January 7 & 8 , 2015

Prepared by Julian Kalac

Master Black Belt Lean Six Sigma

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Prevent problems from recurring

Reduce possible injury to personnel

Reduce rework and scrap

Increase competitiveness

Promote happy customers and stockholders

Ultimately, reduce cost and save money

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Invariably, the root cause of a problem is not the initial reaction or response.

It is not just restating the Finding

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The “5 Whys” Pareto Analysis (Vital Few, Trivial Many) Brainstorming Flow Charts / Process Mapping Cause and Effect Diagram Tree Diagram Benchmarking (after Root Cause is

found)

Some tools are more complex than others

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1. Mistaking symptom for Root Cause

2. Looking for a single cause- often 2 or 3

which contribute and may be interacting

3. Ending analysis at a symptomatic cause

4. Assigning as the cause of the problem the

“why” event that preceded the real cause

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For example, a normal response is:Equipment FailureHuman Error

Initial response is usually the symptom, not the root cause of the problem. This is why Root Cause Analysis is a very useful and productive tool.

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Such as:

Process or program failure

System or organization failure

Poorly written work instructions

Lack of training

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Symptoms, Failure Modes

and Scrap

(e.g. unrecoverable tooling

Costs, labor hours spent on

changes, expediting costs)

Rework and Cost of Poor

Quality

(e.g. Engineering Changes)

Root Cause in

Process Issues

(e.g. Product Design

and Development,

defining specifications)

$$$

$$$ $

$$

$$

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Root Cause Analysis is an in-depth process or technique for identifying the most basic factor(s) underlying a variation in performance (problem).

Focus is on systems and processes

Focus is not on individuals

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Significant or consequential events Repetitive human errors are occurring

during a specific process Repetitive equipment failures associated

with a specific process Performance is generally below desired

standard

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THE

PROCESS

PROCESS

OUTPUTS

CONTROLLED

VARIABLES

CUSTOMER

PROCESS

INPUTS

UNCONTROLLED

NOISE

VARIABLES

Process and Its Variables

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Develop possible solutions

Define and implement an action plan (e.g., improve communication, revise processes or procedures or work instructions, perform additional training, etc.)

Monitor and assess results of the action plan for appropriateness and effectiveness

Repeat analysis if problem persists- if it persists, did we get to the root cause?

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Assign the task to a person (team if necessary) knowledgeable of the systems and processes involved

Define the problem

Collect and analyze facts and data

Develop theories and possible causes - there may be multiple causes that are interrelated

Systematically reduce the possible theories and possible causes using the facts

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We know we must change X to create a change in Y…

But how do we know which Xs to change

and how to change them ?

14

Y =f (x1, x2, …)

process output key process input factors

affecting process outputfunction of

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Problem - Flat Tire

Why? Nails on garage floor

Why? Box of nails on shelf split open

Why? Box got wet

Why? Rain thru hole in garage roof

Why? Roof shingles are missing

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Count 14 14 11 9 7 7 3 3 3 3162 2 2 1 513934 20 19 19 15 15

Percent 3 3 2 2 1 1 1 1 1 132 0 0 0 127 7 4 4 4 3 3

Cum % 86 89 91 93 94 96 96 97 97 9832 98 99 991005966 70 74 78 80 83

Co

un

t

Defect

Oth

er

EB D

amag

ed

Supp

lier Clea

nlines

s

EB M

arking

Supp

lier Ru

sted

, Co

rrod

ed

EB Inc

orrec t

Mat

erial

EB D

ocum

enta

tion

EB D

imen

sion

Supp

lier Miss

ing Pa

rts

ESD P

acka

ging

Supp

lier La

b Tes

t Fa

ilure

Supp

lier Sh

elf L

ife E

xcee

ded

Supp

lier W

rong

Con

figur

ation

Supp

lier O

ther

Workm

ansh

ip

Supp

lier In

corre

ct M

ater

ial

Supp

lier Dam

aged

Pack

aging

Supp

lier D

imen

sions

EB O

ther

Supp

lier Do

cumen

tat io

n

Supp

lier Marking

180

160

140

120

100

80

60

40

20

0

Supplier Material Rejections May 06 to May 07

Vital Few

Trivial Many

60 % of

Material

Rejections

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Cause and Effect DiagramLoading My Computer

MAN/WOMAN METHODS

MATERIALS MACHINERY

OTHERCannot

Load

Softwar

e on PC

Inserted CD Wrong

Instructions are Wrong

Not Enough

Free Memory

Inadequate System

Graphics Card Incompatible

Hard Disk Crashed

Not Following

Instructions

Cannot Answer Prompt

Question

Brain Fade

CD Missing

Wrong Type CDBad CD

Power Interruption

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EFFECT

CAUSES (METHODS) EFFECT (RESULTS)

“Four M’s” Model

MAN/WOMAN METHODS

MATERIALS MACHINERY

OTHER

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MethodsMaterials

Machinery Personnel

Effect =

Problem/Desired

Improvement

C/N/X

c

c

X

cc

n n

nnn

C = Constant Factor

N = Noise factor

X = Experimental Factor

1) Select an effect (usually a result or outcome of the project

2) Choose your “Major Bones”

3) Brainstorm causes/reasons why each item affects the outcome: the effect

4) Perform the C/N/X Analysis

5) Select the significant causes

Time: 30 minutes; Report-out: 10 minutes

Causes

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Result Cause/Result Cause/Result Cause

Result Primary

Causes

Secondary

CausesTertiary

Causes

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Poor Safety Performance

Stale/Tired Approaches

Inappropriate Behaviors

Lack of Employee Attention

Lack of Models/ Benchmarks

No Outside Input

Research Not Funded

No Money for Reference Materials

No Funds for Classes

No Consequences

Infrequent Inspections

Inadequate Training

No Publicity

Lack of Sr. Management Attention

No Performance Reviews

No Special Subject Classes

Lack of Regular Safety Meetings

Zero Written Safety Messages

No Injury Cost Tracking

Result Cause/Result Cause/Result Cause

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Benchmarking: What is it?

"... benchmarking ...[is] ...'the process of identifying, understanding, and adapting outstanding practices and processes from organizations anywhere in the world to help your organization improve its performance.'"—American Productivity & Quality Center

Benchmark refers to a measure of best practice performance. Benchmarking refers to the search for the best practices that yields the benchmark performance, with emphasis on how you can apply the process to achieve superior results.

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All process improvement efforts require a sound methodology and implementation, and benchmarking is no different. You need to:

Identify benchmarking partners Select a benchmarking approach Gather information (research, surveys,

benchmarking visits) Distill the learning

Select ideas to implement Pilot Implement

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DPMO / Control Chart

20000

25000

30000

35000

40000

45000

50000

55000

60000

65000

70000

75000

80000

85000

90000

95000

100000

2/5/2001

2/19/2001

3/5/2001

3/19/2001

4/2/2001

4/16/2001

4/30/2001

5/14/2001

5/28/2001

6/11/2001

6/25/2001

7/9/2001

7/23/2001

8/6/2001

8/20/2001

9/3/2001

9/17/2001

10/1/2001

10/15/2001

10/29/2001

11/12/2001

11/26/2001

12/10/2001

12/24/2001

DP

MO

Baseline

DPMO

UCL

LCL

Mean

Goal

Process

Change

REGIONAL

CONTROL

BEGINS

PAST BKLOG PAST BKLOG P-DUE PAST

UNITS DUE PM DUE LUBE SVC DUE

REGION ASSIGN PM DAYS LUBE DAYS GOAL SVC

NETWORK 2327 1 0 107 4 93 77

CENTRAL 151 0 0 8 4.8 6 8

F.B.U. 74 0 0 0 0 3 2

MIDWEST 178 2 1 9 4.6 7 3

NORTHEAST 312 0 0 33 9.7 12 18

SOUTHERN 389 0 0 43 10.1 16 36

WESTERN 259 0 0 19 6.7 10 11

TOTAL 3689 3 0 219 5.4 150 155

OFFLINE 203 4 1.8 37 16.8 1 4

NEW ACCOUNT EXCEPTION SUMMARY 12/08/2003

Item

No. Problem/Opportunity Benefit

Person(s)

Responsible

Due

Date

%

Complete Comments

1

2

3

4

5

6

7

8

Kaizen Event Newspaper

Team: Kaizen Event:

Kaizen Newspaper

The Control

Plan explains

how the

Dashboard

Works and

what to do if

performance

goes out of

control

Improvement Actions and Activities

Updated: __/__/__ By:________

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How Control FMEA Works

Process

Step or

Input

Potentia

l Failure

Mode

Potentia

l Failure

Effects

Potential

Causes

of

Failures

Current

Process

Controls

Severity

Rating

(SEV)

Occur-

rence

Rating

(OCC)

Indetec

t-ability

Rating

(DET)

Risk

Priority

Number

(RPN)

What is

the

Improv

ement

implem

ented?

What

can

go

wron

g

with

the

Impr

ovem

ent?

Wha

t is

the

Effe

ct

on

the

Out-

puts

?

How

bad

is it?What

are

the

Causes

?

How

often

do

they

Occur?How

can

they

be

found

or

preven

t-ed?

How

well

can

they

be

preve

nt-ed?

Where

is our

greate

st

Risk?

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Why determine Root Cause? What Is Root Cause Analysis? When Should Root Cause Analysis be

performed? How to determine Root Cause Useful Tools to Determine Root Cause

1. Five Whys2. Pareto Analysis3. Cause and Effect Diagram4. Tree Diagram5. Brainstorming

Common Errors of Root Cause

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Numbers, words, quantities, values stored sitting in piles or queues waiting for future use

Charts, summaries, spread sheets, etc. that organize the data

Presentations, plans and tools that explain and communicate the information

Processes, organizations and team using the information to improve, manage, build systems and develop cultures

Push the data “up” to become Wise

Always loop back to check the data

Wisdom

Knowledge

Data

Information

Where are you

looking from?

The WISDOM TOWER: Changing Perspectives