. Low/no funding for staff7. Excessive levels of leadership8. Too much paperwork/forms and reports required






Pareto Chart Analysis FindingsWeaknesses in Coast Guard Technology/Facilities1. Not enough facilities2. Communications with older age members is challenging3. Not enough emphasis to members to view web sites for communications4. POMS to fragile5. Emphasis on E learning not available to all members6. No FAQ on web sites7. Inputting of data into AUXDATA is by a volunteer member and may not be

inputted or slow to input8. CG is reluctant to pay damage claims9. CG will not furnish boats in this district increasing wear-tear on member

boats






Coast Guard Study Findings

Using the SWOT analysis, it was found that the top area weakness was OPERATIONS.

The second weakness was poor bottom to top CHAIN of COMMUNICATIONS.






Failure Modes and Effects Analysis (FMEA)Also called: potential failure modes and effects analysis; failure modes, effects and criticality analysis (FMECA). Description Failure modes and effects analysis (FMEA) is a step-by-step approach for identifying all possible failures in a design, a manufacturing or assembly process, or a product or service. Source: http://www.asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html



http://www.asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html�



Types of FMEA System - focuses on global system functions

Design - focuses on components and subsystems

Process - focuses on manufacturing and assembly processes

Service - focuses on service functions

Software - focuses on software functions

Source: http://www.npd-solutions.com/fmea.html



http://www.npd-solutions.com/fmea.html�



FMEA Procedure

1. Describe the plan/process/product/program and its functions.

2. Populate the FMEA table with necessary identification information.

3. Identify the function or functions associated with the plan/process/product/program.

4. Identify the failure mode, i.e., what could go wrong.

http://www.npd-solutions.com/fmea.html






4. Identify Failure Modes. A failure mode is defined as the manner in which a component, subsystem, system, process, etc. could potentially fail to meet the design intent. Examples of potential failure modes include: Corrosion Hydrogen embrittlement Electrical Short or Open Torque Fatigue Deformation CrackingBreakage


FMEA Procedure (cont.)






5. Identify potential EFFECTS of each failure mode. Examples of failure effects include: Injury to the user Inoperability of the product or process Improper appearance of the product or process Odors Degraded performance NoiseDeath








6. Assign a SEVERITY rating from the SEVERITYscale indicating the magnitude of the failure effect.1 = not severe. 10 = catastrophic.










FMEA Procedure (cont.)Severity Scale

Rating Description Definition (Severity Scale)

10 Extremely dangerous

Failure could cause death of a customer (patient, visitor, employee, staff member, business partner) and/or total system breakdown.

98

Very dangerous Failure could cause major or permanent injury and/or serious system disruption with interruption in service.

7 Dangerous Failure causes minor to moderate injury with a high degree of customer dissatisfaction and/or major system problems requiring major repairs or significant re-work.

65

Moderate danger Failure causes minor injury with some customer dissatisfaction and/or major system problems.

43

Low to Moderatedanger

Failure causes very minor or no injury but annoys customers and/or results in minor system problems that can be overcome with minor modifications to system or process.

2 Slight danger Failure causes no injury and customer is unaware of problem however the potential for minor injury exists; little or no effect on system.

1 No danger Failure causes no injury and has no impact on system.

Source: Goodman (1996)





7. Identify the causes for each failure mode. A failurecause is defined as a design weakness that mayresult in a failure. Examples of potential causes include: Improper torque applied Improper operating conditions Contamination Erroneous algorithms Improper alignment Excessive loading Excessive voltage










7. Assign an OCCURRENCE rating from the OCCURRENCE scale indicating the magnitude of the failure cause.1 = Virtually certain not to occur.

10 = Virtually certain to occur.










Rating Description Potential Failure Rate10 Certain probability of occurrence Failure occurs at least once a day.

1 in 59 Failure is almost Inevitable Failure occurs every 3 or 4 days.

1 in 1087

Very high probability of occurrence Failure occurs once per week.1 in 50

65

Moderately high probability ofoccurrence

Failure occurs once per month.1 in 100

43

Moderate probability of occurrence Failure occurs once every 3 months.1 in 500

2 Low probability of occurrence Failure occurs once per year.1 in 1000

1 Remote probability of occurrence Failure almost never occurs; no one remembers last failure.

FMEA Procedure (cont.)Occurrence Scale

Source: Goodman (1996)





8. Identify Current Controls (design or process). Current Controls (design or process) are the mechanisms that prevent the cause of the failure mode from occurring or which detect the failure before it reaches thecustomer.Detection is an assessment of the likelihood that the Current Controls (design and process) will detect the Cause of the Failure Mode or the Failure Mode itself, thus preventing it from reaching the Customer.










Examples of Current Controls (design or process) might include:Temperature GaugeEarly Warning SystemTwo ProofreadersBank Notice that your account is below a certain amountLexus Rear View Camera when in reverse










8. Assign a DETECTION rating from the DETECTIBILITY scale indicating the magnitude of the failure effect.1 = Virtually certain to Detect.

10 = Virtually certain not to Detect.









78th MORS Symposium (MORSS)75Source: Goodman (1996)

FMEA Procedure (cont.)Detection Scale

Rating Description Definition10 No chance of

detectionThere is no known mechanism for detecting the failure.

98

Very Remote /Unreliable

The failure can be detected only with thorough inspection and this is not feasible or cannot be readily done.

76

Remote The error can be detected with manual inspection but no process is in place so that detection left to chance.

5 Moderate chance ofdetection

There is a process for double-checks or inspection but it is not automated and/or is applied only to a sample and/or relies on vigilance.

43

High There is 100% inspection or review of the process but it is not automated.

2 Very High There is 100% inspection of the process and it is automated.

1 Almost Certain There are automatic “shut-offs” or constraints that prevent failure.





9. Compute Risk Priority Numbers (RPN). The Risk Priority Number is a mathematical product of the numerical Severity, Occurrence, and Detection ratings:

RPN = (Severity) x (Occurrence) x (Detection)RPN values may range from 1 to 1000.

The RPN is used to prioritize items than require additional quality planning or action.


FMEA Procedure






10. Determine Recommended Action(s) to address potential failures that have a high RPN.

- Assign Responsibility and a Target Completion Date forthese actions.- Indicate Actions Taken. After these actions have beentaken, re-assess the severity, probability and detection and review the revised RPN's.

- Update the FMEA as the design or process changes, the assessment changes or new information becomes known.








http://www.asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html

FMEA Example

Function Potential Failure Mode

Potential Effects of Failure

S Potential Cause(s) of Failure

O Current Process Controls

D RPN

CRIT(S x O)

Dispense amount of cash requested by customer

Does not dispense cash

Dissatisfied Customer

Incorrect entry to demand deposit system

Discrepancy in cash balancing

8 Out of Cash

Machine jams

Power failure during transaction

5

3

2

Internal low cash alert

Internal jam alert

None

5

10

10

200

240

160

40

24

16

Dispenses too much cash

Bank loses money

Discrepancy in cash balancing

6 Bills stuck together

Denominations in wrong trays

2

3

Loading procedure (ruffle ends of stack)

Two-person visual verification

7

4

84

72

12

18

Takes too long to dispense cash

Customer is somewhat annoyed

3 Heavy computer network traffic

Power interruption during transaction

7

2

None

None

10

10

210

60

21

6












http://www.asq.org/img/laq/fmea-fig1.gif�



Reliability Analysis Quick Subject Guide

Source: http://www.weibull.com/basics/fmea.htm



http://www.weibull.com/basics/fmea.htm�



Assignment #7

Conduct a FMEA for that recurring military problem related to: ex: British Petroleum Blowout Preventer








The Failure Mode and Effects Analysis Approach actually provides a very nice segue into the last technique known as Quality Control or Action Plan.






Control Techniques

Quality Control-To effectively maintain new standard methods, you really need to:· Verify the results and validate that changes adhere to all operating and compliance policies.

· Document the new methods in such a way that people will find them easy to use, and provide training to everyone who will use the new methods.

· Monitor implementation and make regular course corrections.· Summarize your learning and share them with co-workers involved in

similar projects, with customers, and with managers who need to know the final outcome.

· Think about what should be taken on next in the process to further improve the sigma level(s).

http://www.thequalityweb.com/controlsixsig.html



http://www.thequalityweb.com/controlsixsig.html�



Control Techniques

1. Control charts2. Data Collection3. Flow diagrams4. Charts to compare the before and after, such as

frequency plots, Pareto charts, etc.5. Quality Control Process Chart6. Establishing Standardization (Control Plan)

http://www.thequalityweb.com/controlsixsig.html



http://www.thequalityweb.com/controlsixsig.html�



Assignment #8

Write a Quality Control Action Plan that will provide documentation and instructions on how to maintain the new found quality of your solution to that recurring military problem related to:






A Tutorial Review

•We detected and identified a problem.•We identified key performance parameters or indicators for that problem.•We conducted a “5 Whys?” analysis to identify the root cause of that problem.•We identified categories of causation for variability of that problem.•We constructed a Fishbone Cause and Effects Chart for that problem.•We performed a Pareto Chart Analysis of causes of that problem.•We conducted a FMEA related to that problem.•We identified some fixes to that problem with the FMEA table.•We created a Quality Control plan or Action Plan for the maintenance of the

quality of the solution(s) to that problem. … … …





CLOSING:

-We have devised a way to minimize variability.-We have a better perspective on making sure the desired outcome and the actual outcome are one in the same.

-We have defeated the battle against discrepancy. -Our plans, products, processes, programs and procedures willyield our desired results and help us achieve our SMART goals.

- Operation Eagle Claw, the JCIDS process, the OSPREY, the Space Shuttles Challenger and Columbia programs were not vainly wasted.

-So thanks to Root Cause Analysis …





For quality of the nail, the shoe will not be lost.



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For quality of the shoe, the horse will not be lost.



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For quality of the horse, the rider will not be lost.



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For quality of the rider, the battle will not be lost.



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For victory in battle, the kingdom will not be lost.



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For protecting the kingdom, freedom and liberty will never be lost.



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And all for the quality of a nail...





Well, …. Almost. Anybody got a nail?

Source http://www.guardian.co.uk/environment/2010/jun/20/gulf-oil-spill-bp-lying



http://www.guardian.co.uk/environment/2010/jun/20/gulf-oil-spill-bp-lying�












The root cause of success.

Go forth into the world rejoicing in the spirit of Quality and accomplishing your desired Goals.

Thanks be to Quality!





Solving Tomorrow’s Problems Today …

And Resolving Yesterday’s Problems As Well.





Thank You!

Questions ??



77 lewis root cause -77 mors

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