8d Training 9-8-2008-Root Cause Analysis
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Transcript of 8d Training 9-8-2008-Root Cause Analysis
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Training Materials For Reference Only Slide 1
Finding and eliminating (forever) the root
cause of a problem.
HBC 8D Process for Problem Solving
Course Duration: 4.0 hours
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Training Materials For Reference Only Slide 2
Course Objectives
At Completion YOU should:
Understand HBCs 8D process Know when to use the 8D Process
Be able to write an 8D Summary Report
Be comfortable using typical problem solving tools
Know how to get additional help/training
I hear...I forgetI see...and I rememberI do...and I understand
Ancient Chinese Proverb
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Origin of HBCs 8D process Fit with:
Hawker Beechcraft Performance System (HBPS) Initiatives
Existing processes Overview of the 8 Steps
0 - Decide to use the HBC 8D Process1 - Describe the Problem
2 - Assemble a Team3 - Implement Interim Containment4 - Find Root Cause5 - Develop Corrective Action
6 - Implement Permanent Fix7 - Prevent Recurrence8 - Recognize the Team
Additional Information contacts, reference material
Agenda
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Round Robin Introductions
Your Name
Where you work -position/responsibilities
Personal objectives for this course
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Root Cause: The very basic reason why, how, & when the conditionoccurred.A Root Cause Mentality: An insatiable desire to understand why things gowrong, why people do what they do, and how things got into their presentstate. (C. Robert Nelms)
This takes persistence
Interim Containment Action: This is the action taken which shouldaddress and correct the actual nonconforming condition.
Permanent Corrective Action: This should address the root cause ofa nonconformance and prevent future occurrences of the problemwhich caused the nonconformance.
Contributing Cause: This factor contributed to the problem, but it is
not the root cause. Keep going to get to Root Cause.
Verification: Making sure that something is going to work prior toimplementation.
Validation: Checking to make sure that the change is working (afterimplementation)
Definitions
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A systematic approach to effectively identify the
cause chain of a nonconformance and topermanently eliminate the source(s) of problems.
Directed at reducing, and if possible eliminating,quality system escapes and the costs associated withpoor quality.
Root Cause / Corrective Action (RCCA) is:
More on Root Cause
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Origin of HBCs 8D Process
8D (8 Disciplines) first standardized by the U.S.government during World War 2
Military Standard 1520: Corrective action and disposition
system for nonconforming material Popularized by Ford Motor Company in the 1960s and
1970s (called Global 8D or G8D) 8D now a standard in the Auto Industry
8D fills a void we currently have at HBC We reference root cause (internally, with our suppliers and
customers) BUT, we dont provide a standard process to get to root cause
HBC 8D a Structured Process (and Tool Set) for Root Cause Corrective Action
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HBPS Initiative Positioning
Goal solve the problem Smooth land (drain the lake,
remove boulders) No leaks in the boats (rental
income while lake is here)
Pick the best fit methodology Drain the lake (remove waste)
use LEAN Six Sigma Remove boulders (variation
reduction) use Lean SIX SIGMA
Leaks (immediate problems thatmust be fixed) use HBC 8D
Use the right tools for the job Common tools will be used by all
methodologies
This Analogy: Bucket can beused to empty the lake, removerubble, and bail out the boat
In general, Lean Six Sigma projects take longer; 8D is for everyday, immediate problems.
http://www.clipart.com/en/close-up?o=898840&a=c&q=lake&k_mode=all&s=286&e=300&show=&c=&cid=&findincat=&g=&cc=4935:17:7083:251:0:4298:6&page=20&k_exc=&pubid=&color=&b=k&date= -
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Time
Planning
0
40
0
Lessons Learned
Sporadic Spike
(Special Cause: HBC 8D)
Control (During Production)
Significant Shift
AND/ORVariation Reduction(Lean SIX SIGMA)Common cause
(random)variation/waste
(LEAN Six Sigma)
Special cause(assignable) variation
HBPS Initiative Positioning (alt. view)
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8D Process Fit
Policy & Procedures 12 0008 Corrective ActionSystem
Quality Assurance Instruction (QAI) -- QAI 03-01-015
Corrective Action Response and Review Requirements
Corrective Action requests resulting from: Nonconforming material
Out of control processes Internal audits Supplier issues Customer complaints Operator self-verification process Other nonconformances in product or process
Via: PCAS - Production Corrective Action System FCAS - Field Corrective Action System IQAG - Internal Quality Audit Group OSV - Operator Self Verification + Management Directive
8D adds structure (defined steps, language) to what we already have.
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Changes being made to: WI 04-09-009 Creating and Updating
Corrective Action Records in SAP WI 04-09-014 Responding to the Corrective
Action in SAP
WI 04-14-005 issuing Corrective ActionRequests for Major Noncompliances
Documents Created in SAP: Q1 Customer Complaint Q2 Vendor Product Non-Conformance Q3 HBC Product Non-Conformance
Q4 Vendor Product CA Q5 HBC Product CA Q6 Vendor Audit CA/PA Q7 HBC Audit CA/PA
HBC 8D form will be attached to the
appropriate Q1-Q7 record in SAP Reference Hard Copy of HBC 8D Formhandouts
8D Process Fit (cont.)
Work Instructions are being modified now to incorporate 8D.
Wh t i 8D?
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What is 8D?
1. Corporate Standard
2. Standardized Problem Solving
Process
Language, Methodology
3. Reporting Format
8 Di i li (8D )
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8 Disciplines (8Ds)
D-0 Decide to use the 8D Process existing processes
D-1 Describe Problem
D-2 Establish TeamD-3 Implement Interim Containment
D-4 Find Root Cause
D-5 Choose Corrective Action
D-6 Implement Permanent Corrective Action
D-7 Prevent Recurrence
D-8 Congratulate Team
Wh t t i 8D l i ?
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What can trigger an 8D analysis?
When do we
use the
8DProcess?
Problem with Cause Unknown
Need to Cure - Not Mask Problem
Justifies a Structured/Team ApproachFactors Severity, Cost, Time, etc.
Examples:
Whenever you open a QN, ask yourself if Root Cause/8D should be done.
Wh i iti t 8D l i ?
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Who can initiate an 8D analysis?
Request for an 8D analysis can be made by: Customer
Current Sales/Support Interface
HBC Employee Initially, by contacting QA reps
Eventually, anyone
Working out details defining when it makes sense
Not all problems need an 8D level of analysis
HBC Supply Chain
Supplier will perform the 8D
Management
Anyone can use the process. Using SAP makes sure we capture/share knowledge.
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Place in 8D Process
D-0 Decide to use the 8D Process
D-1 DESCRIBE THE PROBLEMDESCRIBE THE PROBLEM
Why is it important for a Problem Solving
team to start with Describe the Problem?
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8D Step 1 Describe the Problem
What is the problem?
This should be a short, simple and concise definition.
IF YOU CANNOT SAY IT
SIMPLY, YOU DO NOTUNDERSTAND THE
PROBLEM
REMEMBER:
A problem well stated is aproblem half solved!
Information about the problem
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What is the problem?
Where was it detected? How serious is the problem?
How many occurrences?
Who is affected? When did it surface?
Remember: on the problem.
Information about the problem
Problem Definition/Analysis Prompts
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Problem Definition/Analysis Prompts
Who?
Who notified you of the problem?- Manufacturing, Engineering, SAP QN Review, QA
Audit, etc.Who are the people involved with the problem? (for step 2 team formation)
- Supplier, customer, material handlers, assemblers, supervisors,engineers, QA personnel, etc.
High Level information belongs in the Problem Description, Investigate all others in Step 3 & 4.
Problem Definition/Analysis Prompts
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Problem Definition/Analysis Prompts
What?
What is the part name/number/other identification?What type of product or process?
- Detail, assembly, vendor part- Part manufacturing process, assembly process?
What is the type of nonconformance?- Scratch, Dent, Oversize hole, Fit?
- Lack of communication, waiting too long for info/parts?What characteristic of the part/process is having the failure
- hole radius, linear dimension?
- manufacture of the part, movement, inspection?What method of measurement was used to identify the failure?What are special circumstances surrounding the problem?
- new personnel, equipment move, new tool, etc.?
What environmental conditions existed?- extremely cold/hot, rainy, humidity, lighting, etc.?
What is the design/nonconformance criteria in question?- Drawing, Spec, Task Planning, Policy, Process?
What training has been done or is available?What hardware or software is associated with the issue? Have there been recent administrative, program or equipment changes?
Problem Definition/Analysis Prompts
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When in the build process/production schedule/work shift did the problemoccur?
- note: occurrence point and detection point may(and usually arent) at the same time
When in the task did the problem occur? (what step?)When in the functional test did the problem occur (what step?)When in the day, week, month did it/has it occurred (patterns)?
Problem Definition/Analysis Prompts
When?
Problem Definition/Analysis Prompts
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Where is the part being contained?Where is the part being used?
Where is the geographical location of the failure?What plant/line/station cell? Is the problem in-house or external (supplier) or external (in the field)?Where are similar nonconformance records located?
Problem Definition/Analysis Prompts
Where?
Problem Definition/Analysis Prompts
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Problem Definition/Analysis Prompts
Impact?
How many times and in what period? Cost of nonconformance in dollars? Safety impact? Cost of delay?Warranty cost? Impact to worker morale/productivity? Has this issue been fixed before? Impact on Business processes?
- production- delivery- product use- field reliability
Impact on Customer Satisfaction?
Importance of Problem Description
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Importance of Problem Description
Focuses team on same objective
Direction set here is used throughout the HBC8D process (foundation)
Forces all to agree on the scope and goal
Note: Operational Definitions MUSTaccompany the Problem Description What does failure mean?
What is bad?
What does success look like? Ice-scrapingvideo
Tool: Is / Is Not for Problem Definition
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Tool: Is / Is Not for Problem Definition
Reasons to use IS - IS NOT
Establishes points of comparison
Leads to a more complete problem description
Provides a Test base for Root Cause
Gives you a fingerprint of the problemDraws better boundaries around the problem
SCOPE whats in, whats out
Tool: Is / Is Not for Problem Definition
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Development of IS:
Identity - What is the problem?
Space - Where is the problem?
Time - When is the problem happening?(also When did it start?)
Mass - How Big is the problem?
Tool: Is / Is Not for Problem Definition
Development of IS NOT
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IS IS NOT(What, Where, When, How Big) would you EXPECTEXPECT to..
SEE, HEAR, FEEL, SMELL, OBSERVE . . .
.....but DO NOT?DO NOT? ((close cousinsclose cousins))
>>>>>>>>>>>>>>>>>>>>
Development of IS NOT
(What, Where, When, How Big) IS it?
(What, Where, When, How Big) could it be but it IS NOT ?
Once you have the Problem Defined, get feedback from others
(coworkers, manager, others) who have done 8D/RCCA
Reasons to use IS - IS NOT
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Reasons to use IS IS NOT
Establishes points of comparison
Leads to a more complete problem description
Provides a Test base for Root Cause
Gives you a fingerprint of the problem
Draws better boundaries around the problem SCOPE whats in, whats out
Document Your Work
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1) Open a QN in SAP2) Fill Out Section 1 of the 8D Summary Report
- go to the Quality Forms link on the QA home page
3) Attach the 8D Summary Report file to the QN
Step 2 in the HBC 8D Process
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p
D-0 Decide to use the 8D Process
D-1 Define the Problem
DD--2 Form the Team2 Form the Team
8D - Step 2: Form a Team
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p
A Team may be:
formal (scheduled meetings, for ex.) or
informal (consulted as needed)
Agree on work group guidelines
CustomerComplaint
Advantages/Disadvantages of Teams
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Advantages/Disadvantages of Teams
WHY DO TEAMS FAIL?
WHAT ARE THE BENEFITS
OF A TEAM APPROACH?
What have been your experiences with teams??
Major Problems with Team Problem
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Solving
Problem incorrectly describedProblem incorrectly described ! ! !! ! ! (biggest inhibitor)(biggest inhibitor)
Make sure Problem Description is accurate and team
members agree Problem solving process rushed
Poor team participation
No logical (group) process
Lack of technical skills
Management impatience Permanent Corrective Action Not Implemented
Typical Team Organization
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yp ca ea O ga a o
Champion/Sponsor
Leader
Recorder rotate this role
Team Members(SMEs - Subject Matter Experts)
Facilitator (optional)
Customer/Supplier
Are we having
fun yet?
Recommend: 4-7 members
(10 max.)
10, consider subteams
Ask the initial team: Who else needs to be involved, but isnt here?
Step 3 in the HBC 8D Process
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D-0 Decide to use 8D Process
D-1 Define the Problem
D-2 Establish a Team
DD--33 CHOOSE, IMPLEMENT AND VERIFYCHOOSE, IMPLEMENT AND VERIFY
INTERIM CONTAINMENT ACTIONINTERIM CONTAINMENT ACTION-- basically youbasically yourere DispositioningDispositioning thethe
QNQN
8D Step 3: Implement Interim
C t i t A ti
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Containment Action
Decide whether you need to use one
Choose the best (benefits vs. risks) Tools
Brainstorming to generate ideas
Pros/Cons lists; Effort (or cost or time) vs.Benefit (or risk) graphic.
Action Plan
Test feasibility of the containment action(Verify it will work)
Commit to it Implement
Validate containment action effectiveness
ActionPlan
ALWAYS +s and s to every decision. BALANCE (and action) are the Keys!
L H
L
H
Ideal
Effort
Benefit
Purpose of Interim Containment
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p
Used to buy time to find root cause whileprotecting your customer (external or
downstream operation) from the problem Authorized first aid, but. . . . .
can be costly
attacks symptoms (not the cause)
has a masking effect
Purpose of this step:Enforce SCOPE and EFFECTIVENESS of customerprotection needed
Its OK to not have containment, its NOT OK to not THINK about it.
Int. Cont. Action vs. Typical BAND AID
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yp
__X__ Attacks Symptoms __X__
__X__ Added Costs __X____X__ Monitored while being used _____
__X__ Documented &Data Collected _____
__X__ Verified for effectiveness _______X__ Replaced by Perm. Correction _____
InterimContainment
Action BANDAID
Key Points of Step 3: Interim Containment
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y p
Act quickly (and carefully) Use the team to come up with the list of potential actions
Minimizes risk, results in better ideas
Pick the best overall Containment Action(s) Consider actions that may be needed to address other areas: Product in the field WIP Work In Process
Product in transit/at the Supplier Spares
Use Action Plan to make sure nothing falls through the cracks Examples:
VERIFICATION and VALIDATION Airworthiness Directives Service Bulletins Kits for field
DONT STOP HERE!!! XX
ActionPlan
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Fill Out Section 3 of the 8D
Summary Report
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BREAK FOR 10 MINUTES
Where are We?
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Place in the HBC 8D Process D-0 Decide to use 8D Process
D-1 Define the Problem
D-2 Establish a Team
D-3 Choose, Implement and Verify Interim Containment
Action (I.C.A.)
DD--44 FIND ROOT CAUSEFIND ROOT CAUSE
Root Cause Analysis Common Tools
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Your BrainEspecially the Collective Brain of your team
Data Thought Map Process Map
Brainstorming 5 Whys Cause and Effect (Fishbone) Diagram
Graphical Analysis (misc. graphs) +
What tool to use? Problem ->Questions->Data/Tools ->More QuestionsROOT CAUSE
Thought Map
General Information about Step 4
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Dont try to do solutions before the analysis iscomplete.
It is futile to continue doing things the same way while
expecting different results. Dont fall into the trap of jumping to conclusions.
OUR DESIRE TO ACT, OVERPOWERS OUR NEED TO UNDERSTAND(Brad Baker, CONOCO)
This cant be a part time job. Assign aPoint Of Contact (POC) to focus on closure.
The RCCA response ECD must be basedon a planned list of things to do (Action Item
Lists).
Data Collection
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Types of data to collect:
1. Location: where problem was detected2. Personnel: who found problem
3. Specifications: what are the requirements
4. Environment: noise, lighting, temperature, etc5. Sequence of events
6. Equipment
7. Training8. Other occurrences
9. Recent changes: personnel, process, weather
Insufficient data can result in solving only the specific instance.
Challenge the basis for why its beendetermined to be an isolated eventand why it couldnt potentially be a
systemic problem
Tools: Thought Map
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Once the problem is defined, natural tendency is to rush forward
RESIST THE URGE!!
Take a few minutes to plan your journey to root cause
1) Write your Problem Statement at the top of the page
2) Capture questions that you have Assumptions, potential causes, sources of the problem that dont belong in
the problem statement SHOULD be captured as questions3) Answer each question with data
4) Questions (and data) will lead to more questions
5) Capture dead-ends as well as fruitful paths
1) Why?
NOTE: Review the Problem Definition (Step 1) often!
Used: When? ________________________ Why?__________________
Thought Map example: Drill Bit Quality
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What is the currentbit brand
and quality used?
Is the perceivedbit quality difference
real or just perception?
What specific featuresof the bit performance
are perceived as
the problem?
Is it possible to
attribute QNs and other
sheet metal defects to
bit quality?
Is there a statist ically
significant difference
in the number of holes
drilled before dull?
What other factors
contribute to manual,
hand drilling performance?
How much isthe difference?
What are the bit
performance
indicators?
1 - Penetration Sharpness
2 - Straightness
3 - CenteringWhat is considered
the premium bit?
1 Number of holes dril led
2 - Straightness
3 Centering
4 Penetration
5 QNs Resulting
Precision TwistBrand
Bruckner provides astandard, such asMichigan Twist
LEGEND:
Dashed LinesIndicate Links
What is the difference
in cost for the bits?
Tools: Process Mapping/Value
Stream Mapping
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Stream Mapping
Graphical Depiction of How Its DoneTerminator (start/stop)Process Step
Decision PointConnector (off-page)
General Rules:
Left to Right Yess/Nos consistent
?
??
?
How would you map out the process for 8D so far?
Used: When? ________________________ Why?__________________
Assembly Transport InspectionOutpu
ts
Inputs
Transport Storage Machine Transport
Tools: 5 (OK, maybe just 3) Senses
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Talk to, Listen to, Observe:
People performing the jobSuppliers
(internal/external)
Customers(internal/external)
You are a root cause detective. Use all the tools you can.
Tools: Brainstorming
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When the best solution isnt obvious, one technique forgenerating ideas (possible root causes, potential interimcorrective or permanent actions) is brainstorming.
1. Generates a large number of ideas2. Encourage free-thinking3. Dont criticize4. Encourage everyone to participate
5. Record all ideas. There is no bad idea.6. Let ideas incubate give it a little time
A minimum group of atleast three people to make
this work
Used: When? ________________________ Why?__________________
Tools: 5 Whys
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1. Why? There was oil on the floor.2. Why? The machine in that cell was leaking oil.
3. Why? A pressure fitting on the machine failed.
4. Why? Inspection of hoses and fittings is not part of the preventive
maintenance (PM) schedule.5. Why? The PM system does not consider Equipment Manufacturers
recommendations to develop PM schedules.
6. Why?- Theres check to make sure this is done.
Dont stop with Because we dont have enough people, money, time
its a fact of life.
Solve the problem with the people, money, time you DO HAVE.
An employee in the plant
slipped and fell while
performing their regular duties.
Peel the onion- challenge the basis for root
cause. Most people can only support 1-2layers of questions with their basis for root
cause or corrective action.
Used: When? ________________________ Why?__________________
Tools: Cause and Effect Diagram
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A Cause-and-Effect (fishbone or Ishikawa) diagram an easily applied tool used to analyze possible causes to aproblem.
Non-conforming coating
Manpower
- inexperienced
Methods
- incorrect prep of
metal surface
Machinery
- microscope
Materials
- poor quality of
standards
- microscope setting notoptimized to detect the
smearing
-not following the frozen
coating parameters
- inadequate training
-inadequate technique
MUST BE TESTED ANDVERIFIED!
5 Ms and an E - addMeasures andEnvironment for 6 Bones
Used: When? ________________________ Why?__________________
Tools: Graphical Analysis
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Histogram Used to show patterns/distribution in ordered data
Categories on the x-axis, # of occurrences on they axis.
Pareto Chart (80/20 rule) Used when many problems or causes and you
want to focus on the most significant
Causes on x-axis, Results on the left (primary) y-axis, Cumulative % on the right (secondary) y-axis.
Scatter Diagram
Used to illustrate relationships between 2variables. 1 variable on each axis.
"Correlation does not imply causality." Ex. Shark Bites and Ice Cream
Purpose of Graphical Analysis: ________________________________
Word of Caution: Stay on Track!
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Use Common Sense:
1. The more significant or involvedthe problem, the more detail may
be needed to identify the RootCause
1. Also more advanced tools
2. Avoid data that leads to other
problems.1. Dont get sidetracked
1. Review Step 1 ProblemDescription.
2. Use the Thought Map
Start
GoalSide
Issue
Side
Issue
Side
Issue
Complex problems usually require at least a fishbone diagram of the potential
root causes sorted from the brainstorm list
Define the actions to validate or dismiss each one Technical problems usually require a structured FMEA
Document Your Findings
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Fill Out Section 4 of the 8D
Summary Report
8D Step 5: Choose Corrective Action
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Place in the HBC 8D Process: D-0 Decide to use 8D Process
D-1 Define the Problem
D-2 Establish a Team
D-3 Choose, Implement and Verify Interim Containment Action(I.C.A.)
D-4 Find Root Cause
DD--5 DETERMINE PERMANENT CORRECTIVE5 DETERMINE PERMANENT CORRECTIVEACTIONACTION
Decision Making Steps(note: can also be used in Step 3)
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Training Materials For Reference Only Slide 58
1. Define end result (action verb & object) Eliminating/Preventing/Reducing (verbs) Errors/Safety Incidents/QN/s (objects)
2. List decision criteria
GIVENSGIVENS - Mandatory WANTSWANTS - Desirable
3. Decide relative importance ofwantswants 1-104. Identify the possible choices5. Compare possible choices against the decision criteria6. Analyze risk
IF/THEN terms:If we choose to___________,
Then _________ will happen.
7. Make the final BALANCED choice and VERIFY
NOTE: Use the Action Item Tracking Sheet toCapture and Track Actions
ALWAYS +s and s to every decision. BALANCE (and action) are the Keys!
ActionPlan
Track Action Items to Completionand Summarize Results
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Training Materials For Reference Only Slide 59
Use the Corrective Action Plan Worksheetin the 8D File and Summarize in Section 5
of the 8D Summary Report
8D - Step 6: Implement the Fix
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Training Materials For Reference Only Slide 60
Place in the HBC 8D Process:D-0 Decide to use D8 Process
D-1 Choose team members
D-2 Define problem
D-3 Choose Interim Corrective Action(s) & verify
D-4 Find Root Cause
D-5 Choose & verify Permanent Corrective Action
DD--66 IMPLEMENT PERMANENTIMPLEMENT PERMANENT
CORRECTIVE ACTIONCORRECTIVE ACTION
Goals of Permanent Corrective Action
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Training Materials For Reference Only Slide 61
Permanent Corrective Action MUSTMUST:Address the systemic problem (in addition to this
specific instance)
Eliminate the Root CausePrevent recurrenceBe implemented in a timely manner
Include a detailed plan (especially if it will takeconsiderable time and people)Be comparable to the risk involved
Risk to the customer, employee, organization, public, etc.
Be verified Objectively Three knowledgeable people must agree
Keys to Successful Corrective Action
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Training Materials For Reference Only Slide 62
Persistence Natural Tendency to slack off once the Fix is determined
and partially implemented
Follow the Action Plan to Completion
Involve Do-It-Level people Key to preventing recurrence
Review Interim Containment Action(s) Remove/discontinue any not needed adds cost, time, etc.
VERIFY IT!!!
VALIDATE IT!!! ActionPlan
More than Just Do It
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Training Materials For Reference Only Slide 63
Why should we do planning and NEWproblem prevention when considering
implementing a permanent corrective action
forTHIS problem? see next slide.
Why Planning and Problem Prevention?
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Training Materials For Reference Only Slide 64
Many of our current problems are the result ofnot following through with previous plans
Must allocate limited resources effectivelyOptimize implementation Dont waste Time/$$
Prevent other problems from occurringWith change comes risk of creating NEW
problems
Control Mr. Murphy
Summarize the Key PermanentCorrective Actions
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Training Materials For Reference Only Slide 65
Fill Out Section 6 of the 8D Form
8D - Step 7: Prevent Recurrence
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Training Materials For Reference Only Slide 66
D-0 Decide to use D8 ProcessD-1 Choose team members
D-2 Define problem
D-3 Choose Interim Containment Action(s) & verify
D-4 Find Root Cause
D-5 Choose & verify permanent corrective action
D-6 Implement Permanent Corrective Action(s)
DD--77 PREVENT RECURRENCEPREVENT RECURRENCE
Steps to Preventing Recurrence
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Training Materials For Reference Only Slide 67
Identify what systems, practices, orprocedures allowed the problem to occur
The whys
Identify and implement improvements
VALIDATE the results
Poka yoke is the Japanese term that means fail safing or
Tool: Mistake-Proofing
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Training Materials For Reference Only Slide 68
Poka-yoke is the Japanese term that means fail-safing or
"mistake-proofing" Examples:
Cant start car until in park, Child-proof caps, laser beam shut-offs for machinery
Others??
One of the best ways to prevent problems fromoccurring/recurring
Use mistake-proofing techniques when there are: Process steps where human intervention is required Decision points in the process Repetitive tasks where physical manipulation of objects
is required Steps where errors are known to occur
Opportunities for predictable errors to occur
Mistake-Proofing Levels of Prevention
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Training Materials For Reference Only Slide 69
Defect is the
evidence of anerror
More Proactive
Beware of Root cause was HumanError
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Training Materials For Reference Only Slide 70
HUMAN ERRORS do not make a root causeHow does HBC approach human error?
Positive Defects can be eliminated Create a mistake-proof environmentAsk Why?
Focus on the Process/Product NOT the Person
Apply Mistake-Proofing device for 100% inspection
Negative Defects are inevitable People make mistakes
Place blame Detect at final inspection Sampling inspection Some are bound to reach the customer
Once Root Cause is Determined,Broaden your Thinking
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Training Materials For Reference Only Slide 71
How Can We Standardize Lessons Learned & SystemImprovements?
Communication Same/similar problem other plants
Same/similar problem different
systems Content Quality
Appropriate Quantity
Effect
Root Cause
Potential Causes
Current/Future Problems in other areas
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Training Materials For Reference Only Slide 72
Fill Out Section 7 of the 8D Form Prevention of Recurrence
8D - Step 8: Congratulate the Team
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Training Materials For Reference Only Slide 73
D-0 Decide to use D8 ProcessD-1 Choose team members
D-2 Define problem
D-3 Choose I.C.A., verify
D-4 Find Root Cause
D-5 Choose & verify P.C.A.D-6 Implement P.C.A.(s)
D-7 Prevent recurrence
DD--88 CONGRATULATE THE TEAMCONGRATULATE THE TEAM
How to Congratulate the Team
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Training Materials For Reference Only Slide 74
Review significance of contribution Provide appropriate recognition for all members
Document the efforts & results
Celebrate successful completion
Celebrations dont have to beelaborate/expensive
Be creative
How Would You Congratulate YourTeam?
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Training Materials For Reference Only Slide 75
What are some things that have worked well in thepast?
What are some things that didnt?
5 minutes
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Training Materials For Reference Only Slide 76
Fill Out Section 8 of the 8D Form
(and attach completed file to the
appropriate QN)
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Training Materials For Reference Only Slide 77
Comments, Suggestions??
Please fill out class/instructor
Evaluation Forms
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Training Materials For Reference Only Slide 78
Reference Material
QA Intranet Website
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Training Materials For Reference Only Slide 79