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Transcript of 77 Lewis Root Cause -77 MORS
Root Cause Analysis: Tools of Lean Six Sigma
78th MORS Symposium (MORSS)1
Root Cause Analysis: Tools of Lean Six Sigma
78th MORS Symposium (MORSS)2
Solving Tomorrow’s Problems Today …And Resolving Yesterday’s Problems As Well.
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78th MORS Symposium (MORSS)3
Tutorial Presentation for the 78th MILITARY OPERATIONS RESEARCH SOCIETY Symposium
21 – 24 June 2010Marine Corps University,
Quantico, Virginia
Presented by Kenneth W. Lewis, Ph.D., 23 June 2010 @ 1215 Hours
US Army Logistics University Fort Lee, VA
Root Cause Analysis: Tools of Lean Six Sigma
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PREMISE:All human beings look forward to achieving goals.
Goals might be Big or Small,Tangible or Intangible,Physical, Mental, Emotional,Career Oriented, Status Oriented, Finance Oriented,Military Oriented, Politically Oriented,Or Otherwise.
Regardless, all human beings look forward to achieving goals.
Goals are easier to grasp if they are SMART GOALS.
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SMART Goals are
Specific Who? – What? – Which? – Where? – Why?are answerable.
Measureable How much? How many? How often?Attainable You can plan your steps to actually achieve
that goal.Realistic You have the will and the ability to work
towards achieving that goal.Timely That goal is Grounded within a timeframe.
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So let us consider the GOAL …
… as the desired end state of some plan, process or procedure
Some carefully executed plan …Some ingeniously produced widget …Some thoughtfully offered service …Some successful emergency response …
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That plan might be … “Operation Eagle Claw” – April 1980
That Product or Widget might be … the V-22 Osprey Tilt-Rotor Aircraft – 1984 to Present
That Program might be … Space Shuttles Challenger January 1986 or
Columbia February 2003
That Service might be … the JCIDS or CBA process – March 2002
That Emergency Response might be …The BP Gulf Coast Oil Spill Disaster of 2010
They all represent some military related examples of plans, products, procedures, which have been executed, produced, implemented with some desired outcome or GOAL.
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Root Cause Analysis: Tools of Lean Six Sigma
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Recent Problems:
•Haiti Earthquake Disaster and Recovery Capability Gap•British Petroleum Oil Disaster and Recovery Capability Gap in the Gulf Coast•US Army Velcro Capability Gap
8
BP oil leak: now partner company says firm was "reckless" as public relations disaster gets worse Photo: EPA/US COAST GUARD
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History of the previous slide recallsthat the actual outcomes did not align with the desired or expected outcomes.
There was Discrepancy – Discord – Separation between the actual and desired end state or goal.
What you see is what you get. – Flip Wilson, ComedianWhat you get is not what you expected. – Discrepancy What did you expect?
There was VARIABILITY!- Behavior Not True to Type – Aberrant – Subject to Change (Merriam-Webster)
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78th MORS Symposium (MORSS)
The Inquisitive OR Analyst will look at the actual outcome, compare it to the desired outcome or goal, and then begin to ask
WHY? WHY? WHY? WHY? WHY?
The answer to “WHY?” lies in the Root Cause that led to that variability of the GOAL.
So we begin the journey of finding the WHY by conducting a Root Cause Analysis –
A part of the Six Sigma process that seeks to identify problematic causes of operational failures so that a solution can be put in
place which will solve that problem and/or prevent reoccurrence of that problem.
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Abstract:
Variability = Descrepancy between Observed and Desired Outcomes.Variability in plans, products, services is inevitable.
Variability is problematic when•variability is not explainable.•variability results in an unsatisfactory outcome.
Identification of root causes of variability allows us to• minimize variability associated with outcomes,• maximize likelihood of achieving satisfactory outcomes, • create and implement action plans to maintain desired outcomes.
Review of Six Sigma Tools will help• Identify root causes of variability,• Provide remedies to potential problems due to variability,• Improve quality of desired outcomes of plans, products, or services.• Prevent future incidents –Source: Walker (2000)IELD DEMONSTRATION WORKSHOP ON ROOT CAUSE ANALYSIS FOR MARINE CASUALTIES AND ENVIRONMENTAL INCIDENTS
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Brief Overview of Six Sigma
Question: What is the Six Sigma Foundation?
Answer: To improve business or enterprise processes by using theDMAIC approach to problem solving.
Process Steps:
1) Defining Opportunities (What is Important?)2) Measuring Performance (How are we doing?)3) Analyzing Opportunity (What is Wrong or What is currently happening?)4) Improving Performance (What needs to be done?)5) Controlling Performance (How do we sustain performance?)
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Brief Overview of Six Sigma Tools
Improvement teams use the DMAIC methodology to root out and eliminate the causes of defects:
D - Define a problem or improvementopportunity.
M - Measure process performance.A - Analyze the process to determine the
root causes of poor performance;determine whether the process canbe improved or should be redesigned.
I - Improve the process by attacking rootcauses.
C - Control the improved process to holdthe gains.
Source: http://www.asq.org/learn-about-quality/six-sigma/overview/dmaic.html
The DMAIC Methodology
Measure
Modify Design? Redesign
Control
Analyze
Improve
Define
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Brief Overview of Lean Six Sigma
Lean Six Sigma is distinguished from other quality systems by several themes:
• Focus on the customer rather than process, inputs, or outputs. • Data- and fact-driven management:
with an emphasis on measurement of quantitative data.• Process is the key vehicle of success. – monitoring the input, throughput, and output• Proactive management.
Implementing Six Sigma in an organization requires a high level of management buy-in. The work is delegated, but accountability is not.
• Emphasis on root causes:digging down beyond proximal causes to find what is really going on.
• Creating sustained changes, with control mechanisms in place to ensure changes aresustained over the long term.
Source: What is Six Sigma?, Pete Pande and Larry Holpp, McGraw-Hill, 2002.
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Definitions:
Root Cause Analysis (RCA)A structured evaluation method that identifies the root causes for an undesired outcome (event) and the actions adequate to prevent recurrence.
Event or the ProblemA real-time occurrence describing one discrete action, typically an error, failure, or malfunction.Examples: pipe broke, power lost, lightning struck, person opened valve, etc…
Cause (Causal Factor)Root cause analysis should continue until organizational factors have been identified, or until data are exhausted. The antecedent behavior that led to the observed final behavior.
Source: www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf
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Definitions:
Proximate Cause(s)The event(s) that occurred, including any condition(s) that, existed immediately before theundesired outcome, directly resulted in its occurrence and, if eliminated or modified, would haveprevented the undesired outcome. Also known as the direct cause(s).
Root Cause(s)One of multiple factors (events, conditions or organizational factors) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated, or modified would have prevented the undesired outcome. Typically multiple root causes contribute to an undesired outcome.
ConditionAny as-found state, whether or not resulting from an event, that may have safety, health, quality,security, operational, or environmental implications.
Source: www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf
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Definitions:
Organizational FactorsAny operational or management structural entity that exerts control over the system at any stage inits life cycle, including but not limited to the system’s concept development, design, fabrication,test, maintenance, operation, and disposal. Examples: resource management (budget, staff,training); policy (content, implementation, verification); and management decisions.
Contributing Factor(s)An event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence.
BarrierA physical device or an administrative control used to reduce risk of the undesired outcome to anacceptable level. Barriers can provide physical intervention (e.g., a guardrail) or procedural separation in time and space (e.g., lock-out-tag-out procedure).
Source: www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf
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• Clearly define the undesired outcome.• Conduct “5 Whys” analysis to identify root causes.• Create an event and causal factor tree.• Gather data, including a list of all potential causes.• Check your logic and eliminate items that are not
causes.• Generate solutions that address both proximate
causes and root causes.Source: www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf
Overview of Steps in Root Cause Analysis
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Root Cause Analysis Techniques for this Presentation
• Identify the Problem• Identify the Key Performance Parameters or Indicators• Apply the “5 Whys” Technique• Apply the Ishikawa Fishbone Cause and Effect Chart Technique• Apply the Pareto Chart Technique• Apply the Failure Modes and Effects Analysis Technique• Apply the Control Plan or Action Plan
+ 8 Tutorial Assignments
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Assignment #1
Identify a recurring military problem related to:1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis
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Assignment #2
Identify those key performance parameters or indicators used to measure success or failure of the plan, product or service related to that recurring military problem related to:1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis
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Assignment #3
Use the “5 Whys?” technique to Identify the root cause of that recurring military problem related to:1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis
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The 5 Why's Root Cause Analysis Technique
By repeatedly asking the question "Why" at least five times, you can peel away the layers of symptoms which can lead to the root cause of a problem.
Why? Why? Why? Why? Why?
Source: http://www.emsstrategies.com/dd020106article.html
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“Five Whys?” Chain of Causation Example
Problem: Injuries occur with great frequency.
Effects Causes
Injury Caused by Fall
Fall Caused by Wet Surface
Wet Surface Caused by Leaky Valve
Leaky Valve Caused by Seal Failure
Seal Failure Caused by Poor Maintenance
Source: Quality Progress: October 2008
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Effects Causes
Loss of Kingdom Caused by Loss of Battle
Loss of Battle Caused by Loss of Rider
Loss of Rider Caused by Loss of Horse
Loss of Horse Caused by Loss of Shoe
Loss of Shoe Caused by Loss of Nail
Loss of Nail Caused by ?????????
“Five Whys?” Chain of Causation ExampleProblem: The Kingdom of Liberty and Freedom was lost.
Can you do this with the Army Velcro Problem?
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5-Why’s Exercise - Jefferson Memorial, Washington, DC - True Story
Problem:Excessive amounts of seagull droppings were requiring the monument to be pressure washed much more frequently than other memorials, causing erosion and deterioration of the granite.
Inquiry:How Might We Stop the Seagulls from Swarming around the Jefferson Memorial?
Source: Terry Madden (2005)http://74.125.93.132/search?q=cache:jjmZJ8xd3z0J:www.irmi.com/conferences/crc/handouts/crc25/workshops/cuttingedgesafetyapplyinglean.pdf+root+cause+analysis+jefferson+memorial&cd=6&hl=en&ct=clnk&gl=us
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5-Why’s Exercise - Jefferson Memorial, Washington, DC - True Story
Possible Solutions:• Elaborate system of spikes and nets (high- cost solution)• Loud noises to chase off the birds (and tourists)• Kill the birds• Or, let’s ask “why?” several times...
Source: Terry Madden (2005)http://74.125.93.132/search?q=cache:jjmZJ8xd3z0J:www.irmi.com/conferences/crc/handouts/crc25/workshops/cuttingedgesafetyapplyinglean.pdf+root+cause+analysis+jefferson+memorial&cd=6&hl=en&ct=clnk&gl=us
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5-Why’s Exercise - Jefferson Memorial, Washington, DC –True Story (cont.) Source: Terry Madden (2005)
• The Jefferson Memorial is requiring excessive power washes. Why?• Because seagulls are swarming to the monument and depositing large
amounts of droppings. Why?• Because they are feeding on an unusually large amount of spiders living
under the roof line. Why?• Because the spiders are feeding on an unusually high number of midge
flies as they hatch throughout the day. Why?• Because midge fly larva is literally caked under the roof line of the
memorial. Why? ………
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5-Why’s Exercise - Jefferson Memorial, Washington, DC –True Story (cont.) Source: Terry Madden (2005)
Root Cause...As it turns out, the lights that illuminate the memorial were set to come on automatically 20 minutes before dusk. This twilight condition created a ideal condition for midge flies to mate.
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5-Why’s Exercise - Jefferson Memorial, Washington, DC –True Story (cont.) Source: Terry Madden (2005)
Solution: The automatic lights were reset to reduce the twilight condition
Result:– Fewer midge flies– Fewer spiders– Fewer seagulls– Less droppings– Fewer power washings– Slower Deterioration of the Jefferson Memorial
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http://www.slideshare.net/gibsonjunkie/jefferson-memorial
Jefferson Memorial Slide Show
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Assignment #4
Identify those categories of causation that contribute to the variability in outcome of the plan, product or service of that recurring military problem related to:
1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis
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Causal Categories:
Source: http://www.emsstrategies.com/dd020106article.html
Categories Categories Categories
Man Machine Equipment
Machine Method Process
Material Measurement People
Method Material Material
Measurement People Management
Mother Nature Environment Environment
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Other Causal Categories:
Source: http://www.emsstrategies.com/dd020106article.html
Categories Categories Categories
Method Doctrine Political Element
Machine Organization Military Element
Material Training Economic Element
Management Materiel Social Element
Manpower Leadership and Education
Information Element
Personnel Infrastructure Element
Facilities Physical Environment Element
Time Element
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CONTEMPORARY OPERATIONAL ENVIRONMENT VARIABLES (PMESII-PT)
Political. Describes the distribution of responsibility and power at all levels of governance or cooperation.
Military. Explores the military capabilities of all relevant actors in a given operational environment.
Economic. Encompasses individual behaviors and aggregate phenomena related to the production, distribution, and consumption of resources.
Social. Describes the cultural, religious, and ethnic makeup within an operational environment.
https://rdl.train.army.mil/soldierPortal/atia/adlsc/view/public/10536-1/FM/2-0/chap1.htm;jsessionid=hGfGJ2qZ3C3hghQGGP88HvSSXhcKsc3pYQ1KB62r1TLw7b1yy9vb!467865
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CONTEMPORARY OPERATIONAL ENVIRONMENT VARIABLES (PMESII-PT)
Information. Describes the nature, scope, characteristics, and effects of individuals, organizations, and systems that collect, process, disseminate, or act on information.
Infrastructure. Is composed of the basic facilities, services, and installations needed for the functioning of a community or society.
Physical Environment. Defines the physical circumstances and conditions that influence the execution of operations throughout the domains of air, land, sea, and space.
Time. Influences military operations within an operational environment in terms of the decision cycles, operational tempo, and planning horizons. (FM 3-0)
https://rdl.train.army.mil/soldierPortal/atia/adlsc/view/public/10536-1/FM/2-0/chap1.htm;jsessionid=hGfGJ2qZ3C3hghQGGP88HvSSXhcKsc3pYQ1KB62r1TLw7b1yy9vb!467865
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The Fishbone Diagram Root Cause Analysis Technique:
•Causal Categories resemble the skeleton of a fish. •The failure event or problem is stated in the box to the right. •Major causes are usually summarized as Methods, Measurements, Machines,Materials, and People.
Under each category, identify potential causes for the problem relating to the category.
For example: Incorrect parts being delivered to the assembly area is a potential cause for the “Materials” category.
Source: http://www.emsstrategies.com/dd020106article.html
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Ishikawa Fishbone Diagram - Wikipedia
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Fishbone Diagram Example
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The nail was lost.
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Operation Eagle Claw RememberedOperation Eagle Claw rememberedthe members from the 8th Special Operations Squadron who died in the fatal accident during Operation Eagle Claw were (from left to right) Capt. Richard Bakke, Tech. Sgt. Joel Mayo, Capt. Lyn McIntosh, Capt. Hal Lewis and Capt. Charles McMillan. (Courtesy photo)
The wreckage that was left after the RH-53 Sea Stallion Helicopter and MC-130 Aircraft collided in the desert during Operation Eagle Claw April 25, 1980. (Courtesy photo)Source: http://www.hurlburt.af.mil/news/story_media.asp?id=123095779
Root Cause Analysis: Tools of Lean Six Sigma
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Recent Problems:
•Haiti Earthquake Disaster and Recovery Capability Gap•British Petroleum Oil Disaster and Recovery Capability Gap in the Gulf Coast•US Army Velcro Capability Gap
42
BP oil leak: now partner company says firm was "reckless" as public relations disaster gets worse Photo: EPA/US COAST GUARD
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People
British Petroleum Oil Spill Disaster 2010
ProcessEquipment
Management MaterialEnvironment
The BPBlowout PreventerDevice Failed
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Assignment #5
Use your chosen categories of causation to construct a Fishbone Cause and Effect Diagram for that recurring military problem related to:1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis
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Creating A Cause-and-Effect DiagramPlace the problem in the square to the right and construct a fish vertibrae with 5, 6, or 7 extensions. The 6 basic categories are easily remembered from the anagram "5 ME". Source: http://thequalityweb.com/cause.html
MAN - Does the operator have the proper training, experience, and ability to perform the function?
METHOD - Are the work instructions available and up-to-date? Do they reflect the best method to perform the task? Are the proper tools available? Are the process parameters specified clearly?
MACHINE - Does the machine have the capability to produce the product as specified? Does the machine have the ability to produce the product on a consistent basis? Are there regular routine maintenance and preventative maintenance tasks? Are they performed according to schedule?
MATERIAL - Are the correct materials available for the process? What is the quality of the material used in the process? Is there more than one supplier and does quality vary with different suppliers? What types of material problems could exist?
MEASUREMENT - Are the measurement instruments adequate for the process? Are they maintained correctly and regularly calibrated? Are the measurement instruments affected by environmental conditions such as temperature, vibration, dirt, etc.?
ENVIRONMENT - Is the manufacturing environment affected by temperature, humidity, dust and dirt, power fluctuations or seasonal differences?
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People Machines Measurements
Methods Materials
Incorrectly Assembled Parts
CommunicationTraining
Standard Work Charts
incorrect
Incorrectparts
delivered to line
FixturesAble to
assemble
incorrectly - no
poke-a-yoke
Not verified at
process
Inexperienced
operators not
trained as well
as others.
Lack of
communication
between
testers and
assemblers.
Source: http://www.emsstrategies.com/dd020106article.html
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The Pareto Chart Analysis Technique Source: http://www.schools.utah.gov/sars/servicesinfo/module4/04pchart.pdf
Pareto Chart - Named after Vilfredo Pareto, a 19th century economist who postulated that a large share of wealth is owned by a small percentage of the population.
The descending bar chart is used to separate the “vital few” from the “trivial many”.
Based on the Pareto Principle which states that 80 percent of the problems come from 20 percent of the causes.
A Pareto Chart can answer the following questions: o What are the largest issues facing our team or business? o What 20% of sources are causing 80% of the problems? o Where should we focus our efforts to achieve the greatest improvements?
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The Pareto Chart Analysis Technique Source: http://www.schools.utah.gov/sars/servicesinfo/module4/04pchart.pdf
When is the Pareto Chart useful?The Pareto analysis technique is used primarily to identify and evaluate nonconformities
Pareto Charts convey information in a way that enables you to see clearly the choices that should be made, they can be used to set priorities for many practical applications. Some examples are:
o Process improvement efforts for increased unit readiness o Skills you want your division to have o Customer needs o Suppliers o Investment opportunities
-
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The Pareto Chart Analysis Technique Source: http://www.schools.utah.gov/sars/servicesinfo/module4/04pchart.pdf
Consider the following example:Your business was investigating the delay associated with processing credit card applications. You could group the data into the following categories and their frequencies of occurrence.
Category Frequency No address 9 Illegible 22 Current customer
15
No signature 40 Other 8 Total 94
Category Frequency No signature 40 Illegible 22 Current customer
15
No address 9 Other 8 Total 94
Step 1Construct a Frequency Chart
Step 2 Order the categories according to descending frequency.
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Category Frequency Percentage Cumulative Percentage
No signature 40 43% 43% Illegible 22 23% 66% Current customer 15 16% 82% No address 9 10% 92% Other 8 8% 100%
Step 3 and Step 4Compute Relative Frequencies and Cumulative Relative Frequencies
The Pareto Chart Analysis Technique Source: http://www.schools.utah.gov/sars/servicesinfo/module4/04pchart.pdf
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Step 5 Draw the descending bar chart and the cumulative line graph together
Frequency 40 22 15 9 8Percent 42.6 23.4 16.0 9.6 8.5Cum % 42.6 66.0 81.9 91.5 100.0
CategoryOthe
r
No Add
ress
Curren
t Cus
tomer
Illegib
le
No Sign
ature
90
80
70
60
50
40
30
20
10
0
100
80
60
40
20
0
Freq
uenc
y
Perc
ent
Pareto Chart of Category
The Pareto Chart Analysis Technique Source: http://www.schools.utah.gov/sars/servicesinfo/module4/04pchart.pdf
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Things to look for on your Pareto Chart: In most cases, two or three categories will tower above the others. These few categories which account for the bulk of the problem will be the high-impact points on which to focus. If in doubt, follow these guidelines:
1. Look for a break point in the cumulative percentage line. This point occurs where the slop of the line begins to flatten out. The factors under the steepest part of the curve are the most important.
2. If there is not a fairly clear change in the slope of the line, look for the factors that make up at least 60% of the problem. You can always improve these few, redo the Pareto analysis, and discover the factors that have risen to the top now that the biggest ones have been improved.
3. If the bars are all similar sizes or more than half of the categories are needed to make up the needed 60%, try a different breakdown of categories that might be more appropriate.
The Pareto Chart Analysis Technique Source: http://www.schools.utah.gov/sars/servicesinfo/module4/04pchart.pdf
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Assignment #6
Using your chosen categories of causation and associated frequencies of occurrences construct a Pareto Chart for that recurring military problem related to:
1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis
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The District 11 Southern Region (SR) Auxiliary Strategic Plan for 2007-2008:The District 11 of the Southern Region (SR) reviewed its Strategic Plan of 2005-6:Issues of review included:
- With the Management tools of SWOT Analysis (Strengths – Weaknesses – Opportunities – Threats)- Balanced Score Card- Pareto Chart Analysis
Problems IssuesUnavailable fuel for Patrols Operations IssuesCoast Guard Training to serve the Sector needs
Human Resource Issues
AUX Structure Alignment Organizational Management IssuesCommunication Technology IssuesAUX Officer Training Facilities Issues
Source: DISTRICT 11 (SR) AUXILIARY STRATEGIC PLAN 2007-2008
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Pareto Chart Analysis Findings:Weaknesses in Coast Guard Operations1. New Boat Crew requalification requirements2. Poor bottom to top chain of communications3. Old, poorly maintained facility equipment4. Poor direction for MOM (Marinetime Observation Mission) patrols5. Members on limited income find it hard to participate6. Limited planning and goals
Source: DISTRICT 11 (SR) AUXILIARY STRATEGIC PLAN 2007-2008
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Pareto Chart Analysis FindingsWeaknesses in Coast Guard Human Resources1. Average age of the member is over 502. Low membership participation (80/20 rule)3. Poor emphasis on member retention4. Poor mentoring5. AP status requires too much time6. Members don’t follow chain of leadership7. Poor recruitment of youth8. No plan in flotillas for new members9. Need more emphasis on Elected Officer training at flotilla and Division10. Need more qualified coxswains11. Too much paperwork12. Too many levels in the organization
Source: DISTRICT 11 (SR) AUXILIARY STRATEGIC PLAN 2007-2008
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Pareto Chart Analysis FindingsWeaknesses in Coast Guard Organizational Management1. Poor communication by leaders2. Staff officers are not effective3. Flotillas struggle to survive with poor focus on increasing membership4. Poor inter-flotilla communications5. Members get positions based on popularity not ability6. Low/no funding for staff7. Excessive levels of leadership8. Too much paperwork/forms and reports required
Source: DISTRICT 11 (SR) AUXILIARY STRATEGIC PLAN 2007-2008
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Pareto Chart Analysis FindingsWeaknesses in Coast Guard Technology/Facilities1. Not enough facilities2. Communications with older age members is challenging3. Not enough emphasis to members to view web sites for communications4. POMS to fragile5. Emphasis on E learning not available to all members6. No FAQ on web sites7. Inputting of data into AUXDATA is by a volunteer member and may not be
inputted or slow to input8. CG is reluctant to pay damage claims9. CG will not furnish boats in this district increasing wear-tear on member
boats
Source: DISTRICT 11 (SR) AUXILIARY STRATEGIC PLAN 2007-2008
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Coast Guard Study Findings
Using the SWOT analysis, it was found that the top area weakness was OPERATIONS.
The second weakness was poor bottom to top CHAIN of COMMUNICATIONS.
Source: DISTRICT 11 (SR) AUXILIARY STRATEGIC PLAN 2007-2008
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Failure Modes and Effects Analysis (FMEA)Also called: potential failure modes and effects analysis; failure modes, effects and criticality analysis (FMECA). Description Failure modes and effects analysis (FMEA) is a step-by-step approach for identifying all possible failures in a design, a manufacturing or assembly process, or a product or service. Source: http://www.asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html
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Types of FMEA System - focuses on global system functions
Design - focuses on components and subsystems
Process - focuses on manufacturing and assembly processes
Service - focuses on service functions
Software - focuses on software functions
Source: http://www.npd-solutions.com/fmea.html
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FMEA Procedure
1. Describe the plan/process/product/program and its functions.
2. Populate the FMEA table with necessary identification information.
3. Identify the function or functions associated with the plan/process/product/program.
4. Identify the failure mode, i.e., what could go wrong.
http://www.npd-solutions.com/fmea.html
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4. Identify Failure Modes. A failure mode is defined as the manner in which a component, subsystem, system, process, etc. could potentially fail to meet the design intent. Examples of potential failure modes include: Corrosion Hydrogen embrittlement Electrical Short or Open Torque Fatigue Deformation CrackingBreakage
http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
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5. Identify potential EFFECTS of each failure mode. Examples of failure effects include: Injury to the user Inoperability of the product or process Improper appearance of the product or process Odors Degraded performance NoiseDeath
http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
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6. Assign a SEVERITY rating from the SEVERITYscale indicating the magnitude of the failure effect.1 = not severe. 10 = catastrophic.
http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
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FMEA Procedure (cont.)Severity Scale
Rating Description Definition (Severity Scale)
10 Extremely dangerous
Failure could cause death of a customer (patient, visitor, employee, staff member, business partner) and/or total system breakdown.
98
Very dangerous Failure could cause major or permanent injury and/or serious system disruption with interruption in service.
7 Dangerous Failure causes minor to moderate injury with a high degree of customer dissatisfaction and/or major system problems requiring major repairs or significant re-work.
65
Moderate danger Failure causes minor injury with some customer dissatisfaction and/or major system problems.
43
Low to Moderatedanger
Failure causes very minor or no injury but annoys customers and/or results in minor system problems that can be overcome with minor modifications to system or process.
2 Slight danger Failure causes no injury and customer is unaware of problem however the potential for minor injury exists; little or no effect on system.
1 No danger Failure causes no injury and has no impact on system.
Source: Goodman (1996)
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7. Identify the causes for each failure mode. A failurecause is defined as a design weakness that mayresult in a failure. Examples of potential causes include: Improper torque applied Improper operating conditions Contamination Erroneous algorithms Improper alignment Excessive loading Excessive voltage
http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
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7. Assign an OCCURRENCE rating from the OCCURRENCE scale indicating the magnitude of the failure cause.1 = Virtually certain not to occur.
10 = Virtually certain to occur.
http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
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Rating Description Potential Failure Rate10 Certain probability of occurrence Failure occurs at least once a day.
1 in 59 Failure is almost Inevitable Failure occurs every 3 or 4 days.
1 in 1087
Very high probability of occurrence Failure occurs once per week.1 in 50
65
Moderately high probability ofoccurrence
Failure occurs once per month.1 in 100
43
Moderate probability of occurrence Failure occurs once every 3 months.1 in 500
2 Low probability of occurrence Failure occurs once per year.1 in 1000
1 Remote probability of occurrence Failure almost never occurs; no one remembers last failure.
FMEA Procedure (cont.)Occurrence Scale
Source: Goodman (1996)
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8. Identify Current Controls (design or process). Current Controls (design or process) are the mechanisms that prevent the cause of the failure mode from occurring or which detect the failure before it reaches thecustomer.Detection is an assessment of the likelihood that the Current Controls (design and process) will detect the Cause of the Failure Mode or the Failure Mode itself, thus preventing it from reaching the Customer.
http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
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Examples of Current Controls (design or process) might include:Temperature GaugeEarly Warning SystemTwo ProofreadersBank Notice that your account is below a certain amountLexus Rear View Camera when in reverse
http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
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8. Assign a DETECTION rating from the DETECTIBILITY scale indicating the magnitude of the failure effect.1 = Virtually certain to Detect.
10 = Virtually certain not to Detect.
http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
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FMEA Procedure (cont.)Detection Scale
Rating Description Definition10 No chance of
detectionThere is no known mechanism for detecting the failure.
98
Very Remote /Unreliable
The failure can be detected only with thorough inspection and this is not feasible or cannot be readily done.
76
Remote The error can be detected with manual inspection but no process is in place so that detection left to chance.
5 Moderate chance ofdetection
There is a process for double-checks or inspection but it is not automated and/or is applied only to a sample and/or relies on vigilance.
43
High There is 100% inspection or review of the process but it is not automated.
2 Very High There is 100% inspection of the process and it is automated.
1 Almost Certain There are automatic “shut-offs” or constraints that prevent failure.
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9. Compute Risk Priority Numbers (RPN). The Risk Priority Number is a mathematical product of the numerical Severity, Occurrence, and Detection ratings:
RPN = (Severity) x (Occurrence) x (Detection)RPN values may range from 1 to 1000.
The RPN is used to prioritize items than require additional quality planning or action.
http://www.npd-solutions.com/fmea.html
FMEA Procedure
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10. Determine Recommended Action(s) to address potential failures that have a high RPN.
- Assign Responsibility and a Target Completion Date forthese actions.- Indicate Actions Taken. After these actions have beentaken, re-assess the severity, probability and detection and review the revised RPN's.
- Update the FMEA as the design or process changes, the assessment changes or new information becomes known.
http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
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http://www.asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html
FMEA Example
Function Potential Failure Mode
Potential Effects of Failure
S Potential Cause(s) of Failure
O Current Process Controls
D RPN
CRIT(S x O)
Dispense amount of cash requested by customer
Does not dispense cash
Dissatisfied Customer
Incorrect entry to demand deposit system
Discrepancy in cash balancing
8 Out of Cash
Machine jams
Power failure during transaction
5
3
2
Internal low cash alert
Internal jam alert
None
5
10
10
200
240
160
40
24
16
Dispenses too much cash
Bank loses money
Discrepancy in cash balancing
6 Bills stuck together
Denominations in wrong trays
2
3
Loading procedure (ruffle ends of stack)
Two-person visual verification
7
4
84
72
12
18
Takes too long to dispense cash
Customer is somewhat annoyed
3 Heavy computer network traffic
Power interruption during transaction
7
2
None
None
10
10
210
60
21
6
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Reliability Analysis Quick Subject Guide
Source: http://www.weibull.com/basics/fmea.htm
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Assignment #7
Conduct a FMEA for that recurring military problem related to: ex: British Petroleum Blowout Preventer
1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis
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http://www.npd-solutions.com/fmea.html
FMEA Procedure (cont.)
The Failure Mode and Effects Analysis Approach actually provides a very nice segue into the last technique known as Quality Control or Action Plan.
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Control Techniques
Quality Control-To effectively maintain new standard methods, you really need to:· Verify the results and validate that changes adhere to all operating and compliance policies.
· Document the new methods in such a way that people will find them easy to use, and provide training to everyone who will use the new methods.
· Monitor implementation and make regular course corrections.· Summarize your learning and share them with co-workers involved in
similar projects, with customers, and with managers who need to know the final outcome.
· Think about what should be taken on next in the process to further improve the sigma level(s).
http://www.thequalityweb.com/controlsixsig.html
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Control Techniques
1. Control charts2. Data Collection3. Flow diagrams4. Charts to compare the before and after, such as
frequency plots, Pareto charts, etc.5. Quality Control Process Chart6. Establishing Standardization (Control Plan)
http://www.thequalityweb.com/controlsixsig.html
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Assignment #8
Write a Quality Control Action Plan that will provide documentation and instructions on how to maintain the new found quality of your solution to that recurring military problem related to:
1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing3) Operations and Planning4) Logistics Planning, Development and Distribution5) Military / Civil Affairs6) Computer and Electronic Information Processing and Evaluation7) Training and Operations Exercise Coordination8) Allocating Resources to Defense Strategies and The Army Plan9) Analysis
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A Tutorial Review
•We detected and identified a problem.•We identified key performance parameters or indicators for that problem.•We conducted a “5 Whys?” analysis to identify the root cause of that problem.•We identified categories of causation for variability of that problem.•We constructed a Fishbone Cause and Effects Chart for that problem.•We performed a Pareto Chart Analysis of causes of that problem.•We conducted a FMEA related to that problem.•We identified some fixes to that problem with the FMEA table.•We created a Quality Control plan or Action Plan for the maintenance of the
quality of the solution(s) to that problem. … … …
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CLOSING:
-We have devised a way to minimize variability.-We have a better perspective on making sure the desired outcome and the actual outcome are one in the same.
-We have defeated the battle against discrepancy. -Our plans, products, processes, programs and procedures willyield our desired results and help us achieve our SMART goals.
- Operation Eagle Claw, the JCIDS process, the OSPREY, the Space Shuttles Challenger and Columbia programs were not vainly wasted.
-So thanks to Root Cause Analysis …
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For quality of the nail, the shoe will not be lost.
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For quality of the shoe, the horse will not be lost.
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For quality of the horse, the rider will not be lost.
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For quality of the rider, the battle will not be lost.
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For victory in battle, the kingdom will not be lost.
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For protecting the kingdom, freedom and liberty will never be lost.
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And all for the quality of a nail...
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Well, …. Almost. Anybody got a nail?
Source http://www.guardian.co.uk/environment/2010/jun/20/gulf-oil-spill-bp-lying
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The root cause of success.
Go forth into the world rejoicing in the spirit of Quality and accomplishing your desired Goals.
Thanks be to Quality!
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Solving Tomorrow’s Problems Today …
And Resolving Yesterday’s Problems As Well.
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Thank You!
Questions ??