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    Cause-Effect Diagram: Examples

    The Quality Toolbook> Cause-Effect Diagram > Examples

    When to use it | How to understand it| Example| How to use it | Practical variations

    Example

    The managing director of a weighing machine company received a number of irate letters,complaining of slow service and a constantly engaged telephone. Rather surprised, he asked hissupport and marketing managers to look into it. With two other people, they first defined the keysymptom as 'lack of responsiveness to customers' and then met to brainstorm possible causes,using a Cause-Effect Diagram, as illustrated.

    They used the 'Four Ms' (Manpower, Methods, Machines and Materials) as primary cause areas, andthen added secondary cause areas before adding actual causes, thus helping to ensure that allpossible causes were considered. Causes common to several areas were flagged with capital letters,and key causes to verify and address were circled.

    On further investigation, they found that service visits were not well organized; engineers justpicked up a pile of calls and did them in order. They consequently set up regions by engineer and

    sorted calls; this significantly reduced traveling time and increased service turnaround time. Theyalso improved the telephone system and recommended a review of suppliers' quality procedures.

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    Fig. 1. Example Cause-Effect Diagram

    Other examples

    A sales team, working to increase the number of customers putting the company on

    their shortlist for major purchases, identifies through a survey that the key problem is that

    the customers perceive the company as a producer of poor quality goods. They use a Cause-Effect Diagram to brainstorm possible causes of this.

    A pig farmer gets swine fever in her stock. To help ensure it never recurs, she uses aCause-Effect Diagram to identify possible causes of the infection, and then checks if they canhappen and implements preventive action to ensure none can happen in future.

    A wood turner notices that his chisels sometimes become blunt earlierthan usual. He uses a Cause-Effect Diagram to identify potential causes.Checking up on these, he finds that this happens after working with oak.Consequently, he resharpens the chisels after turning each oak piece.

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    Cause-Effect Diagram: How to do it

    The Quality Toolbook > Cause-Effect Diagram > How to do it

    When to use it | How to understand it | Example | How to do it | Practical variations

    How to do it

    1. Form a small team of people to work on the problem. Ideally, their knowledge andskills will be complementary, to give a broad but expert group. If it has not been alreadydefined, meet first to define the key symptom or effect of the problem under scrutiny. Aimfor a brief, clear phrase which describes what is happening to what, such as, 'Low sales ofMkII Costor'.

    Make sure that only a single effect is described, as this may result in several sets of causes.For example, an effect of 'damp and dirty conditions' could have different causes ofdampness and of dirt.

    2. Write down the key effect or symptom at the center-right of the page (or whiteboardor flipchart, if you are doing it in a group), and draw a spine horizontally from it to the left.

    3. Draw the main cause area 'ribs' (typically around four to six), one for each of whatappears to be the primary cause areas. If these are uncertain, then the 'Four Ms'(Manpower, Methods, Machines and Materials) provide a good starting point, as illustrated inFig. 1. In these gender-free days, an exact alternative is the four Ps (People, Processes,Plant and Parts).

    Fig. 1. The default 'Four Ms'

    4. Use Brainstorming to build the diagram, adding causes or cause areas to theappropriate ribs or sub-ribs as they appear.

    If a cause appears in several places, show the linkage by using the same capitalletter next to each linked cause, as illustrated.

    Beware of adding 'causes' which are actually solutions. These often are expressedas a negative; further consideration may find a truer cause. For example, a bettercause than 'no heating' may be 'low ambient temperature', as it opens up thepossibility of additional practical solutions, such as 'installing insulation'.

    Beware also of things which are knock-on effects, rather than causes, e.g. given an

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    effect of 'Inadequate telephone system', a sub-cause may be 'Insufficient lines', but'Dissatisfied staff' is a knock-on effect.

    Ways of finding more causes include:

    Keep asking 'Why?'. A popular phrase is, 'Ask Why five times'.

    Look at the diagram without talking. Look for patterns.

    Take a break. Do something to take your mind off your current lineof thought.

    Involve other people, especially those who have expertise in the

    problem areas.

    Leave the chart on the wall for a few days to let ideas incubate andencourage passers-by to contribute.

    If the diagram becomes lop-sided or cramped, you may want to reorganize the diagramwith different major ribs.

    5. Discuss why the found causes are there. Look for and circle key causes which requirefurther attention. Avoid having too many key causes, as this may result in defocusedactivities. If there is no clear agreement, use a Voting system.

    6. Consider the key causes again. Are any more important than others? If so, put asecond circle around them, or put numbers next to them to show their relative priority.

    7. If necessary, gather data to confirm key causes are real, and not just assumed.Repeat the process as necessary.

    8. Plan and implement actions to address key causes.

    Cause-Effect Diagram: Practical variations

    The Quality Toolbook > Cause-Effect Diagram > Practical variations

    When to use it | How to understand it | Example | How to do it|Practical variations

    Practical variations

    Add 'mini' Cause-Effect Diagrams at each point along a Flowchart or any otherrelevant diagram, to identify potential problems, as in Fig. 1. This can also be done in a Force-Field Diagram.

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    Customer call

    logged

    Service call

    scheduled

    Start

    Engineer

    visit

    Wrong data

    Poor phone line

    Not confirmed

    Customer displeased

    Handled poorly

    Call log

    misplaced

    Delay

    Engineer unavailable

    Parts unavailable

    Heavy call load

    Unable to fix

    Bad parts

    Insufficient knowledge

    Customer

    Handled poorly

    displeased

    Start

    Do it in two stages. First ask 'What could be a cause?', identifying all cause areas(e.g. under 'machines' this could be car, phone, computer, etc.), then ask 'How could itcause problems?' to find possible causes in each of these areas (e.g. under 'phone' could be'no visual communication', 'interrupts other activities', etc.). This is a rigorous approach thatwill result in a very dense diagram, but which may help to find unexpected causes.

    Write down all causes in a simple list before building the chart. An Affinity Diagramcan then be used to organize the causes, to help find the main cause areas.

    Differentiate cause areas from actual causes, for example by circling or underliningthem.

    Start with a fairly quick pass at identifying causes, select key causes from these, andthen to home in on these key causes, tracking back to root causes. This can speed up the

    process, but can also result in other causes being missed.

    The 'four Ms' are sometimes called the 'four Ps' which are People, Process, Productand Plant. Common additional major cause areas include Programs, Policy, Plans,Environment, Maintenance, Management, Money, Measurement.

    Indicate differing confidence in causes, for example, where there is a mixture ofmeasured, unmeasured and speculative causes, show the difference by putting a box aroundmeasured causes and underlining unmeasured causes.

    Start with a desired effect, and determine what must be done to cause it.

    Start with an effect on the left of the page and determine the possible knock-oneffects, as in Fig. 2.

    Start with an effect in the middle of the page and expand its causes to the left, and itsknock-on effects to the right.

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    Lack of

    to customers

    responsiveness

    Staff

    Overworked

    Want more pay

    Stressed

    UpsetcustomersGive up

    Losecommitment

    Demotivated

    LeaveGet more

    difficult

    Decrease

    Tell others

    We get badreputation

    Buy elsewhere

    Dissatisfied

    Loss of

    goodwill

    Less repeatsales

    Sales

    Morecold calls

    Lost sales

    Less revenue

    High servicecosts

    Customers

    Loss ofcustomers

    Cost to company

    Complain more

    Fig. 2. Showing possible knock-on effects

    Decision Tree: Examples

    The Quality Toolbook > Decision Tree > ExamplesWhen to use it | How to understand it | Example | How to use it| Practical variations

    Example

    The management team of a manufacturer of space heaters were trying to decide whether to releasea revolutionary new heater, or whether to continue testing it. Releasing it immediately wouldensure good sales, as no other manufacturers had anything like it. However, this would be at anestimated 10% risk of serious problems which would result in halving the revenue. Another sixmonths testing would reduce the chance of problems to 5%, but at an estimated 8% risk of acomparable heater being introduced by the competition. They decided to use a Decision Tree tocalculate the Expected Monetary Value (EMV) of the options in order to help decide what to do.

    The figure below shows the figures and the Decision Tree. The final figures indicated that in terms

    of EMV, the options had very similar value, as the threat of competition canceled out the gains inreliability. They followed this up by repeating the calculations with a small range of probabilityfigures, to investigate the sensitivity of the model. This showed that a change in problem risk hadthe greatest effect, so they decided to continue testing.

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    Fig. 1. Calculating a Decision Tree

    Other examples

    A machine shop team use a Decision Tree to balance the possible future demand forincreased productivity with methods of achieving this. They find that a 10% increase can bebest met with training and improved work processes, but a further 10% increase will requirenew machinery.

    The safety team in a power plant use a Decision Tree to understand the overloadsituation and to develop contingency measures for unacceptable hazards.

    A doctor investigating a disease uses a Decision Tree to understand the possible

    effects of using imperfect tests and possible developments.

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    Independent events do not depend on the actions, and are

    just as likely to happen whatever action is taken. For example, thedynamics of the national economy are not affected by an investmentin a new product, yet may still affect future sales.

    5. For each action (step 3) and event (step 4), determine a value thatdescribes the gain that will be achieved if this combination occurs. This is

    commonly called the payoff or outcome and may be shown in a payoff table, asillustrated in Fig. 1.

    .

    Fig. 1. Payoff table

    This measurement will require a common unit, related to the original objective (step 1).This is typically a financial measure, but can be others, such as time, efficiency, etc. It can

    be useful to include the cost of performing the actions in this figure, rather than justusing the return gained. Thus 'profit' or 'return on investment' may be better than simple'revenue'.

    6. The basic Decision Tree can now be drawn, as in Fig. 2. Start with a smallsquare on the left of the page with lines radiating for each possible action (step 3).At the end of each line, draw a small circle with one line coming out of it for eachpossible subsequent event (step 4). At the end of each of these lines write in the

    payoff (step 5). Actions and events may either be written in full or as codes from atable, such as in Fig. 1. The final diagram will look something like Fig. 2.

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    Fig 2. Basic Decision Tree

    7. Decide how to select the best actions by using a defined strategy todetermine the 'real' value of the payoffs identified in step 5. Common strategiesare outlined below and shown in the illustration further below, which shows howdifferent strategies can result in different activities being selected.

    Maximin, which looks for the best worst-case situation, and is

    the 'pessimist's choice'. Thus, in Fig. 3, A2 is selected.

    Maximax, which seeks to maximize to profit by selecting the

    option with the highest potential return. It can thus be viewed asthe 'optimist's choice'. Thus, in Fig. 3, A1 is selected.

    Minimax Regret or Opportunity Loss, which takes the

    conservative approach of seeking to minimize the loss incurredshould the best action not be taken. Thus, in Fig. 3, A1 is selected.

    Expected Monetary Value, or EMV, includes the concept thatan item which is less likely to occur is also worth less. This is a verycommon strategy, based on the sound statistical and financialprinciple that effective value is equal to actual value multiplied byprobability of occurrence. Thus, in Fig.3, A2 is selected.

    Expected Opportunity Loss, which combines the Minimax

    Regret with the statistical principles of EMV to give a conservativestatistical approach. Thus, in Fig. 3, A3 is selected.

    Utility puts other personal values on events and actions. For

    example, actions may be rejected if there is any risk whatsoever ofloss.

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    Fig. 3. Calculations for alternative decision strategies

    8. If the strategy calls for it (e.g. if it is EMV or EOL), determine the probabilityof each action/event combination. It can be very difficult and expensive to getaccurate figures, and decisions may need to be made on the value of accuracy. Forexample, it may be worth spending thousands on a market survey when changinga product line, but a less accurate estimate may be adequate when deciding what

    lockers to put in a changing room.

    Ways of determining these figures include:

    Asking people in surveys of customers, employees, etc.

    Measuring aspects of processes, such as time taken, defects,

    etc.

    Identification and extrapolation of previous trends.

    Investigating variation.

    Probability figures are usually shown as being between 0 (no chance) and 1 (certainty),although percentages may be more familiar and can be used instead as they are directlyequivalent. Event probabilities, particularly for dependent events, can be shown in atable, as illustrated in Fig. 4.

    The final figures may be written on the Decision Tree diagram. Put them in parenthesesunderneath the appropriate event lines.

    Fig. 4. Probabilities of dependent events

    9. Calculate the value of each action, using the strategy selected in step 7, andwrite this above the circle at the end of the action's branch on the tree drawn instep 6. For example, if an Expected Opportunity Loss (EOL) strategy is being used,

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    as in Fig. 3, then the tree from Fig. 2 will appear as illustrated in Fig 5.

    Fig. 5. Adding action values (for EOL strategy)

    10. Select one of the values from step 9, again using the defined strategy ofstep 7 (typically it will be the largest or smallest value). Write this value above thesquare box where the action branches meet. This indicates the action selected, socross out the rejected actions with double lines, as illustrated in Fig. 5.

    11. If required, the tree may be extended with another set of decisions, using

    steps 3 to 10. This caters for consideration of what possible actions and eventsmight occur, if any or all of the events in the first stage occur. This is typically usedin complex situations where there is no payoff before several sets of actions andevents. In this case, delay calculation until the tree is complete and then rippleback the values in the same way as step 9. The result will be a multi-level DecisionTree, as illustrated in Fig. 6.

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    Fig. 6. Multi-level Decision Tree

    12. Carry out the selected actions and check the events and payoff occur asexpected. If they do not, identify causes for another round of processimprovement.

    Decision Tree: Practical variations

    The Quality Toolbook > Decision Tree > Practical variations

    When to use it | How to understand it | Example | How to do it | Practical variations

    Practical variations

    When the complete Decision Tree is large, break it into separate sub-trees.

    This makes it easier to calculate and understand.

    Use a Prioritization Matrix both to select the possible actions to consider and

    to identify the subsequent events.

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    Sometimes multiple events occur between actions. These can be handled by

    rippling back the calculation, as illustrated.

    Use the Decision Tree with the Activity Network, to plan for alternative

    project actions.

    A Probability Tree Diagram (Fig. 1) uses a Decision Tree just to break downsequences of possible events. If probabilities of individual events are known, thenoverall probabilities can be calculated by multiplying at each level, as illustratedbelow. Note that the final set of probabilities still sums to 1, as it represents allpossible outcomes.

    Fig. 1. Probability Tree

    Failure Mode and Effects Analysis (FMEA): Examples

    The Quality Toolbook > Failure Mode and Effects Analysis (FMEA)> Examples

    When to use it |How to understand it | Example | How to use it | Practical variations

    Example

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    A developer of a wordprocessor package received a number of complaints from its customer baseabout some specific features. On further investigation, it found that there were a limited number ofeffects that particularly annoyed customers. Working with their customers, they allocated severityratings to these, as in the table below.

    Effect Severity

    Corruption of hard disk 20

    Loss of whole documents 10

    Character loss 7

    Printout scrambled 4

    An FMEA table was used to record the results of failures found in user trace logs. Only modes thatresulted in the target effects were recorded. Criticality calculations were weighted with the severity

    ratings to take account of the customer priorities. A part of one table is shown in the illustration.

    The analysis found that the mode with the highest weighted criticality score was when the diskbecame full. Further investigation found the actual cause was an uncurbed temporary file. Thesimple measure of putting limitations on the size of this file significantly reduced the defect rate.

    Fig. 1. FMEA table

    Other examples

    A new toaster design team uses FMEA to identify flaws in the design. This highlights

    ways in which the handle can stick and cause the toast to catch fire. This is prevented byadding a specific thermostatic safety release to the design.

    A boilermaker improvement team use FMEA to identify the failure modes that have

    caused certain pressure vessels to split. The result is the design of an effective and lastingsolution.

    A secretary uses FMEA to highlight the possible undesirable effects of a room booking

    system not working properly, and consequently includes checks to reduce the chance of keyeffects of overbooking and key staff not being able to find rooms.

    Failure Mode and Effects Analysis (FMEA): How to do it

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    The Quality Toolbook > Failure Mode and Effects Analysis (FMEA) > How to do it

    When to use it | How to understand it| Example |How to do it | Practical variations

    How to do it

    1. Select the item to be analyzed. If it is a part of another item, then be clearabout the boundary. For example, if the item is 'vehicle doors', it may meanpassenger doors, but not the tailgate.

    2. Identify the overall approach to be used. The FMEA may be a part of a largerset of failure analyses. In this case, the way that items are selected needs to bedetermined. Typical strategies include:

    Top-down analysis, where the system being analyzed isbroken into pieces and FMEAs done on the larger items first. Forexample, starting with a whole vehicle and then successivelybreaking down into lower levels, such as doors, then catches, then

    screws.

    Bottom-up analysis, where the analyses of the smallest piecesare done first, followed by the higher level assemblies from whichthese are made. This is the reverse of top-down analysis.

    Component analysis, where the FMEAs are done on thephysical parts of the system. This will typically use components

    specifications to determine failure levels.

    Functional analysis, where the analysis is of the intendedfunctions and operation of the system. This is looking at failure fromthe product user's standpoint, rather than the engineer's, and willtypically use product specifications to determine failure modes.

    Also decide whether to perform criticality analysis. This will require more effort, but willresult in a numerical value being given to failure modes and effects, thus helping withprioritization of subsequent actions.

    If doing criticality analysis, determine how it will be calculated. The method belowfocuses just on the probability of failure modes and effects, although this can be extendedto account for other important factors, as indicated in the following section on Practical

    Variations.

    Where possible, this method should utilize actual data, for example from product defectrecords. Otherwise define a range categories and corresponding numerical scores, thenuse an allocation method, such as Voting. For example, levels of 'Chance of being found insystem test' being scored on a scale of 1 to 5.

    3. Identify the scope of failure to be examined. The scope defines the

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    boundaries of the examination, and may include criteria such as time period, typeof user, geography of use, etc.

    For example, 'All vehicle doors failing to operate properly in final inspection and test forall shifts'.

    4. Design an appropriate table to capture the right information. This will vary,depending on factors such as if and how criticality is being measured, as in theillustration.

    5. Identify items which may fail and which fall into the scope defined in step 2.This can be determined by asking, 'What can fail?' and may include individualcomponents and any combinations, sub-assemblies, etc.

    If this list becomes unmanageably large, then either reduce the scope of the FMEA, forexample by examining just the catch mechanism rather than all parts of a door, or limitthe detail of examination, for example by examining the catch mechanism as a whole, but

    not its individual components.

    6. If doing criticality analysis, determine the chance of failure for each itemidentified in step 5.

    7. If doing criticality analysis, identify the proportion of the time during thescope described in step 2 for each item identified in step 5 to fail. For example, ifthe scope is a defined test, then one item may only be exercised for 10% of thetest time whilst another item is exercised for 90% of the time (and consequentlyhas more opportunity to fail).

    If all items may fail at any time, then this factor may be ignored, as it is always 100%.

    8. For each item identified in step 5, list all significant failure modes. Thesemay be found by asking, 'How can it fail?'. For example, a hinge can seize, wear,fracture, etc. This can be simplified by identifying a standard list of failure modesfor the item being examined.

    9. If doing criticality analysis, identify the chance of occurrence for each failuremode identified in step 8. If all possible failure modes for an item are identified,their chances of occurrence will total 100%.

    10. For each failure mode identified in step 8, determine all significant effectsthat may be manifested. Ask, 'What is an undesirable result of the identified failuremode?'. Again, this can be simplified by using a standard list of effects (e.g. won'tclose, difficult to close, stuck closed, etc.).

    Note the difference between a failure mode and failure effect; a failure mode results in afailure effect. For example, a broken pedal may result in a cyclist falling off.

    11. If doing criticality analysis, identify the chance of occurrence of each failureeffect identified in step 10. If all possible failure effects are identified, they willtotal 100% for each item.

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    12. If doing criticality analysis, calculate the criticality of each failure effectidentified in step 10, by multiplying together (a) the chance of the overall itemfailing (from step 6), the proportion of time that the item is at risk of failure (fromstep 7), the chance of the failure mode occurring (from step 9) and the chance of

    failure effect occurring (from step 10). This is illustrated in the illustration.

    13. For each mode and effect that appears in more than one line in the table,usually because they are on a standard list, sum the criticality calculations fromstep 12 to determine its overall criticality rating.

    Fig. 1. Building an FMEA table

    14. Examine the criticality scores and identify those failure modes and effects

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    which will require action to be taken, and determine appropriate steps to reducethe chance of undesirable failure. Actions may include:

    Redesigning items to make them likely to fail.

    Adding items to handle failure of other items.

    Adding warning systems to alert when an item fails.

    Failure Mode and Effects Analysis (FMEA): Practical variations

    The Quality Toolbook > Failure Mode and Effects Analysis (FMEA) > Practical variations

    When to use it | How to understand it | Example | How to do it|Practical variations

    Practical variations

    Focus first on a limited set of failure effects, and then work back to find the modesthat cause them, so these can be addressed. This may be approached by selecting failureeffects that customers would find particularly disagreeable. For example, FMEA of a computersystem may focus on data loss.

    Identify a set of severity ratings for failure effects and show the criticality of eachitem in a separate column, as in the illustration. The sum of each column for each item thenshows the severity distribution for that item.

    Fig. 1. Calculating criticality

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    Use a Matrix Diagram to correlate failure modes and failure effects (put items and

    modes in rows, put effects in columns). This will allow the connection between a largenumber of modes and effects to be seen in one diagram.

    MIL-STD-1629 describes two methods of FMEA. 'Method 101' covers basic qualitative

    FMEA, whilst 'Method 102' covers the quantitative criticality calculation. The recommendedcolumns in the worksheet are described in the table below.

    Column title Description Method

    Identification number A number for cross-reference to other information. Both

    Item/functionalidentification(nomenclature)

    An unique identification or description of the itembeing investigated.

    Both

    Function The primary use or function of the item. Both

    Failure modes and causesThe failure mode of the item, also how this may becaused (useful for finding remedies).

    Both

    Mission phase/operationalmode When and how the item is being used when it fails. Both

    Failure effectsThe detectable effects of the item failure, dividedinto local effects, next higher effects and endeffects.

    101

    Failure detection method The method of detecting the failure. 101

    Compensating provisionsOther parts of the system that reduce the effect offailure (e.g. redundancy).

    101

    Severity classSeverity of failure effect. Typically from a set offour standard classifications.

    Both

    Failure probability/failurerate data source Data source for measurements. 102

    Failure rate, p The chance of the item failing during time, t. 102

    Operating time, tProportion of test period during which the item isat risk of failure.

    102

    Failure mode ratio,The chance of the failure mode occurring duringtime t.

    102

    Failure effect probability, The chance of the effect occurring during time t. 102

    Failure mode criticalityThe criticality of the failure mode = product of thefailure effect probability, failure mode ratio, failurerate and operating time, (pt).

    102

    Item criticalityThe criticality of the item = the sum of all failure

    mode criticalities for the item.102

    Remarks Pertinent comments. Both

    Weight the criticality values by multiplying them by a numeric representation of thefailure effect severity. This will result in important effects standing out more clearly, enabling

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    specific actions for these to be more easily prioritized.It can be useful to use a non-linear set of severity values (e.g. 1, 2, 8, 25) to reflect thecommon situation where serious effects are very much more important than medium or loweffects.

    Weight the criticality values by multiplying them by the chance that failure will reach

    a point where it would be especially undesirable (e.g. reaching the customer). This

    recognizes that the importance of a failure may depend on where and when it is found

    Fault Tree Analysis: Examples

    The Quality Toolbook> Fault Tree Analysis > Examples

    When to use it |How to understand it | Example | How to use it | Practical variations

    Example

    A company president recognized that its personnel evaluation system was not effective at

    motivating its employees, and charged the personnel department with improving it. As a part of theinitial analysis of the existing system, they use FTA to identify the different ways that the evaluationsystem can fail and lead to demotivation (see the illustration).

    Identified failure areas were investigated further, and the new system based on a correction ofthese failures. As a result, motivation increased significantly.

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    Fig. 1. Example of Fault Tree

    Other examples

    A hospital team uses FTA to identify how incorrect prescriptions may be given

    through combinations of events. They consequently design a system to prevent such adisaster from happening.

    An airplane parts manufacturer performs FTA as a standard part of the designprocess to identify critical faults which could cause hazardous failure. Any subsequentfailures are checked against the FTA diagram to help improve the overall process.

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    A quality team in a newspaper press room uses FTA to check potential failures of an

    improved color registration process.

    Fault Tree Analysis: How to do it

    The Quality Toolbook > Fault Tree Analysis> How to do it

    When to use it | How to understand it| Example |How to do it | Practical variations

    How to do it

    1. Identify the failure effect to be analyzed. Typically this will be a criticaleffect that must be eliminated or reduced. It should be a complex failure, whichmay be caused by combinations of other failures, rather than a low-level failurewith simple causes.

    This may be found using other tools, such as Failure Mode and Effects Analysis.

    2. Write the failure effect in a box at the top-center of the diagram area. Makethis a clear phrase that describes the effect as precisely as possible, describing not

    only what the failure is, but how it occurs. For example, 'carburetor fails whenengine reaches full temperature'.

    3. List failures that may directly contribute to the failure described in step 2.For example, 'fuel delivery failure', 'air intake blockage', etc.

    When identifying ways in which an item may fail, try looking at the problem from differentangles. For example:

    o Excessive stresses and strains.

    o Potential misuse and abuse.

    o Environmental extremes.

    o Natural variation in the system.

    o Failure of dependent systems.

    o Failure of related processes.

    4. Divide the list of failures in the list derived in step 3 into separate groups,where all members of each group must occur together for the failure in step 2 tooccur. For example, 'dirt in fuel' and 'partially blocked jet'. There are three possible

    outcomes from this:

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    a. There is one group, as all failures identified in step 3 must occurtogether for the failure from step 2 to happen. This is an 'and' group, sodraw an 'and' gate under the failure from step 2 and connect this to boxesunderneath containing the failures from step 3, as in (a) in the illustrationbelow.

    b. No such groups can be found as any one failure from step 3 canresult in the failure effect from step 2. This is an 'or' group, so draw an 'or'gate under the failure from step 2 and connect this to boxes underneathcontaining the failures from step 3, as shown in (b) in the illustrationbelow.

    c. There are several groups. This is a complex grouping, so draw eachgroup with more than one member under an 'and' gate and connect thesegates to an 'or' gate under the failure effect from step 2, as shown in (c) inthe illustration below.

    Fig. 1. Grouping failures under gates

    It may also be worth checking whether any 'and' group actually constitutes anindependent failure effect. This can be shown with an additional failure box above the'and' gate.

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    There may also be additional conditions for a failure or group of failures to occur. Forexample, environmental or procedural conditions such as 'ambient temperature >50 C'or 'engine idling'. These may be shown with an inhibit gate, as in Fig. 2.

    Fig. 2. Adding inhibit gate

    5. For each failure which has no connections below it, decide whether or not todevelop this further by finding other failures which may contribute to it. If thefailure is not to be developed on this diagram, draw it in an appropriate box. Thus,if the failure cannot reasonably be developed further, put it in a circle; if it could bedeveloped, but is not appropriate to do this here, then use a diamond-shaped box.If the failure is to be developed, repeat step 3 to find contributory failures andappropriate gates.

    6. When the diagram is complete, examine it to draw conclusions and plan forappropriate actions. For example, acting to reduce risks such as critical failures

    and safety hazards.

    Scatter Diagram: Examples

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    The Quality Toolbook> Scatter Diagram > Examples

    When to use it | How to understand it | Example | How to use it| Practical variations

    Example

    A town planning team, during an investigation of road accidents, identified a number of possiblecauses. Three main causes were suspected: the speed of the vehicles, the traffic density and thelocal weather conditions. As there was no clear evidence available to support any of thesehypotheses, they decided to measure them, and used Scatter Diagrams to check whether the linkbetween any of the causes was strong enough to take further action.

    In order to get sufficient measures, they made daily measures for two months, using local roadsensors and reports from the ambulance service. Scatter Diagrams were drawn for each possiblecause against the accident count. The results enabled the following conclusion to be made:

    There was a low, positive correlation with traffic density.

    There was an inconclusive correlation with road conditions.

    There was a high, positive correlation with traffic speed, with accidents dropping off

    more sharply under 30 mph.

    As a consequence, more traffic speed control measures were installed, including signs and surfaces.This resulted in a measurable decrease in accidents.

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    Fig. 1. Example Scatter Diagrams

    Other examples

    A baker suspects that the standing time of the dough is affecting the way it rises. AScatter Diagram of rise time against measured bread density shows a fair correlation on aninverse U-shaped distribution. He thus uses the time at the highest point on the curve to getthe best chance of well-risen bread.

    It is suspected that press temperature is causing rejects in a plastic forming process.A Scatter Diagram shows a high positive correlation, prompting a redesign of the press,including the use of more heat-resistant materials. This results in a significant reduction inthe number of rejected pieces.

    A personnel department plots salary against the results of a motivation survey. Theresult is a weak negative correlation. A second Scatter Diagram, plotting time in companyagainst motivation, gives a higher correlation. A motivation program is targeted accordinglyand results in a steady increase in the score given to motivation in the company's next

    personnel survey.

    Scatter Diagram: How to do it

    The Quality Toolbook >Scatter Diagram > How to do it

    When to use it | How to understand it | Example | How to do it | Practical variations

    How to do it

    1. Determine the two items that you wish to compare. One may be identifiedas the suspected cause and the other as the suspected effect. This may come fromthe use of other tools, such as a Cause-Effect Diagram or Relations Diagram.

    2. Identify the measurements to be taken. Both must be variables (i.e.

    measurable on a continuous scale) and it must be possible to measure both at thesame time.

    Make the measurements as specific as possible in order to reduce variation and increasethe chance of a higher correlation. For example, measurements from a single supplier'smaterials may be better than measuring all supplied materials.

    3. Make 50 to 100 pairs of measurements. When doing this, aim to keep all

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    other variables as steady as possible, as they could interfere with the final figures.

    Be very careful when measuring human behavior, as the very act of measurement cancause the measured people to change their behavior, especially if they suspect they maylose out in some way.

    4. Plot the measured pairs on the Scatter Diagram. Design the axes and scaleson the diagram to give the maximum visual spread of points. This may involveusing different scales and making the axes cross at non-zero values (as in thefigure below).

    If investigating a possible cause-effect relationship, plot the suspected cause on the x-

    axis (horizontal) and the suspected effect on the y-axis (vertical).

    Fig. 1. Setting the scale

    5. If the correlation is high, a regression ('average') line may be drawnthrough the plotted points, to emphasize the trend. This may becalculated orestimated by eye (although this should be made clear to any future readers of thediagram).

    6. If the correlation is reasonably linear, then a correlation coefficient may becalculated.

    7. Interpret the diagram and act accordingly. This may be to identifyimprovements or to enable estimation of future effect values. If it is the latter, thestandard error may be calculated, as in the figure below.

    When using a Scatter Diagram to estimate future effect values, only estimate within theknown range of correlation, as the shape may change outside that range.

    Scatter Diagram: Practical variations

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    The Quality Toolbook >Scatter Diagram > Practical variations

    When to use it | How to understand it | Example | How to do it | Practical variations

    Practical variations

    If points on the Scatter Diagram coincide with other points, the fact that onepoint is actually two or more may be highlighted by emboldening them or by usingconcentric circles.

    If measurements are difficult to obtain, as few as 30 measurement pairs canbe used.

    Use a Correlation Table when multiple coincidental points are measured,typically when there are a limited number of possible positions. This is effectivelya cross between a Scatter Diagram and a Check Sheet, where each x-y position isrepresented by a box in which multiple points can be indicated.

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    Fig. 1. Correlation Table

    Separate measurement sets may be shown on the same Scatter Diagram,

    which may be distinguished from one another by using different shaped markersfor each set of points. A typical use is where one variable is being changed, forexample to show measurements of material from several different suppliers.

    Where non-linear correlation appears, rough estimates may be made usingthem by dividing them into approximately linear sections and calculating the

    regression line and standard error as above.

    Tree Diagram: Examples

    The Quality Toolbook >Tree Diagram > Examples

    When to use it | How to understand it | Example | How to use it | Practical variations

    Example

    A hotel restaurant manager, concerned at low patronage figures and various vaguecomplaints, wanted to find out what affected the satisfaction of her customers in orderthat areas for improvement might be identified. She decided to use a Tree Diagram tofind a basic set of factors to measure that, taken together, would cover all areas.Together with the assistant manager, she defined the method of breaking down theroot phrase of 'satisfied customers' as:

    Question to identify children: 'What key factors will directly contributetowards in the parent happening?'.

    Check on children: They should together make up the parent (no key factorsmissing).

    Break down problem a complete level at a time.

    Stop breaking down when there are about ten leaves on the tree.

    The tree generated is shown below. To test the result, a selection of customers were askedto review the diagram, and it was revised accordingly. Measures were then derivedfrom the leaves and a simple process of measurement was set in place. At the end ofeach month, a project was set up to improve the poorest score of the previous month.Over time, the average score gradually went up, and the restaurant became morepopular.

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    Fig. 1. Example Tree Diagram

    Other examples

    An engine design team used a Tree Diagram to record a break-down of theparts of their own and their competitors' engines. Simpler competitive componentswere clearly identified.

    An improvement work team of metal formers used a Tree Diagram to breakdown and share out the tasks involved in doing a presentation to managers of aradical idea for workplace layout.

    A teachers' group, having found key types of truancy with a RelationsDiagram then moved on to use a Tree Diagram to identify legal remedial measuresfor each type.

    Tree Diagram: How to do it

    The Quality Toolbook >Tree Diagram > How to do it

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    When to use it | How to understand it | Example | How to do it | Practical variations

    How to do it

    1. Identify the objective of using the Tree Diagram. Examples of this include:

    o Determine the individual tasks that each person on a project team

    must carry out to achieve a known objective.

    o Describe all sub-assemblies and basic components in a competitor's

    product.

    o Identify a customer's basic needs of a product.

    o Determining the root causes of a problem.

    2. Assemble a small team of people to work on the diagram. These peopleshould be of an analytical (rather than creative) nature, and should have sufficientsubject expertise between them to be able to break down the problem to therequired level of detail.

    3. Define the top-level 'root' statement. This should be a brief phrase whichclearly describes the problem at this level, making it easier to identify itsindividual sub-components. For example, 'Deliver Requirements Proposal'.

    This statement may be derived from the use of another tool. Thus it may be the key causein a Relations Diagram or the top-level header card in an Affinity Diagram.

    Write this statement on a 3" x 5" card and place it on the middle-left of the work area,visible to all team members.

    4. Define the process for breaking down each 'parent' statement into 'child'statements. This can be helped by defining a question to ask of the parentstatement, based on the original objective defined in step 1. Possible questions toask include:

    o What must be done to achieve the parent statement?

    o What are the physical parts of the parent?

    o Why does the parent happen?

    Typically, the child should have a direct (and not distant) relationship with the parent.For example, 'component breakage' may be a direct cause of 'machine failure', ratherthan 'metal fatigue', which causes the component to break.

    This process may also include questions to ask that ensure the child statements together

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    make up a fair representation of the parent statement.

    5. Define the criteria to be used to identify when bottom-level 'leaves' havebeen arrived at, and the problem does not need to be broken down further. Forexample, 'Tasks that may be allocated to a single person, and will take no morethan one week each to complete'.

    6. Apply the process defined in step 4 to the top-level statement from step 3,in order to produce the first-level child statements (although if the top-levelstatement was derived from another tool, then it may be reasonable to also derivethe first-level child statements from the same place).

    Write these statements on 3" x 5" cards, and arrange them to the right of the top-levelstatement card, as below.

    Fig. 1. Arranging the cards

    In many situations, each parent may be expected to have around two to four children.Having one child is often reasonable, but having many children, particularly at thehigher levels, can result in an awkward and unmanageable diagram. If this happens,ask whether some of the children should be appearing at a lower level

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    .

    7. Repeat this process for each card in the first level, first checking whetherthe criteria defined in step 5 indicates that further breakdown is required. Arrangethe child cards to the right of their parents, ensuring that family groups do notmerge.

    8. Continue to repeat the process until the criteria defined in step 5 are metand no further breakdown is required. If cards become cramped together, taketime to rearrange them such that all parent-child relationships between cards areclear.

    9. When the diagram is complete, review the stages, looking forimprovements, such as:

    o Statements which are in the wrong place, for example where

    enthusiasm at early levels has resulted in statements that should be lowerdown the tree.

    o Levels where the child statements together do not represent their

    parent very well.o General imbalances in the tree, for example where an understood

    subject is pursued in detail at the expense of other subjects.

    Where improvements are found, rearrange the cards or repeat the process as appropriate.

    10. Use the completed tree to help achieve the objective as identified in step 1.

    Tree Diagram: Practical variations

    The Quality Toolbook >Tree Diagram > Practical variations

    When to use it | How to understand it | Example | How to do it | Practical variations

    Practical variations

    The diagram may be built vertically, on a flipchart or whiteboard, by usingadhesive memo notes.

    Cards may be dispensed with and the diagram drawn directly on a flipchartor whiteboard. This may be quicker, but it can get untidy if the cards need

    rearranging or a parent has more children than expected, and families crush intoone another.

    A Why-Why Diagram is a Tree Diagram where each child statement is

    determined simply by asking 'why' the parent occurs, as below. It is thus very

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    similar in use to a Cause-Effect Diagram, and techniques may be borrowed fromCause-Effect Diagram usage. Its simplicity can make it useful in less formalsituations.

    Winner Analysis uses a Why-Why Diagram to find out why an action eitherwent wrong or went surprisingly right. Lessons learned are used to help improvefuture situations.

    Fig. 1. Why-Why Diagram

    A How-How Diagram is a Tree Diagram where each child is determined byasking 'how' the parent can be achieved, as below . It is thus useful for creatingsolutions to problems.

    The Why-Why and How-How Diagrams together make a very simple toolset for finding

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    causes of and solutions to problems.

    Fig. 2. How-How Diagram

    Cards containing statements of special note may be marked differently, withasterisks, underlining, etc. Notable cards include key problems, duplicate cards,leaves which are broken down further elsewhere, statements which are explainedin more detail elsewhere, etc.

    Although children usually combine to make up their parent, it is also

    possible that they form a set of alternatives. Where this is done, it should be made

    clear, for example by writing 'or' between cards. An example can be seen in in thediagram above. Where there is a complex combination of 'and's and 'or's, thesymbol set used in Fault Tree Analysismay be applied.

    At each level of breakdown, question each bottom-level card and only break

    down further those cards that look like yielding useful information. This savestime, but could result in significant areas being missed.

    There are a number of different ways that a Tree Diagram can be displayed,

    as shown below.

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    Fig. 3. Different shapes for Trees

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    A Work Breakdown Structure (WBS) is a Tree Diagram that breaks down atask into allocable units. The bottom-level leaves may thus have individual peopleand resources allocated to complete these tasks, complete with estimations of

    effort required. The sum of the effort and resource in all leaves thus gives the totalcost of the overall task.

    Computer-based 'project management tools' often combine work breakdown structureswith Activity Network-style links to enable complex tasks to be designed andcomputed such that they may be completed in the shortest possible time.

    Force Field Diagram: Examples

    The Quality Toolbook >Force Field Diagram > Examples

    When to use it | How to understand it | Example | How to use it | Practical variations

    Example

    One of the options for a steel works planning team looking to save future processing costsis whether to consolidate the strip mill to a single site. To help identify the forcesinvolved, they build a Force-Field Diagram, as in the illustration.

    During completion of the diagram, it was found that the most significant force was not theopposition from unions, as was expected, but the political pressure. In a time ofrecession and shortly before elections, the government was applying significantpressure not to close plants in areas of high unemployment. This, coupled with otherconsolidation costs, gave sufficient reason for this initially attractive solution to be

    abandoned.

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    Fig. 1. Example Force Field Diagram

    Other examples

    A supervisor disagrees with her manager's plans for their department, anduses a Force-Field Diagram to identify how the planned actions will be almostimpossible to implement. In doing this she finds alternative actions which willachieve most of the original objectives, but in a far more efficient manner. Whenpresented with this evidence, the manager readily agrees to the changes.

    A town planning team is investigating the feasibility of employing

    independent street cleaning crews. They use evidence from other towns to buildarguments for and against the proposal, displaying these in a Force-Field Diagram.

    An assembly team in a domestic appliance manufacturer is working on

    reducing the number of washing machines which leak in final test. They test theidea of using silicon-bonded seals, using a Force-Field Diagram. No significantrestraining forces are found, so they continue with implementing the solution.

    Force Field Diagram: How to do it

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    The Quality Toolbook >Force Field Diagram > How to do it

    When to use it | How to understand it | Example | How to do it | Practical variations

    How to do it

    1. Write a statement that describes the decision or situation to be resolved.This should be a brief sentence that will make it easy to distinguish between:

    (a) Driving forces which will act to support the statement.

    (b) Restraining forces which will act against the driving forces.

    (c) Other forces, which will not affect the situation one way or another.

    Where the description is of a possible action to achieve a known objective, include both ofthese in the statement. For example, 'Reduce customer complaints by personallydelivering and setting up all replacements'.

    2. Form a team of people who, between them, will be able to identify the

    forces around the problem.

    3. Write the statement from step 1 at the top of the work area, with a verticalline below, as in the illustration. Indicate which side will contain driving forcesthat will support the statement, and which side will contain restraining forces. Asleft to right is commonly viewed as 'forwards', it is a good idea to put forces 'for'the statement on the left so that these 'drive the problem forwards'.

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    Fig. 1. Laying out the work area

    4. Identify driving and restraining forces that will act for and against the

    statement, writing them on the appropriate side of the central line (do not addarrows yet).

    Questions to ask to help identify the forces involved may include:

    What must we do to make it work? What could happen tomake it fail?

    Who would help? Who would oppose it? Who would ignore it?

    What would happen if the decision was not made or reversed?

    What is the best and worst possible thing that could happen?

    What will happen whatever is decided?

    What are the costs and benefits?

    What are the financial implications?

    How easy or difficult will it be to implement?

    What other forces would support or oppose identified forces?

    5. Identify how to decide on the strength of each force. This includes selectionof the criteria and the method of scoring.

    Criteria help to contrast the significance of each force against other forces, both on thesame side and on the other side of the line. Use the objective from step 1 to help selectthe criteria, which might thus be 'Effect on customer satisfaction'.

    Possible scoring methods include consensus discussion, Voting, Prioritization Matrix orsome other form or objective measurement. The appropriate method will depend onthe severity of the problem and the available time.

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    6. Use the method defined in step 5 to determine the relative strength of eachforce that was identified in step 4. Draw an arrow of appropriate length under theforce to show its strength, pointing into the line, as in the illustration.

    7. Identify the overall force on each side. This may be clear from the diagram,

    or may require more discussion and summation of the forces.

    8. Take appropriate action. Typical actions include:

    o Seeking to validate assumptions made about forces and their relative

    strengths, especially if the results are uncertain.

    o Implementing the identified action, especially where forces for the

    statement are overwhelming.

    o Seeking and evaluating other possible solutions, particularly where

    the diagram is inconclusive or where forces against are overwhelming.

    Fig. 2. Adding forces, for and against

    Force Field Diagram: Practical variations

    The Quality Toolbook >Force Field Diagram > Practical variations

    When to use it | How to understand it | Example | How to do it | Practical variations

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    Practical variations

    Line length enables a variable force to be shown, but may be impractical if

    other variations are used which redirect the line. In this case, show the size ofeach force with graphical methods other than length, such as color, thickness,numbering, etc.

    Show the size of each force with a number. This may be derived from usingtools such as a Prioritization Matrix or Voting. The total force on each side can now

    be easily summed.

    If some forces are clear and provable and some are based more on intuitionor opinion, then mark these differently. For example, circle the well-understoodforces.

    The forces can be shown pointing up and down, although this makes thehorizontal text more difficult to fit, and can also give an impression of the forcegoing down having the effect of 'gravity', giving it more weight.

    Arrows can be drawn going away from the line, to illustrate forces pullingagainst one another rather than pushing against one another. This may be moreillustrative in some situations, for example where two groups are trying to dodifferent things.

    If a force acts directly against a force on the other side, illustrate this by

    pointing the arrows against one another, as in Fig. 1. There will tend to be clustersof arrow heads around key decision points, which may be discussed and resolvedindividually.

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    Fig. 1. Showing opposing forces

    Write forces on 3" x 5" cards or adhesive memo notes to allow them to berearranged while building the diagram. This is particularly useful if showingopposing forces or hierarchies as above.

    Draw the diagram as a see-saw, with stronger forces being shown furtherfrom the fulcrum. This can be helped by first sorting forces on each side into orderof strength.

    Show how forces are built up with a hierarchy, as in the illustration. Whereforces in the hierarchy are given numerical force values, the number for the mainforce may be determined by summing its contributory forces. This is effectivelycombining the Cause-Effect Diagram with the Force-Field Diagram.

    This may be combined with the method shown in Fig. 2. to show relationships both within

    and between forces for and against the argument.

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    Fig. 2. Combining with cause-effect diagramming

    Where relations between driving and restraining forces are very

    intermingled and it is difficult to put them on either side of a line, build a RelationsDiagram, and mark the forces with positive and negative numbers.

    Process Decision Program Chart (PDPC): Examples

    The Quality Toolbook >Process Decision Program Chart (PDPC) > Examples

    When to use it | How to understand it | Example | How to use it | Practical variations

    Example

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    A dress production team at a clothes manufacturer was improving the cutting-out processin order to minimize material wastage. They decided to use PDPC on the workbreakdown structure to identify potential problems and ways of avoiding them.

    As the most expensive element is the material itself, they defined a significant risk as,'Anything that might cause the cut cloth to be ruined', and viable countermeasures as,'Anything that will reduce the risk, and which costs less than 100 pieces of cloth' .

    Fig. 1. PDPC example

    The resulting PDPC is shown above. As a result of this, the cutting was tested on cheaper

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    material, resulting in the material clamp being redesigned to prevent drag, a startnotch provided for the cutter and the general area being inspected for sharp corners tominimize snag problems. The cutting operator was involved in the PDPC process andthe subsequent tests, resulting in her fully understanding the process. The final cuttingprocess thereafter ran very smoothly with very little error.

    Other examples

    A structural engineering project manager uses it to help find problems in aplan for constructing a road bridge.

    A kitchen hygiene improvement team uses PDPC to check for possible areas

    where infection could come into contact with consumable foodstuffs. An individualsub-project is then spawned for all identified danger areas.

    A mailroom project to improve delivery times uses it to help check the

    proposed solution, checking in particular that it will not have any side-effects that

    might upset other processes.

    Process Decision Program Chart (PDPC): How to do it

    The Quality Toolbook >Process Decision Program Chart (PDPC) > How to do it

    When to use it | How to understand it | Example | How to do it | Practical variations

    How to do it

    1. Identify the objective of using PDPC. For example, 'To identify risks in a

    specific area of a plan, and to identify countermeasures where the cost of the riskoccurring is greater than a certain figure'.

    Ensure that the situation merits the use of PDPC. This will usually be when risks are eitherunknown or may have serious consequences if they occur.

    The plan should be available and complete, unless the PDPC activity is being used as anintegral part of the planning process.

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    2. Identify the areas of the plan which need to be examined in order to meetthe objectives. If it is a large plan, then attempting to examine all elements of itwill result in a practical limitation on the effort that can be put into each element.It is usually better to use PDPC only on the higher risk areas of the plan.

    3. Gather the people to work on the PDPC. Between them, they should have aswide a view as possible of the situation, so that diverse risks may be identified.These may include:

    High-level managers who can see the 'big picture' and relationships withother people and events.

    Experts in specific elements of the plan who can see potential problems

    with planned actions.

    People experienced in planning and using PDPC, who may have discoveredother problems in similar situations.

    4. Identify the criteria for making decisions during construction of the PDPC.These include:

    How to identify a risk (step 5). For example, 'Something that has asignificant effect on the schedule completion time'.

    How to select risks that need countermeasures to be identified (step 6). For

    example, 'The top 10% of identified risks and also those for which simplecountermeasures are obvious'.

    How to identify countermeasures (step 7). For example, 'A measure that

    has a good chance of reducing the identified risk'.

    How to select countermeasures to implement (step 8). For example, 'Thosewhich cost less than the savings they would make if they were implemented'.

    Factors to consider when identifying selection criteria include:

    Time. How much time would a risk cost? Is it on the critical path of theschedule? How much time could countermeasures save?

    Cost. What would be the overall cost of a risk occurring? What would be the

    cost of a countermeasure? Would it be worth it?

    Control. How much control do you have for preventing the risk? Whatcontrol would you have should it occur? How could you change that?

    Information. How much do you know about the risk? What warning would

    you have of its impending occurrence?

    5. For each plan element to be considered, identify potential problems that

    could occur. Ask, 'What if .