root cause analysis - beechcraft

Training Materials – For Reference Only Slide 1

Finding and eliminating (forever) the root cause of a problem.

HBC 8D Process for Problem Solving

Course Duration: 4.0 hours

Presenter�

Presentation Notes�

Welcome to Root Cause Analysis Training. This class has been designed to give you additional information and methods that you will be able to apply to analyze the root cause of those problems that just keep cropping up because, they have never been traced all the way back to their true source. �


Course Objectives

At Completion YOU should:• Understand HBC’s 8D process• Know when to use the 8D Process• Be able to write an 8D Summary Report• Be comfortable using typical problem solving tools• Know how to get additional help/training

I hear...I forget I see...and I remember I do...and I understand Ancient Chinese Proverb

Presenter�


“At the end you will know when to use the tools that you will learn: Problem Solving, Decision Making, Planning and Problem Prevention, and be able to write an 8D report”. “Assessing Questions are used to double check your work through each discipline to see if you are ready to move on to the next step”. “How many of you have written an 8D before?” “Did you use a team?” “How many of you have customers that want an 8D completed today?” That is possible to a certain extent. “How many get 8D’s from your suppliers?” “Are they good ones or do the problems come back again?” “We’re going to be talking about these things in this course.” �


• Origin of HBC’s 8D process• Fit with:

– Hawker Beechcraft Performance System (HBPS) Initiatives– Existing processes

• Overview of the 8 Steps0 - Decide to use the HBC 8D Process1 - Describe the Problem2 - Assemble a Team3 - Implement Interim Containment4 - Find Root Cause5 - Develop Corrective Action6 - Implement Permanent Fix7 - Prevent Recurrence8 - Recognize the Team

• Additional Information – contacts, reference material

Agenda

Presenter�


As you all know, in order to solve a problem, you need to know exactly what the problem is, before you can search for the solution. In this class we will talk about the tools and processes that can assist you through: Problem definition Understanding the problem causes Evaluating the problem solutions �


Round Robin Introductions

• Your Name• Where you work -

position/responsibilities• Personal objectives for this course

Presenter�


Read Slide - - - Instructor go first (Write objectives on flip chart) put check marks by those that are repeats Explain team set-up (mixed locations, expertise - cross functional) Tell them that they will be working on wall charts on areas near them Remove objective sheet and tape to wall out of site. At this point I also tell them I will be giving lectures up here so just listen. Most of this stuff is somewhere in their books. However, if something really strikes them, write it down. Note: You’ll be posting many important points. �


• Root Cause: The very basic reason why, how, & when the condition occurred.A Root Cause Mentality: An insatiable desire to understand why things go wrong, why people do what they do, and how things got into their present state. (C. Robert Nelms)

• This takes persistence

• Interim Containment Action: This is the action taken which should address and correct the actual nonconforming condition.

• Permanent Corrective Action: This should address the root cause of a nonconformance and prevent future occurrences of the problem which caused the nonconformance.

• Contributing Cause: This factor contributed to the problem, but it is not the root cause. Keep going to get to Root Cause.

• Verification: Making sure that something is going to work prior to implementation.

• Validation: Checking to make sure that the change is working (after implementation)

Definitions

Presenter�


It is important to understand a few basic definitions in order to use these problem solution tools effectively. Remedial Action: This is the action taken which should address and correct the actual nonconforming condition. An example would be a disposition on a notification. Root Cause: The very basic reason why the condition occurred. Corrective Action: This should address the root cause of a nonconformance and prevent future occurrences of the problem which caused the nonconformance. �


• A systematic approach to effectively identify the cause chain of a nonconformance and to permanently eliminate the source(s) of problems.

• Directed at reducing, and if possible eliminating, quality system escapes and the costs associated with “poor quality”.

Root Cause / Corrective Action (RCCA) is:

More on Root Cause

Presenter�




Origin of HBC’s 8D Process

• 8D (8 Disciplines) first standardized by the U.S. government during World War 2

– Military Standard 1520: “Corrective action and disposition system for nonconforming material”

• Popularized by Ford Motor Company in the 1960’s and 1970’s (called Global 8D or G8D)

• 8D now a standard in the Auto Industry• 8D fills a void we currently have at HBC

– We reference root cause (internally, with our suppliers and customers)• BUT, we don’t provide a standard process to get to root cause

HBC 8D – a Structured Process (and Tool Set) for Root Cause Corrective Action


HBPS Initiative Positioning

• Goal – solve the problem – Smooth land (drain the lake,

remove boulders)– No leaks in the boats (rental

income while lake is here)• Pick the “best fit” methodology

– Drain the lake (remove “waste”) – use LEAN Six Sigma

– Remove boulders (variation reduction) – use Lean SIX SIGMA

– Leaks (immediate problems that must be fixed) – use HBC 8D

• Use the right tools for the job– Common tools will be used by all

methodologies• This Analogy: Bucket – can be

used to empty the lake, remove rubble, and bail out the boat

In general, Lean Six Sigma projects take longer; 8D is for everyday, immediate problems.

http://www.clipart.com/en/close-up?o=898840&a=c&q=lake&k_mode=all&s=286&e=300&show=&c=&cid=&findincat=&g=&cc=4935:17:7083:251:0:4298:6&page=20&k_exc=&pubid=&color=&b=k&date=


Time

Planning

0

40

0

Lessons Learned

Sporadic Spike(Special Cause: HBC 8D)

Control (During Production)

Significant ShiftAND/ORVariation Reduction(Lean SIX SIGMA)Common cause

(random) variation/waste

(LEAN Six Sigma)

Special cause (assignable) variation

HBPS Initiative Positioning (alt. view)


8D “Process” Fit

• Policy & Procedures – 12 0008 Corrective Action System

• Quality Assurance Instruction (QAI) -- QAI 03-01-015 – Corrective Action Response and Review Requirements

• Corrective Action requests resulting from:– Nonconforming material– Out of control processes– Internal audits– Supplier issues– Customer complaints– Operator self-verification process– Other nonconformances in product or process

• Via: – PCAS - Production Corrective Action System– FCAS - Field Corrective Action System– IQAG - Internal Quality Audit Group– OSV - Operator Self Verification– + Management Directive

8D adds structure (defined steps, language) to what we already have.


• Changes being made to:– WI 04-09-009 – Creating and Updating

Corrective Action Records in SAP– WI 04-09-014 – Responding to the Corrective

Action in SAP– WI 04-14-005 issuing Corrective Action

Requests for Major Noncompliances• Documents Created in SAP:

– Q1 – Customer Complaint– Q2 – Vendor Product Non-Conformance– Q3 – HBC Product Non-Conformance– Q4 – Vendor Product CA– Q5 – HBC Product CA– Q6 – Vendor Audit CA/PA– Q7 – HBC Audit CA/PA

• HBC 8D form will be attached to the appropriate Q1-Q7 record in SAP

– Reference Hard Copy of HBC 8D Form handouts

8D “Process” Fit (cont.)

Work Instructions are being modified now to incorporate 8D.


What is 8D?

1. Corporate Standard2. Standardized Problem Solving

Process• Language, Methodology

3. Reporting Format

Presenter�


Corporate Standard - Fact based, used to solve not mask a problem - HBC will use it internally as well as with our customers and suppliers - Can communicate with each other effectively - Customer requirements say you have to have a problem solving method. Problem Solving Process - - It is a process- very methodical and systematic approach - many people get involved (not just for Quality anymore). - Opinions aren’t allowed. That’s why its called 8 ‘Disciplines’. “Little brainstorming is used - based on facts & data through verification and validation.” Reporting Format “The 8D form simply documents the results of your problem solving activities as we go through the process and tools. It’s a summary of your work. You’ll have data and supporting documentation to back up your work. - Can be used by 1 person just for documentation when you know the root cause. But have to verify you know the root cause first. - If you are documenting a problem that you know the root cause of, then the 8D form can be used for documentation. But can you VERIFY the root cause? Ask them: How do you do that?” ---“Make the problem come and go.” �


8 Disciplines (8D’s)

D-0 Decide to use the 8D Process – existing processesD-1 Describe Problem D-2 Establish TeamD-3 Implement Interim ContainmentD-4 Find Root CauseD-5 Choose Corrective Action D-6 Implement Permanent Corrective ActionD-7 Prevent RecurrenceD-8 Congratulate Team


What can “trigger” an 8D analysis?

“When do we use the

8D Process?”

• Problem with Cause Unknown• Need to Cure - Not Mask Problem• Justifies a Structured/Team Approach

– Factors – Severity, Cost, Time, etc.• Examples:

Whenever you open a QN, ask yourself if Root Cause/8D should be done.


Who can initiate an 8D analysis?

• Request for an 8D analysis can be made by:– Customer

• Current Sales/Support Interface– HBC Employee

• Initially, by contacting QA rep’s• Eventually, anyone

– Working out details defining when it makes sense– Not all problems need an 8D level of analysis

– HBC Supply Chain• Supplier will perform the 8D

– Management

Anyone can use the process. Using SAP makes sure we capture/share knowledge.


Place in 8D Process

D-0 Decide to use the 8D Process

D-1 DESCRIBE THE PROBLEMDESCRIBE THE PROBLEM

Why is it important for a Problem Solving team to start with “Describe the Problem”?

Presenter�


Pocket 8D card - read D2 Ask the question and see what they say. Point out it is the #1 inhibitor for team problem solving NEXT SLIDE >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>�


8D Step 1 – Describe the Problem

What is the problem?This should be a short, simple and concise definition.

“IF YOU CANNOT SAY IT SIMPLY, YOU DO NOT

UNDERSTAND THE PROBLEM”

REMEMBER:

A problem well stated is a problem half solved!


• What is the problem?• Where was it detected?• How serious is the problem?• How many occurrences?• Who is affected?• When did it surface?

Remember: on the problem.

Information about the problem

Presenter�


In order to begin the process, don’t be afraid to write down as much information about the problem as you can. Where was problem detected? How serious is the problem? How many occurrences? �


Problem Definition/Analysis Prompts – Who?

Who notified you of the problem?- Manufacturing, Engineering, SAP QN Review, QA Audit, etc.

Who are the people involved with the problem? (for step 2 – team formation)- Supplier, customer, material handlers, assemblers, supervisors, engineers, QA personnel, etc.

High Level information belongs in the Problem Description, Investigate all others in Step 3 & 4.


Problem Definition/Analysis Prompts – What?

What is the part name/number/other identification?What type of product or process?

- Detail, assembly, vendor part- Part manufacturing process, assembly process?

What is the type of nonconformance?- Scratch, Dent, Oversize hole, Fit?- Lack of communication, waiting too long for info/parts?

What characteristic of the part/process is having the failure- hole radius, linear dimension?- manufacture of the part, movement, inspection?

What method of measurement was used to identify the failure?What are special circumstances surrounding the problem?

- new personnel, equipment move, new tool, etc.?What environmental conditions existed?

- extremely cold/hot, rainy, humidity, lighting, etc.? What is the design/nonconformance criteria in question?

- Drawing, Spec, Task Planning, Policy, Process?What training has been done or is available?What hardware or software is associated with the issue?Have there been recent administrative, program or equipment changes?


When in the build process/production schedule/work shift did the problem occur?

- note: occurrence point and detection point may (and usually aren’t) at the same time

When in the task did the problem occur? (what step?)When in the functional test did the problem occur (what step?)When in the day, week, month did it/has it occurred (patterns)?

Problem Definition/Analysis Prompts – When?


Where is the part being contained?Where is the part being used?Where is the geographical location of the failure?What plant/line/station cell?Is the problem in-house or external (supplier) or external (in the field)?Where are similar nonconformance records located?

Problem Definition/Analysis Prompts – Where?


Problem Definition/Analysis Prompts – Impact?

How many times and in what period?Cost of nonconformance in dollars?Safety impact?Cost of delay?Warranty cost?Impact to worker morale/productivity?Has this issue been “fixed” before?Impact on Business processes?

- production- delivery- product use- field reliability

Impact on Customer Satisfaction?


Importance of Problem Description

– Focuses team on same objective– Direction set here is used throughout the HBC

8D process (foundation)– Forces all to agree on the scope and goal– Note: Operational Definitions MUST

accompany the Problem Description• What does “failure” mean?• What is “bad”?• What does “success” look like?

Ice-scrapingvideo

Presenter�


Read slide “Starting point for uncovering key characteristics of a problem” “It allows us to draw boundaries around the problem more tightly.” “The Data is a foundation for testing later. It’s used to test that we’ve chosen the best Interim Containment Action and Permanent Corrective Action” “8D process is highly dependent upon a clear problem description” Refer to process tool chart - “E” - we are working in the first column �


Tool: “Is”/”Is Not” for Problem Definition

• Reasons to use “IS” - “IS NOT”– Establishes points of comparison– Leads to a more complete problem description– Provides a Test base for Root Cause– Gives you a fingerprint of the problem– Draws better boundaries around the problem

• SCOPE – what’s in, what’s out


• Development of “IS”: Identity - What is the problem?

Space - Where is the problem?

Time - When is the problem happening? (also When did it start?)

Mass - How Big is the problem?

Tool: “Is”/”Is Not” for Problem Definition

Presenter�


Put up Operational Definition Wall Chart - Write Charlie is Clogging across the top Write in Charlie and Clogging for Object & Defect “What - Where - When- How Big - Laws of Physics” “This is a problem solvers secret weapon. You have to know the right questions to ask. You can hire a consultant off the street that knows nothing about your company and he/she can solve your problems by asking the right questions and getting data and information.” Refer to “Past-Present-Future” diagram little “E” for experience under the first column (Draw lines between What, Where, When and How Big to separate the sections) “COMPLETE THE IS’S”�


IS IS NOT(What, Where, When, How Big) would you EXPECTEXPECT to..

SEE, HEAR, FEEL, SMELL, OBSERVE . . ......but DO NOT? DO NOT? ((close cousinsclose cousins))

<<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>>>>>>>>>>>><<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>>>>>>>>>>>>

Development of “IS NOT”

(What, Where, When, How Big) “IS” it? (What, Where, When, How Big) could it be but it “IS NOT”?

Once you have the Problem Defined, get feedback from others (coworkers, manager, others) who have done 8D/RCCA

Presenter�


“Next question consultant uses.” Tell the “FOYER LIGHT” story. Come home from work and it’s dark out. Flip on foyer light switch - no lights. “What are you going to do next?” Check bulb, check circuit breaker “Is there anything else you can do that would be a “closer cousin” than that? (closely related) Check another light switch. “Yes, that’s a close cousin. Don’t have to stumble around looking for a light bulb or ladder or go into the basement to check the circuit breaker.” “Now what are you going to do?” What’s another “close cousin?” “look outside at your neighbor’s homes” “Yes, you look outside and the neighbors across the street are lit but your side is all dark. See, you don’t need to get a bulb or check your circuit breaker.” �


Reasons to use “IS” - “IS NOT”

– Establishes points of comparison– Leads to a more complete problem description– Provides a Test base for Root Cause– Gives you a fingerprint of the problem– Draws better boundaries around the problem

• SCOPE – what’s in, what’s out


Document Your Work

1) Open a QN in SAP 2) Fill Out Section 1 of the 8D Summary Report

- go to the Quality Forms link on the QA home page 3) Attach the 8D Summary Report file to the QN


Step 2 in the HBC 8D Process

D-0 Decide to use the 8D ProcessD-1 Define the Problem

DD--2 Form the Team2 Form the Team


8D - Step 2: Form a Team

• A “Team” may be:• formal (scheduled meetings, for ex.) or• informal (consulted as needed)

• Agree on work group guidelines

Customer Complaint


Advantages/Disadvantages of Teams

WHY DO TEAMS FAIL?

WHAT ARE THE BENEFITS OF A TEAM APPROACH?

What have been your experiences with teams??


Major Problems with Team Problem Solving

•• Problem incorrectly described Problem incorrectly described ! ! !! ! ! (biggest inhibitor)(biggest inhibitor)

– Make sure Problem Description is accurate and team members agree

• Problem solving process rushed• Poor team participation• No logical (group) process• Lack of technical skills• Management impatience• Permanent Corrective Action Not Implemented


Typical Team Organization

Champion/SponsorLeaderRecorder – rotate this role

Team Members (SME’s - Subject Matter Experts)

Facilitator (optional)Customer/Supplier

Are we having fun yet?

Recommend: 4-7 members(10 max.)

<4, consider leader driving results by consulting with SME’s>10, consider subteams

Ask the initial team: “Who else needs to be involved, but isn’t here?”


Step 3 in the HBC 8D Process

• D-0 Decide to use 8D Process• D-1 Define the Problem• D-2 Establish a Team

DD--33 CHOOSE, IMPLEMENT AND VERIFYCHOOSE, IMPLEMENT AND VERIFYINTERIM CONTAINMENT ACTIONINTERIM CONTAINMENT ACTION

-- basically youbasically you’’re re DispositioningDispositioning the the QNQN


8D Step 3: Implement Interim Containment Action

• Decide whether you need to use one • Choose the best (benefits vs. risks)

– Tools• Brainstorming to generate ideas• Pro’s/Cons lists; Effort (or cost or time) vs.

Benefit (or risk) graphic…. • Action Plan

• Test feasibility of the containment action (Verify it will work)

• Commit to it• Implement• Validate containment action effectiveness

ActionPlan

ALWAYS +’s and –’s to every decision. BALANCE (and action) are the Keys!

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Purpose of Interim Containment

• Used to “buy time” to find root cause while protecting your customer (external or downstream operation) from the problem

• Authorized “first aid”, but. . . . . – can be costly– attacks “symptoms” (not the cause)– has a masking effect

• Purpose of this step:– Enforce SCOPE and EFFECTIVENESS of customer

protection needed

It’s OK to not have containment, it’s NOT OK to not THINK about it.

Presenter�


Read slide “Tell me what types of ICA’s you do when customers call with problems?” �


Int. Cont. Action vs. Typical BAND AID

__X__ Attacks Symptoms __X____X__ Added Costs __X____X__ Monitored while being used _______X__ Documented &Data Collected _______X__ Verified for effectiveness _______X__ Replaced by Perm. Correction _____

Interim Containment Action BANDAID

Presenter�


“Most “band-aid” type actions aren’t as thorough as the 8D ICA.” This does the “Check” in P-D-C-A�


Key Points of Step 3: Interim Containment

• Act quickly (and carefully)• Use the team to come up with the list of potential actions

– Minimizes risk, results in better ideas• Pick the best overall Containment Action(s)• Consider actions that may be needed to address other areas:

– Product in the field– WIP – Work In Process– Product in transit/at the Supplier– Spares

• Use Action Plan to make sure nothing falls through the cracks– Examples:

• VERIFICATION and VALIDATION• Airworthiness Directives• Service Bulletins• Kits for field

• DON’T STOP HERE!!! XXActionPlan

Presenter�


Pull out pocket 8D report - ask them what to write in the D3 section. Give them the mfg date of June 13 and Retail date of June 15. Pass hand out 8D report with section D3 filled in. Look on back side for quick reminders of what is needed for this discipline. Put behind 4.3 D3 just in front of D4 Go to White Section 4.3.3 Reporting Requirements Review Mandatory and Optional requirements Read to themselves 4.3.3 Assessing Questions: Review1, 4, 12, 14 �


Fill Out Section 3 of the 8D Summary Report


BREAK FOR 10 MINUTES


Where are We?

Place in the HBC 8D Process• D-0 Decide to use 8D Process• D-1 Define the Problem• D-2 Establish a Team• D-3 Choose, Implement and Verify Interim Containment

Action (I.C.A.) DD--44 FIND ROOT CAUSEFIND ROOT CAUSE


Root Cause Analysis Common Tools

• Your Brain– Especially the ‘Collective Brain’ of your team

• Data • Thought Map• Process Map• Brainstorming• 5 Why’s• Cause and Effect (Fishbone) Diagram• Graphical Analysis (misc. graphs)• +……

What tool to use? Problem ->Questions->Data/Tools ->More Questions…ROOT CAUSE

Thought Map


• Don’t try to do solutions before the analysis is complete.

• It is futile to continue doing things the same way while expecting different results.

• Don’t fall into the trap of jumping to conclusions.

General Information about Step 4

“OUR DESIRE TO ACT, OVERPOWERS OUR NEED TO UNDERSTAND”(Brad Baker, CONOCO)

• This can’t be a part time job. Assign a Point Of Contact (POC) to focus on closure.

• The RCCA response ECD must be based on a planned list of things to do (Action Item Lists).

Presenter�


Sometimes the only exercise people get is jumping to conclusions. Don’t do it! This often causes the analytical process to stop too soon. Remember that analysis may take a little time, but it is necessary to find the true solution to a problem.�


Types of data to collect:1. Location: where problem was detected2. Personnel: who found problem3. Specifications: what are the requirements4. Environment: noise, lighting, temperature, etc…5. Sequence of events6. Equipment7. Training8. Other occurrences9. Recent changes: personnel, process, weather

Data Collection

Insufficient data can result in solving only the specific instance.

Challenge the basis for why it’s been determined to be an isolated event and why it couldn’t potentially be a

systemic problem

Presenter�


Here are some types of data that you should collect about the problem. Where was the problem detected? Who is the internal or external supplier for the area. Who found the problem? Was it the worker, supervisor, Quality Assurance..? Ensure you know the applicable specifications Could heat, cold, lighting or other environmental factors have had an effect? Try to document the sequence of events What type of equipment is used in this particular operation Investigate the training of the employees, both classroom, and OJT. In other words, how long have they been working in that same area on that same task? Has this problem happened before? Never Seldom Often Have there been any recent changes in personnel, in the weather, or in the process of specifications? �


Once the problem is defined, natural tendency is to rush forwardRESIST THE URGE!!Take a few minutes to plan your “journey” to root cause

1) Write your Problem Statement at the top of the page2) Capture questions that you have

• Assumptions, potential causes, sources of the problem that don’t belong in the problem statement SHOULD be captured as questions

3) Answer each question with data4) Questions (and data) will lead to more questions5) Capture dead-ends as well as ‘fruitful’ paths

1) Why?

NOTE: Review the Problem Definition (Step 1) often!

Tools: Thought Map

Used: When? ________________________ Why?__________________


What is the currentbit brand

and quality used?

Is the perceivedbit quality difference

real or just perception?

What specific features of the bit performance

are perceived as the problem?

Is it possible to attribute QNs and other sheet metal defects to

bit quality?

Is there a statistically significant difference

in the number of holes drilled before dull?

What other factors contribute to manual,

hand drilling performance?

How much is the difference?

What are the bit performance indicators?

1 - Penetration – Sharpness2 - Straightness 3 - Centering

What is considered the ‘premium’ bit?

1 – Number of holes drilled2 - Straightness 3 – Centering4 – Penetration5 – QNs Resulting

Precision Twist Brand

Bruckner provides a standard, such as Michigan Twist

LEGEND:Dashed Lines Indicate Links

What is the differencein cost for the bits?

Thought Map example: Drill Bit Quality


Tools: Process Mapping/Value Stream Mapping

• Graphical Depiction of “How It’s Done”– Terminator (start/stop)– Process Step– Decision Point– Connector (off-page)

• General Rules: – Left to Right– Yes’s/No’s consistent

?

??

?

How would you map out the process for 8D so far?

Used: When? ________________________ Why?__________________

Assembly Transport Inspection

Out

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Inpu

ts

Transport Storage Machine Transport


Tools: 5 (OK, maybe just 3) Senses

• Talk to, Listen to, Observe:– People performing the job– “Suppliers”

(internal/external)– “Customers”

(internal/external)

You are a root cause “detective”. Use all the tools you can.


Tools: Brainstorming

When the best solution isn’t obvious, one technique for generating ideas (possible root causes, potential interim corrective or permanent actions…) is brainstorming.

1. Generates a large number of ideas 2. Encourage free-thinking3. Don’t criticize4. Encourage everyone to participate5. Record all ideas. There is no bad idea.6. Let ideas incubate – give it a little time

A minimum group of at least three people to make

this work

Used: When? ________________________ Why?__________________

Presenter�


With brainstorming it is very important to write down every suggestion, no matter how “off the wall.” Sometimes thinking “outside of the box” is exactly what is needed to stimulate creative problem solving.�


1. Why? – There was oil on the floor.2. Why? – The machine in that cell was leaking oil.3. Why? – A pressure fitting on the machine failed.4. Why? – Inspection of hoses and fittings is not part of the preventive

maintenance (PM) schedule.5. Why? – The PM system does not consider Equipment Manufacturer’s

recommendations to develop PM schedules.6. Why?- There’s check to make sure this is done.

Don’t stop with “Because we don’t have enough people, money, time…– it’s a fact of life.

Solve the problem with the people, money, time you DO HAVE.

Tools: 5 Why’s

An employee in the plant slipped and fell while performing their regular duties.

“Peel the onion”- challenge the basis for root cause. Most people can only support 1-2 layers of questions with their basis for root

cause or corrective action.

Used: When? ________________________ Why?__________________


Tools: Cause and Effect Diagram

A Cause-and-Effect (fishbone or Ishikawa) diagram – an easily applied tool used to analyze possible causes to a problem.

Non-conforming coating

Manpower

- inexperienced

Methods- incorrect prep of metal surface

Machinery

- microscope

Materials

- poor quality of standards

- microscope setting not optimized to detect the smearing

-not following the “frozen”coating parameters

- inadequate training

-inadequate technique

MUST BE TESTED AND VERIFIED!

5 M’s and an E - add Measures and Environment for 6 “Bones”

Used: When? ________________________ Why?__________________

Presenter�




Tools: Graphical Analysis

• Histogram –• Used to show patterns/distribution in ordered data• Categories on the x-axis, # of occurrences on the

y axis. • Pareto Chart (80/20 rule) –

• Used when many problems or causes and you want to focus on the most significant

• Causes on x-axis, Results on the left (primary) y- axis, Cumulative % on the right (secondary) y- axis.

• Scatter Diagram –• Used to illustrate relationships between 2

variables. 1 variable on each axis.• "Correlation does not imply causality."

• Ex. Shark Bites and Ice Cream

Purpose of Graphical Analysis: ________________________________


Use Common Sense:

1. The more significant or involved the problem, the more detail may be needed to identify the Root Cause

1. Also more advanced tools2. Avoid data that leads to other

problems. 1. Don’t get sidetracked

1. Review Step 1 – Problem Description.

2. Use the Thought Map

Word of Caution: Stay on Track!

Start

GoalSide Issue

Side Issue

Side Issue

Complex problems usually require at least a fishbone diagram of the potential root causes sorted from the brainstorm list

• Define the actions to validate or dismiss each one

• Technical problems usually require a structured FMEA

Presenter�


Have you ever known someone who was truly brilliant, but had very little common sense? Remember to apply common sense in working on root cause analysis. We are living in the real world and need common sense solutions. Let’s leave the theory of relativity to the Einstein's. During your search for a root cause, you may uncover really interesting but unrelated data. It’s okay to make a note of it, then file it for later. Keep focused on the goal.�


Document Your Findings

Fill Out Section 4 of the 8D Summary Report


8D – Step 5: Choose Corrective Action

Place in the HBC 8D Process:• D-0 Decide to use 8D Process• D-1 Define the Problem• D-2 Establish a Team• D-3 Choose, Implement and Verify Interim Containment Action

(I.C.A.) • D-4 Find Root Cause

DD--5 DETERMINE PERMANENT CORRECTIVE 5 DETERMINE PERMANENT CORRECTIVE ACTIONACTION


Decision Making Steps (note: can also be used in Step 3)

1. Define end result (action verb & object)• Eliminating/Preventing/Reducing (verbs)• Errors/Safety Incidents/QN/s (objects)

2. List decision criteria–– GIVENSGIVENS - Mandatory–– WANTSWANTS - Desirable

3. Decide relative importance of wants wants 1-104. Identify the possible choices5. Compare possible choices against the decision criteria6. Analyze risk

IF/THEN terms:If we choose to___________,Then _________ will happen.

7. Make the final BALANCED choice and VERIFY

NOTE: Use the Action Item Tracking Sheet to Capture and Track Actions

ALWAYS +’s and –’s to every decision. BALANCE (and action) are the Keys!

ActionPlan

Presenter�


Red Section 2.2 - follow along REVIEW steps quickly. �


Use the Corrective Action Plan Worksheet in the 8D File and Summarize in Section 5

of the 8D Summary Report

Track Action Items to Completion and Summarize Results

Presenter�


Pull out pocket 8D report - ask them what to write in the D5 section. Assist them with verification verbiage. Pass hand out 8D report with section D5 filled in. Look on back side for quick reminders of what is needed for this discipline. Put behind 4.5 D5 just in front of D6 Go to White Section 4.5.3 Reporting Requirements and Assessing Questions: Review 1,3,12,15,16�


Place in the HBC 8D Process:D-0 Decide to use D8 Process D-1 Choose team membersD-2 Define problemD-3 Choose Interim Corrective Action(s) & verifyD-4 Find Root CauseD-5 Choose & verify Permanent Corrective Action

DD--66 IMPLEMENT PERMANENT IMPLEMENT PERMANENT CORRECTIVE ACTIONCORRECTIVE ACTION

8D - Step 6: Implement the Fix

Presenter�


Pull out 8D pocket card and read D6 “D5 ends at making a choice of what the PCA is going to do. D6 is how are we going to carry it off.”�


Goals of Permanent Corrective Action

• Permanent Corrective Action MUSTMUST:– Address the systemic problem (in addition to this

specific instance)– Eliminate the Root Cause– Prevent recurrence– Be implemented in a timely manner– Include a detailed plan (especially if it will take

considerable time and people)– Be comparable to the risk involved

• Risk to the customer, employee, organization, public, etc.– Be verified Objectively

• Three knowledgeable people must agree


Keys to Successful Corrective Action

– Persistence• Natural Tendency to slack off once the Fix is determined

and partially implemented• Follow the Action Plan to Completion

– Involve “Do-It-Level” people• Key to preventing recurrence

– Review Interim Containment Action(s) • Remove/discontinue any not needed – adds cost, time, etc.

– VERIFY IT!!! – VALIDATE IT!!! Action

Plan


Why should we do planning and NEW problem prevention when considering implementing a permanent corrective action for THIS problem? – see next slide….

More than “Just Do It”

Presenter�


Read the slide. Discuss.�


Why Planning and Problem Prevention?

• Many of our current problems are the result of not following through with previous plans

• Must allocate limited resources effectively– Optimize implementation

• Don’t waste Time/$$

• Prevent other problems from occurring– With change comes risk of creating NEW

problems– Control Mr. Murphy

Presenter�


See if they said the same things.�


Fill Out Section 6 of the 8D Form

Summarize the Key Permanent Corrective Actions

Presenter�


Pull out pocket 8D report - ask them what to write in the D6 section Pass hand out 8D report with section D6 filled in. Implementation dates are mfg: July 10 and Retail: July 10. Put back Look on back side for quick reminders of what is needed for this discipline. Put behind 4.6 D6 just in front of D7 Go to White Section 4.6.4 Reporting Requirements and Assessing Questions: Review 1, 2, 7 “Any questions about D6?” �


D-0 Decide to use D8 ProcessD-1 Choose team membersD-2 Define problemD-3 Choose Interim Containment Action(s) & verifyD-4 Find Root CauseD-5 Choose & verify permanent corrective actionD-6 Implement Permanent Corrective Action(s)

DD--77 PREVENT RECURRENCEPREVENT RECURRENCE

8D - Step 7: Prevent Recurrence

Presenter�


Review where we have been. Take out pocket 8D card and read D7�


Steps to Preventing Recurrence

– Identify what systems, practices, or procedures allowed the problem to occur• The “why’s”

– Identify and implement improvements– VALIDATE the results


• Poka-yoke is the Japanese term that means “fail-safing” or "mistake-proofing"

• Examples:– Can’t start car until in park, Child-proof caps, laser beam shut-

offs for machinery– Others??

• One of the best ways to prevent problems from occurring/recurring

• Use mistake-proofing techniques when there are:– Process steps where human intervention is required– Decision points in the process– Repetitive tasks where physical manipulation of objects

is required– Steps where errors are known to occur– Opportunities for predictable errors to occur

Tool: Mistake-Proofing


Mistake-Proofing – Levels of Prevention

Defect is the evidence of an error

More Proactive


HUMAN ERRORS – do not make a root causeHow does HBC approach human error?• Positive

– Defects can be eliminated– Create a mistake-proof environment– Ask “Why?”

• Focus on the Process/Product NOT the Person– Apply Mistake-Proofing device for 100% inspection

• Negative– Defects are inevitable– People make mistakes– Place blame– Detect at final inspection– Sampling inspection– Some are bound to reach the customer

Beware of “Root cause was ‘Human Error’”


How Can We Standardize Lessons Learned & System Improvements?

• Communication• Same/similar problem other plants• Same/similar problem different

systems• Content Quality• Appropriate Quantity

Once Root Cause is Determined, Broaden your Thinking

Effect

Root Cause

Potential Causes

Current/Future Problems in other areas

Presenter�


Discussion Also talk about how you can use these tools as needed - don’t always have to do the whole 8D but may need to verify root cause and look for risks and how we can prevent problems and protect our plans “Having these worksheets and backup data attached to your 8D is going to help with justification and customer confidence” �


Fill Out Section 7 of the 8D Form – Prevention of Recurrence

Presenter�


Pull out pocket 8D report - ask them what to write in the D7 section - summarize from flip chart information Pass hand out 8D report with section D7 filled in. Look on back side for quick reminders of what is needed for this discipline. Put behind 4.7 D7 just in front of D8 Go to White Section 4.7.3 Reporting Requirements and Assessing Questions: Review 1,6,10�


8D - Step 8: Congratulate the Team

D-0 Decide to use D8 Process D-1 Choose team membersD-2 Define problemD-3 Choose I.C.A., verifyD-4 Find Root CauseD-5 Choose & verify P.C.A.D-6 Implement P.C.A.(s)D-7 Prevent recurrence

DD--88 CONGRATULATE THE TEAMCONGRATULATE THE TEAM

Presenter�


Review where we have been. Take out Pocket 8D card and review D8 Ask: “What would be lost if we do not do D8?” “Who should be responsible for the action of recognition?” (leader & Champion) Ask: The word recognition is used. “What do you think of when someone says ‘reward’?” (money, jacket, touchable item). “What do you think of when someone says ‘recognition’?” (pat on the back, acknowledgement, hand-shake) “Which motivates people the most?” (recognition)�


How to Congratulate the Team

• Review significance of contribution• Provide appropriate recognition for all members• Document the efforts & results• Celebrate successful completion

• Celebrations don’t have to be elaborate/expensive

• Be creative

Presenter�


Recognition needs to fit the individual Timing is Now - not to wait until the customer says something “You never use the customer as your verifier” Message needs to go in all directions: - Up to management - Across to dealers, customers, colleagues & suppliers - Down to employees “This is the last message given and gives closure to the 8D”�


How Would You Congratulate Your Team?

What are some things that have worked well in the past?

What are some things that didn’t?

5 minutes

Presenter�


Discuss “If you were on this team and solved this problem, how would you congratulate your team at Danneal?”�


Fill Out Section 8 of the 8D Form (and attach completed file to the

appropriate QN)

Presenter�


Pull out pocket 8D report - ask them what to write in “see action plan” IF YOU WANT: Turn to Blue section 1.2.61 and read what Danneal did. NOTE: If you don’t have time, tell them they can review that on their own. They had a dinner, one person got promoted, all got fans, etc. Just tell them. Turn to White section 4.8.3 and review Reporting Requirements and Assessing Questions. �


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Reference Material


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