Root Cause Analysis (RCA) The Boeing Problem Solving Model … · 2019-11-28 · Presented By...

www.armsreliability.com

Presented By

Jennifer MacKay

Associate Technical Fellow, The Boeing Company

1

Root Cause Analysis (RCA) &The Boeing Problem Solving Model (BPSM)

Bridging the ‘Problem Solving’ Skills Gap

Author, 11/26/2019, Filename.ppt | 1


Why Root Cause Analysis?

“At the core of all industry is the desire to make money. Anything that negatively impacts this goal is usually

attacked by performing root cause analysis.”ARMS Reliability - 2018


Presentation Outline

Section 1

Section 2

Section 3


Section 1

Jen & The Boeing Company

• Enterprise Overview

• My Work Environment


The Boeing Company Headquarters: Chicago, IL

Commercial

Defense, Space, & Security

• The world's largest aerospace company • Over 140k employees in more than 65 countries• Leading manufacturer of commercial jetliners and defense, space and security systems• America’s biggest manufacturing exporter

Global Services

The Boeing Company


The Boeing Company

Jen

’s D

esk

Everett, WAUSA


Jen’s Factory Desk – 777 Moving Line


777 Airplane Program777-300 Extended Range

Three million parts in a 777 provided by more than 900

suppliers from 17 countries around the world


Jennifer MacKayAerospace Application

Boeing employee since 1991

Associate Technical Fellow in Root Cause Analysis (RCA)

RCA Instructor > 1,500 engineers, technicians, and quality investigators

RCA Mentor, Consultant, & Champion

10www.armsreliability.com

www.armsreliability.com4

Former SPEEA President: Society of Professional Engineering Employees in Aerospace (SPEEA)

Former IFPTE Vice President: International Federation of Professional and Technical Employees (IFPTE)

Former CESO Delegate: Council of Engineers and Scientists Organization (CESO)

Former SRLC Executive Board Member: Spokane Regional Labor Council

Former SAWDC Member: Spokane Area Workforce Development Council

Jennifer MacKayActivist Application

http://en.wikipedia.org/wiki/File:Logo_IFPTE.gif


Why do you care?

Copyright: <a href='https://www.123rf.com/profile_atic12'>atic12 / 123RF Stock Photo</a>

Companies want

Skilled Problem Solvers

Companies cant’ find Skilled Problem Solvers

SKILLS GAPin the

Problem SolvingSkill-Set


Section 2

The Skills Gap

• Definition / Studies

• Bridging the Gap


What is a Skills Gap?

https://static.googleusercontent.com/media/edu.google.com/en//pdfs/skills-of-the-future-report.pdf

Forbes: A skill gap is a gap between what employers want or need their

employees to be able to do, and what those employees can actually do when they walk into work.Forbes article “The Most Serious Skill Gap Of All” 8/18/2016

Bloomberg: Skills companies want in top talent but can’t find. Skills that are

important but in short supply. Bloomberg’s annual “Employers Survey” https://www.bloomberg.com/graphics/2016-job-skills-report/ 2015 & 2016

Economist: The gap between what students learn in school and what they do in

real life. Economist Intelligence Unit report “Driving the skills agenda” https://static.googleusercontent.com/media/edu.google.com/en//pdfs/skills-of-the-future-report.pdf 2015

https://www.forbes.com/sites/lizryan/2016/08/18/the-most-dangerous-skills-gap-of-all/#1daaa8c242d3

https://www.bloomberg.com/graphics/2016-job-skills-report/

https://static.googleusercontent.com/media/edu.google.com/en/pdfs/skills-of-the-future-report.pdf


More Wanted – Harder to Find

More Wanted – Easier to Find

Less Wanted – Harder to Find

Less Wanted – Easier to Find

Bloomberg's 2015 MBA rankings. Surveyed 1,320 job recruiters at more than 600 companies. They chose their top 5 most important skills and the 5 hardest to find skills from a list of 14 skills.

The Sweet Spot

http://blog.accepted.com/2015/10/26/2015-bloomberg-business-mba-rankings/


Most people think that

they are a good problem

solver by nature.

“… believe that they have

become very good at

given skills without

receiving formal

education in them.”

https://static.googleusercontent.com/media/edu.google.com/en//pdfs/skills-of-the-future-report.pdf

No Problem…


Disconnect

Structured Problem-Solving

Vs.

Winging-It

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Section 3

The BPSM & Apollo RCA

• MacKay application


BPSMThe Boeing Problem Solving Model

Boeing Problem Solving ModelThe Boeing Problem Solving Model provides a structured approach to continuous improvement through problem solving.

•Principle based

•Applies to problems of any size and scope

•Works for all aspects of the business

Authored by Corrective Action & Preventive Action PRO-6490 & BPI-6022


Problem Solving Tool Box

5-Why’s

Apollo Root Cause Analysis (ARCA)

Fishbone Diagram (Cause & Effect)

Fault Tree Analysis

Brainstorming

6-Sigma (DMAIC)

Toyota’s 8 Steps

Accelerated Improvement Workshop (AIW)

Failure Modes & Effects Analysis (FMEA)


Define / Describe the ProblemStep 1

1

2

3

4

5

DEFINE and DESCRIBE the

Problem or Opportunity

Identify ROOT

CAUSES

Identify and VALIDATE

PROPOSED Solutions

IMPLEMENTthe

Solutions

SUSTAIN the

Gains Boeing

Problem Solving

Model


Step 1: Define & Describe the Problem

BPSM • Containment

• Investigation

Copyright: <a href='https://www.123rf.com/profile_bialasiewicz'>bialasiewicz / 123RF Stock Photo</a>Copyright: <a href='https://www.123rf.com/profile_bialasiewicz'>bialasiewicz / 123RF Stock Photo</a>

Ask What,

When,

Where,

& Significance Questions = Problem Statement


MacKay IntegrationStep 1: Define & Describe the Problem

Investigation: Design/Plan/Build ‘As-Designed’ Condition:

• Engineering Drawings, PL/DL’s, 3D Models• Specifications (Boeing & Regulatory)• Tool Designs• All Levels: Raw Mtl, Dtl, Assy & Instl

‘As-Planned’ Condition: • Accurate• Sufficient• In the Proper Sequence• Mfg Plans & Tool Use Instructions

‘As-Built’ Condition:• Interview Witnesses & SME’s• Observe the Process – Monitor Several AP’s• Data Collection & Review

Historic: RH/LH, Tool Units, 1st /2nd shift Real-Time: Metrology &

Detail Part MeasurementsAsk What, When, Where, & Significance Questions


Identify Root CausesStep 2

1

2

3

4

5



Identify ROOT

CAUSES


PROPOSED Solutions

IMPLEMENTthe

Solutions

SUSTAIN the

Gains Boeing

Problem Solving

Model


Step 2: Identify Root Causes

Root Cause Analysis (RCA): The process of identifying the root causes of a detected or potential nonconformity or other undesirable situation utilizing one or more RCA methods or tools (e.g., Cause and Effect Diagram, 5-Why Analysis, Cause Tree). PRO-6490

BPI-4024

1

2

3

4

5



Identify ROOT

CAUSES


PROPOSED Solutions

IMPLEMENTthe

Solutions

SUSTAIN the

Gains Boeing

Problem Solving

Model


ARCAThe Apollo Root Cause Analysis Methodology

Gano, Dean L. “Apollo Root Cause Analysis – A New Way of Thinking” Apollonian Publications, 1999, 2003

“There is no such thing as a single right answer.Rather, Solutions are found in an infinite set of causes.”

Event Based - Most problems do not have one right answer,

– multiple root causes thus multiple solutions.

Dean L. Gano

Gano, Dean L. “Apollo Root Cause Analysis – A New Way of Thinking” Apollonian Publications, 1999, 2003


DefinitionCause-Mapping

Cause-Mapping:A root cause analysis tool that provides a visual explanation of why an incident occurred. It connects individual cause-and-effect relationships to reveal the system of causes within an issue.

Begin with the Problem, what it is that you want to fix. This becomes your starting point or Primary Effect.

Then map the reasons why the problem occurred as ‘causes’ on your Cause-Map.

To explore both action and condition contributors, differentiate your causes as Action Causes or Conditions Causes.

Action Causes are those actions that occurred (or failed to occur) that caused the problem while Condition Causes are those conditions already in place that allowed those Actions to happen.


“Things don’t just happen, they are made to happen.”John F. Kennedy

MacKay IntegrationStep 2: Root Cause Analysis


Example: 777 Wing Majors- Wing Skin Panel Scrap

Condition Why

The tool can physically

be used in an up-side-

down condition.

Action Why

Mechanic applied Drill

Starts at incorrect

locations

www.armsreliability.com 31

Action Causes & Condition Causes

Any manual task that can possibly be done incorrectly – will be done incorrectly

Even highly skilled top performers can simply ‘have a bad day’.


Collaborative Approach:Cross-Functional / Formal Workshop - Invite those who…

• Know the most about the problem• Can best help you implement your solutions

Streamlined Approach:Perform initial investigation and create the a Cause Map draft on your own, work 1-on-1 with SME’s as needed to finalize the cause map– No formal workshop.

Tip: Resources are usually limited so be judicious when planning workshops. Hold several half-day sessions in lieu of full-day workshops.

The Cause-Mapping Exercise

Cause Maps can be created with pen & paper, sticky notes on a white-board, or with software applications such as PowerPoint, Visio, Excel, or RealityCharting®.

My personal Cause-Mapping tool of choice is RealityCharting®.


How far back should you go?


Apollo’s Reasons to Stop

Desired Condition

More Information Needed

Lack of Control

Other Cause Paths

More Productive

Potential Solution


Identify Potential SolutionsStep 3

1

2

3

4

5



Identify ROOT

CAUSES


PROPOSED Solutions

IMPLEMENTthe

Solutions

SUSTAIN the

Gains Boeing

Problem Solving

Model


Step 3: Identify & Validate Proposed Solutions

Each Cause Path without a StopShould have a Potential Solution

• Local SME’s – Subject Matter Experts• Internal Research & Development• Benchmarking

Lack of Control

Desired Condition


Down-Select

Down-select until you have a Solution Set you have confidence in.

(2) Selected & Implemented(7) Potential Solutions Identified

Employ Tools to Help select and prioritize:• Return on Investment (ROI)• Impact & Changeability Analysis


Implement SolutionsStep 4

1

2

3

4

5



Identify ROOT

CAUSES


PROPOSED Solutions

IMPLEMENTthe

Solutions

SUSTAIN the

Gains Boeing

Problem Solving

Model


Most Difficult Step• Relying on Multiple Organizations with

differing hierarchy & priorities

• Extensive Implementation Time Frame

• Employee Movement / Attrition

Implementation Effort & Cost Varied: Simple, Efficient, Inexpensive

Complex, Revolutionary, Capital Expense

Tracking is Key

MacKay IntegrationStep 4: Implement Solutions


RCA Project Repository

• Single point of visibility

• Common metrics and reporting

• Searchable: Accessible to anyone searching for ideas that can be replicated


Sustain the GainsStep 5

1

2

3

4

5



Identify ROOT

CAUSES


PROPOSED Solutions

IMPLEMENTthe

Solutions

SUSTAIN the

Gains Boeing

Problem Solving

Model


Step 5: Sustain the Gains

Non-Conformance Generated Projects:• Built-In Verification System• Formal Validation Sign-Off

Process Improvement Projects• 30/60/90 Day Post-Implementation

Review


MacKay IntegrationStep 5: Verify / Validate Outcome

Sustaining the Gains- Validation:

One way to express the importance of the Validation step, is to share with you an experience I had when I failed to follow-up:


BPSMThe Boeing Problem Solving Model

https://collab2.web.boeing.com/sites/rcapm/RCA_Present/_layouts/15/start.aspx#/SitePages/Home.aspx.https://collab2.web.boeing.com/sites/rcapm/RCA_Present/_layouts/15/start.aspx#/SitePages/Home.aspx

Our longest running Non-Conformance Issues BCA-Wide

https://collab2.web.boeing.com/sites/rcapm/RCA_Present/_layouts/15/start.aspx#/SitePages/Home.aspx.https://collab2.web.boeing.com/sites/rcapm/RCA_Present/_layouts/15/start.aspx#/SitePages/Home.aspx 46

In-Service Quality Issues


RCA Resource all Commercial Programs

Renton Waste Water Treatment Plant – Capacity Issue


Supplier Quality & Supply Chain ME Support: External Supplier RCA Training and Workshop Facilitation


Engineering Process Problems 777 Program-Wide


BPSM/RCCA

A: BPSM Basics 78983

Required

1-Hr Web Based

B: BPSM Application 78984

Recommended

8 or 16-hr Instructor Led

RCA Cause Mapping

A: PE110 Cause Mapping

Recommended

8-Hr Instructor LedJennifer MacKay - expand pool

Project

Management

A: PE101

Recommended

6-Hour Instructor LedSusan Murphy

Mastery

Trained: Complete the curriculum

Practitioner: Lead a formal RCA

Facilitator: Facilitate multiple projects to the

satisfaction of a Facilitator or BDE

Boeing Designated Expert

Obtain Industry RCA Training & Certification

Apollo RCA / ARMS Reliability

Growing the Problem Solving Skill SetCurriculum Flow

CF105: Curriculum Flow for Integrated Problem Solving Levels

http://wsso-support.web.boeing.com:2015/redirect.html?URL=https://mlcat.web.boeing.com/cat/?IntgrCd=CRSEENRL&SystemID=Evtopstraining&[email protected]&CourseCode=78983

http://wsso-support.web.boeing.com:2015/redirect.html?URL=https://mlcat.web.boeing.com/cat/?IntgrCd=CRSEENRL&SystemID=Evtopstraining&[email protected]&CourseCode=78984


Summary


Companies want Skilled Problem Solvers

Boeing Job Classifications • Engineering • Information Technology (IT)• Contracts & Pricing• Environment, Health, & Safety• Facilities

Key Competency:

Provides technical solutions to complex problems that require ingenuity and creativity.

Copyright: <a href='https://www.123rf.com/profile_semisatch'>semisatch / 123RF Stock Photo</a>

“Can you tell us about a time when you had to solve a

complex problem?”


For every Action or Inaction that caused a problem

A Condition existed that allowed it to happen Questions?

Root Cause Analysis (RCA) The Boeing Problem Solving Model … · 2019-11-28 · Presented By...

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