8d Problemsolvingmethod 130828060105 Phpapp02

5/19/2018 8d Problemsolvingmethod 130828060105 Phpapp02

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8D-Problem solving

method

Dr.ing. tefan KOVACS


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Contents

Goal of this corse

!istoric of 8D

Glossar" #hat is 8D $

Global 8D

8D-% factor" &rocedre

'he main ste&s of 8D


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GOAL OF THIS COURSE

'he stdents shold be able to se8D in their crrent activit"( based onthe gidelines of the % factor"&rocedre or inde&endentl" ifneeded.

'he stdents shold retain some

o&erative methods li)e *#( *#+!(,ishbone( etc.


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History of 8D

'he develo&ment of a 'eam Oriented ProblemSolving strateg"( based on the se of statisticalmethods of data anal"sis( as done at ,ord otorCom&an". 'he e/ectives of the Poertrain

Organi0ation 1transmissions( chassis( engines2anted a methodolog" here teams 1designengineering( manfactring engineering( and&rodction2 cold or) on recrring &roblems. 3n

4586( the assignment as given to develo& amanal and a sbse7ent corse that oldachieve a ne a&&roach to solving toghengineering design and manfactring &roblems.


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!istor" of 8D

'he manal for this methodolog" as docmentedand dened in 9'eam Oriented ProblemSolving91'OPS2( rst &blished in 458:. 'he manaland sbse7ent corse material as &iloted at #orld

!ead7arters in Dearborn( ichigan. an" changesand revisions ere made based on feedbac) from the&ilot sessions. 'his has been ,ord;s a&&roach to&roblem solving ever since. 3t as never based on an"militar" standard or other e/isting &roblem solving

methodolog". 'he material is e/tensive and the 8Dtitles are merel" the cha&ter headings for each ste& inthe &rocess. ,ord also refers to their crrent variant asG8D 1Global 8D2


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!istor" of 8D-ilitar" sage

'he onconforming aterial; . 'hismilitar" standard focsed on nonconforming material and thedis&osition of the material.

'he 8D Problem Solving Process is sed to identif"( correct andeliminate recrring &roblems. 'he methodolog" is sefl in&rodct and &rocess im&rovement. 3t establishes a &ermanentcorrective action based on statistical anal"sis of the &roblem. 3tfocses on the origin of the &roblem b" determining @oot

Cases. 'his ;Determine a @oot Case; ste& is a &art of the militar"

sage of the 8D;s bt as not a reference in the develo&ment ofthe 8D &roblem solving methodolog" and is not referenced orinclded in the 'OPS manal or corse.


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Glossar"

Action plan-'his is a formal record of assignments(res&onsibilities and timing.

Adanced prod!ct "!ality plannin#-A cross fnctionala&&roach that enables commnication and feedbac) to othroghot the organi0ation for im&roved 7alit" and &rodctivit".

APBP focses on lin)ing Prevent @ecrrence ithEF Dened &rodct develo&ment &rocess 1event( timing( 7alit"of event2F G--@ 1Green( ello( @ed2 &rogram control &rocess 1macro

vie of critical &ath2.

F Design Balit" @evie 1DB@2 or micro vie of or)ingdocments.F Hngineering change management 1Verication and

Validation2F Anal"tical 'ools


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Glossar"

Co$$on ca!se-Process in&ts and conditionsthat reglarl" contribte to the variabilit" of&rocess ot&ts. Iecase Common Cases arereglar contribtors( the Process or S"stemVariabilit" is dened in terms of them.

Contain$ent action-Veried action thatimmediatel" sto&s the S"m&tom from reachingthe cstomer.

Correctie action-Action that &ermanentl"eliminates the @oot Case of a &roblem.Selected in D* and im&lemented in D6.


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Glossar"

C%a$pion-Someone ho has athorit" btdoes not &artici&ate directl" in the teams&roblem solving activities. A s&&orter and

&ersader of the teams actions. Co$$on ca!se-Process in&ts and

conditions that reglarl" contribte to thevariabilit" of &rocess ot&ts. Iecase

Common Cases are reglar contribtors(the Process or S"stem Variabilit" isdened in terms of them


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Glossar"

Decision $a&in#-Process sed to select the best CorrectiveAction. Assess im&act and ris)s.

Desi#n '!ality Reie(s-A &rocess that measres theProdct Develo&ment Process. H/amines information acrossthe cross-fnctional Prodct Develo&ment 'eam in terms ofEF 'he abilit" of the design to meet cstomer needs and ants.F Com&arison ith Iest-3n-Class 1I3C2F Abilit" to meet AJordable 'argets 1A,'2F evel of robstness of both the &rocess and the &rodct.F 'hings-Gone-#rong L 'hings-Gone-@ight in &rocess

1inclding 'eam fnctioning2.F Dening Balit" of the HventM for the engineering &rocess.F Design Verication Plan N @e&ort


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Glossar"

E$po(ere$ent-A &roactive&rocess( to delegate( athori0e( orenable the 'eam members to haveOnershi& and to be res&onsible forchanging the rles.

Escape- Primar" 7estion in &roblem

solving hich e/&lains ho the&roblem reached the cstomer.


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Glossar"

Infor$ation data)ase-A tool for @ootCase Anal"sis that organi0es all )nondata abot a &roblem into for categoriesE

F #hat( #here( #hen and !o Iigb" sing 3s L 3s >ot com&arisons in D+. 'hedatabase is anal"0ed for DiJerences andChanges leading to @oot Case in D.

Corrective actions are evalated singDecision a)ing and Verication in d.Actions are im&lemented in D6


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Glossar"

*ana#e$ent reie(-Qointl" agreed to b"anagement and 'eam for &eriodic revie of&rogress to obRectives. 'his is the teamso&&ortnit" to obtain management assistance

here re7ired. *ana#e$ent decision $a&in#-'he techni7e

chosen b" ,ord to achieve strctral changes tomeet cstomer satisfaction. 'his a&&roach consists

of theor"( methods and &hiloso&h" for e/tractinginformation from data( converting data intoinformation that enables s to im&rove the 7alit"of managerial decisions.


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Glossar"

+areto c%art-'"&e of bar chart sed in &roblemdescri&tion to 7antif" concerns L defects indescending order of im&ortance. 3t or)s on the&rinci&le that += of the &roblems are res&onsible

for 8= of the occrrences. +aynter c%art-Chart that identies mlti&le

&roblem descri&tions and &rovides validation ofcontainment and corrective actions over time. 'he

chart consists of to-dimensional trac)ing of as&ecic nmber of &roblems along the a/is andoccrrences of failres in ee)s or months alongthe % a/is.


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Glossar"

+o&a-,o&e-Hrror Proong - 'echni7es sesim&le and ine/&ensive devices to &reventerrors abot to occr or detect errors and

defects that have occrred. +olicy deploy$ent-S"stem focs

&roviding direction and alignment focsingon &rocess #hats and !os to develo&

diJerent measres at diJerentorgani0ational levels to achieve common&olic" andLor goal


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Glossar"

+ro)le$ Description Analysis-Process to organi0e and gathera&&ro&riate information abot the S"m&tom into a ProblemDescri&tion throgh the se of @e&eated #!;s and the3nformation database.

+ro)le$ I$proe$ent *et%odolo#y-Strctred a&&roach to

ensre that or &rocesses better met cstomer needs and antsover time( in an ecient manner( ith a minimm of aste anderror. 'he stages areEF 3dentif" the o&&ortnit"F Dene the sco&e

F Anal"0e the crrent &rocessF Hnvision ftre &rocessesF Pilot and Verif" the &ro&osed changesF 3m&lement changesF Continall" im&rove


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Glossar"

+rocess $eas!ra)les- 3ndicators identied and monitored on an ongoingbasis that reslt in consistent &rodct 7alit" and greater cstomersatisfaction.

+rod!ct deelop$ent process-A gro& of events and &rocesses thatincldesEF S"stem design s&ecication

F Balit" fnction de&lo"mentF 'echnolog" reviesF @is) assessmentF Balit" road ma&F Serviceabilit"F Design and &rocess verication &lan and re&ortF Design and &rocess ,HA 1,ailre odes HJects Anal"sis=F Critical( safet" and signicant characteristicsF Control &lans and o chartsF Process ca&abilit"F 3nitial sam&le revieF Process revie


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Glossar"

'!ality F!nction Deploy$ent- A&lanning tool sed b" mlti-disci&linar" teams for translating

cstomer needs and e/&ectationsinto a&&ro&riate s"stem andcom&onent re7irements. 'he ot&t

of B,D &rocess is the identication ofs"stem and com&onent signicantcharacteristics as ell as )e" &rocess

and &rodction characteristics.


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Glossar"

'!ality Operatin# Syste$-anfactring&lant - A data driven management &rocessdesigned b" ,ord to get to the @oot Case of

&roblems b" em&lo"ing the Prevent@ecrrence methodolog". A s"stem formathich incldes and H/ective Smmar" of )e"&lant measrables( a Preventive ,ocs on&erformance of &rodcts dring &rodctdevelo&ment( a Cstomer focs gro& ofmeasrables reecting Voice of the Cstomer(and in internal ,ocs of &rocess measrables.


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Glossar"

Reco#nie #aps-Process of nding the distancebeteen hat shold be ha&&ening and hat isactall" ha&&ening. H/am&les of ga&s are Iest-3n-Class verss crrent &erformance( Cstomer

H/&ectations verss hat cstomer receives( Planverss actal.

Repeated .H,s-ethod for im&roved ProblemDescri&tion that moves from the &roblem S"m&tom

to the Problem Descri&tion b" as)ing #! to obtainbetter denition of obRect( concern and7antication. 'his 7estion is as)ed re&eatedl"ntil a level is reached hich can be acted &on.


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Glossar"

Special ca!se-Process in&ts and conditions hichSPO@AD3CA contribte to the variabilit" of &rocessot&ts. 'he variabilit" de to one or more S&ecialCases can be identied b" the se of control charts.

'he &rocess or s"stem variabilit" is dened ithotthem.

Syste$ desi#n speci/cation-A tool hich tili0esB,D methodolog" to identif" the need to add or reviseengineering and test s&ecications to corres&ond to all

s&ecic cstomer re7irements. 'he ot&t of SDS isrevised s"stem and com&onent engineeringre7irements and testing s&ecications 1DVPN@2.


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Glossar"

0-Loop- Process of Verif"ing Containment andCorrective Actions before im&lementation andValidating the actions over time afterim&lementation. 'his &rocess is &erformed b" sing

the same indicator that demonstrated the &roblem. 0alidate-Proof develo&ed A,'H@ im&lementation

and over time. 'he action ta)en mst do hat isintended b" &roviding before and after data

com&arison( and mst not introdce a ne&roblem. Proof mst be develo&ed b" sing thesame indicator that demonstrated the &roblem andshold be trac)ed on the Pa"nter chart.


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.%at is 8 D 1

8D is a &roblem-solving methodolog"for &rodct and &rocessim&rovement. 3t is strctred into

ei#%t disciplines( em&hasi0ingteam s"nerg". T%e tea$ as (%oleis )etter and s$arterthan the

7alit" sm of the individals. Hachdisci&line is s&&orted b" a chec)listof assessment 7estions( sch as

9hat is rong ith hat9( 9hat(9


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#hat is 8D $ Generalschema


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#hat is 8D $

3t cold be sed to identif"( correctand eliminate the recrrence of7alit" &roblems.

Actall"( e cold s&ea) abot 8152ste&s( described in detail in thiscorse.


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8D and t"&ical o&erationochart


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Glo)al 8D

3n the late 455=s( ,ord develo&ed arevised version of the 8D &rocess(that the" call 9Global 8D9 1G8D2

hich is the crrent global standardfor ,ord and man" other com&aniesin the atomotive s&&l" chain. 'he

maRor revisions to the &rocess are asfollosE


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Global 8D

Addition of a 0D (D-Zero)ste& as a gatea" tothe &rocess. At D=( the team docments thes"m&toms that initiated the eJort along ith an"Hmergenc" @es&onse Actions 1H@As2 that ere

ta)en before formal initiation of the G8D. D= alsoincor&orates standard assessing 7estions meantto determine hether a fll G8D is re7ired. 'heassessing 7estions are meant to ensre that in a

orld of limited &roblem-solving resorces( theeJorts re7ired for a fll team-based &roblem-solving eJort are limited to those &roblems thatarrant these resorces.


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Global 8D

Addition of Hsca&e Point to D throgh D6. 'he ideahere is to consider not onl" the @oot caseof a&roblem( bt e7all" im&ortantl"( hat ent rongith the control s"stem in alloing this &roblem to

esca&e. Global 8D re7ires the team to identif" andverif" this Hsca&e Point 1dened as the earliestcontrol &oint in the control s"stem folloing the@oot Case that shold have detected the &roblem

bt failed to do so2 at D. 'hen( throgh D* andD6( the &rocess re7ires the team to choose( verif"(im&lement( and validate Permanent CorrectiveActions to address the Hsca&e Point.
http://en.wikipedia.org/wiki/Root_causehttp://en.wikipedia.org/wiki/Root_cause


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#hen is an 8D rec7ired $

Often( a 8-D is a cstomer res&onse at a &roblem.,eedbac) from the cstomer shos concern ith a&rodct or service.

3deall"( a $eas!ra)leill indicate hen a 8-D

shold start. #hen an ndesirable trend in a&rocess develo&s (corrective action can be ta)en toredce the case of the variation before as"m&tom occrs in the &rocess and esca&es to the

cstomer. A decision mst be made regarding if the s"m&tom

cold be /ed or re7ires frther anal"sis. 3f so( a8-D team mst assembled.


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Case std"

Shold a cstomer as) for solving ofthe &roblem $ Perha&s it is a minor&roblem 1hich cold became

serios2 and he is not thin)ing tore&ort it.

Shold the enter&rise a&&l"ing 8D be

avare of ever" &roblem( no matterho small it is $

Please( give some e/am&les of

maRor( medim and minor &roblems


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8D-2 factory proced!re

343'his &rocedre establishes the &rocess sedat % factor" @omania for the anal"sis of e/istingor &otential &roblems in order to identif" theirroot cases( to establish and im&lement the

corrections and corrective L &reventive actions(verication and revie the eJectiveness of theim&lemented actions. Also this &rocedredescribes the a" to record in SAP s"stem the

identied cases( the corrections and thecorrectiveL&reventive actions initiated toeliminate nonconformities and their cases.


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345'he &rocedre a&&lies to % factor"@omanias Isiness


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@eferencesE - % factor" @omanias Balit" anal( codeE CR-*'T

- ISO 7( Balit" anagement S"stems. Iasic&rinci&les and terminolog"T

- ISO 73( Balit" anagement S"stems.

@e7irementsT - D+-339( CorrectiveLPreventive ActionsT

- D+-:3( S&&liers &erformance

measrementsT

- CR+-855( 3nternal aditsT

- CR+-86( Control of nonconforming &rodctT


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643 Corrective action 13SO 5===2 U action toeliminate the case of a nonconformit"(defect or other ndesirable sitation.

>ote 4E 'here can be more than one casefor nonconformit".

>ote +E Corrective action is ta)en to &reventrecrrence hereas &reventive action is

ta)en to &revent occrrence. >ote E 'here is a distinction beteen

correction and corrective action.


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645 Preventive action 13SO 5===2 Uaction to eliminate the case of a&otential nonconformit" or other

ndesirable &otential sitation. >ote 4E 'here can be more than one

case for a &otential nonconformit".

>ote +E Preventive action is ta)en to&revent occrrence hereas correctiveaction is ta)en to &revent recrrence.


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649 @oot Case U Case of a&roblemLnonconformit" that goesbe"ond the obvios( visible as&ect of

the &roblemL nonconformit" and see)sto identif" the base reason for the&roblemLnonconformit". 'his is thecase or cases( hich if eliminated(ill &revent the &roblemLnonconformit"from reoccrring in the ftre.


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;43 Identi/cation and recordin# of t%enonconfor$ities and t%eir ca!ses ;4343'he nonconformities can be detected onE

- receiving( manfactring o( and nal ins&ectionT

- internal and e/ternal 7alit" aditsT

- feedbac) from cstomers 1com&laints( sggestions(etc.2T

- &roRects for im&rovementT

- crrent revies &erformed in Prodction CentersLDe&artmentsT

- evalation of s&&liers &erformanceT

- adits &erformed b" s&&liers.


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;45 Internal correctie andpreentie actions'o establish and im&lement the

corrective and &reventive actions( the8D &rinci&les described belo shall besed.


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D < C+AR initiation=

#hen a &roblem is identied( the Balit"LBalit"Assrance Hngineer anal"ses the o&&ortnit" forcorrectiveL &reventive actions. #hen it is determined that

formal correctiveL&reventative action is arranted( a CPA@is initiated in SAP @L 1in accordance ith Anne/ 6.42. CPAR shall be issued in the following situationsE

- >onconformities fond in internalLe/ternal adits 1cstomers L 3SO LAP32T

- @e&eatable nonconformities 1more than times in a month2T

- @e&air and reor) ith vales more than *.===


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D3 < >!ildin# t%e tea$ for 8Danalysis of t%e pro)le$

'he assigned anager has theres&onsibilit" to initiate the 8D&rocess and in this res&ect(he shallestablish and organi0e an 8D team.


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D3 < >!ildin# t%e tea$ for 8Danalysis of t%e pro)le$

'he 8D team members can be 1as

a&&licable2 the folloing &ersonsE ProcessHngineers(Prodction S&ervisors( Balit"HngineerLS&ervisor( Balit" AssranceHngineer(Design Hngineer( Programmers(

#elding Hngineer( Prchasing @eferent(Planner( O&erators. The 8D team leader isthe assigned Manager.


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D3 < >!ildin# t%e tea$ for 8D analysis oft%e pro)le$

'his team has the folloing tas)sE - 8D &rocess &re&aring 1information(

data(docments( &rodct sam&les( etc2.

- attending the case anal"sis meetings hennecessar".

- anal"0ing and identication of the root cases.

- establishing and &ro&osing of correctiveL&reventiveactions and im&lementing de dates.

- a&&l"ing of the &ro&osed soltions.


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8D-Cameron &rocedre

D5 < +recise de/nition of t%epro)le$

'he 8D team ma)es an initialanal"sis of the &roblem( and if it isnecessar"( reformlates thenonconformit" descri&tion 1in CPA@

too2. 'he method *#+! shall be sed

1#ho$T#hat$T #h"$T #here$T #hen$T

!o mch$T!o often$2


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D6 < Esta)lis%in# of i$$ediate$eas!res ?corrections@ etc4 toeliminate the &roblem L nonconformit"

or to eliminate Lminimi0e the eJects. 'he 8D team anal"ses the necessit"

of immediate actions( i.e. hold on

anfactring(nonconform &rodctsisolation( other cstomersnotication( etc.


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D9 < T%e pro)le$ B nonconfor$ityanalysis to identif" the root case 'he 8Dteam anal"ses the &roblem Lnonconformit"

to identif" the rootcaseLcases. S&ecic methods li)e Analysis ; .%y1 Or

Fis% )one - Is%i&a(a dia#ra$ 1case UeJect diagram2shall be sed.

'he 8D team leader lls the WTAS < 3 U@oot Case Anal"sisM in CPA@ and this tas)shall be closed.


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D; < Esta)lis%in# of correctieBpreentie actions and theirim&lementation to eliminate the

caseL cases


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D; < Esta)lis%in# of correctie Bpreentieactions and their im&lementation to eliminatethe caseL cases

-'he 8D team 8D( after identication ofcases( establishes the actions to eliminatethem. A res&onsible &erson and a de dateshall be assigned to each action.

-'he &reventive actions are established inorder to avoid &otentialnonconformities(accidents or damages( or toim&rove the &rocesses or &rodcts.


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D; < Esta)lis%in# of correctieBpreentie actions and theirim&lementation to eliminate the caseLcases

-'he sorces of nonconformities1>onconformit" re&orts for &rodcts( @e&ortsfor com&laints( etc2 are also recorded in the

correctiveL &reventive actions re&orts toensre identication of the docments hichere the basis for initiating those actions.


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D; < Esta)lis%in# of correctie Bpreentieactions and their im&lementation to eliminate thecaseL cases

Some e/am&le of t"&es of corrective or

&reventive actions 1ithot limiting thereto2 canbeE - modif" the manfactring s&ecication or the

manfactring &rocessT

- &re&are ne technologies or instrctions for non-docmented sb-&rocessesT

- modif"Ls&&lement the &rocedres or instrctions toclarif" s&ecic as&ectsT


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D; < Esta)lis%in# of correctieBpreentie actions and their im&lementationto eliminate the caseL cases

Some e/am&le of t"&es of corrective or&reventive actions 1ithot limiting thereto2can beE - train the &ersonnel in charge 1also after

&re&aring a ne &rocedre or instrction or aftermodif"ing the e/isting ones2T

- endoment ith ne technologies ortoolsLdevicesL measring instrments( etc.


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D: < 0eri/cation ofi$ple$entation andeectieness of

correctiveL&reventive actions 'he stats( im&lementation reslts

and eJectiveness of the ta)en

actions are recorded in theCorrectiveL Preventive Actions @e&ortb" the initiating &erson.


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D < +reentie actions.

3dentif" if is the case to e/tend thecorrective actions also to other

similar &rodctsL&rocesses or if arenecessar" also other long termactions 1modif" &rocedres(

&rocesses(etc.2


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D8


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D

What is done ?Prepare for the 8D

Collect the S"m&toms

S"m&toms Chec)list

Hmergenc" @es&onse Action


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=D

Identify t%e pro)le$.

3s there a singlar &roblem or are&eating &roblem $ #old it be

above or belov AA@P $

3t deserves to be stdied $

3t cold lead toards &roblems thatold manifest in loss( incidents andaccidents $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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=D-Case std"

An" &roblem( here $


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3D

Use Tea$ Approac%

Hstablish a small gro& of &eo&leith the )noledge( time( athorit"

and s)ill to solve the &roblem andim&lement corrective actions. 'hegro& mst select a team leader.


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4D

#hen a &roblem cannot be solved 7ic)l" b" an individal( it is necessar" toform a 'eam. 'he team ill engage in the investigation and resoltion of the&roblem. an" factors are critical to establish a gro& and to ensre that thegro& can or) eJectivel" together.


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4D


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4D

Co$$on ca!ses are the m"riad of ever-&resent factors 1e.g.( &rocessin&ts or conditions2 that contribte in var"ing degrees to relativel"small( a&&arentl" random shifts in otcomes da" after da"( ee) afteree)( month after month. 'he collective eJect of all common cases isoften referred to as s"stem variation becase it denes the amont ofvariation inherent in the s"stem.

Special ca!ses are factors that s&oradicall" indce variation over andabove that inherent in the s"stem. ,re7entl"( s&ecial case variationa&&ears as an e/treme &oint or some s&ecic( identiable &attern indata. S&ecial cases are often referred to as assignable cases becasethe variation the" &rodce can be trac)ed don and assigned to anidentiable sorce. 13n contrast( it is sall" diclt( if not im&ossible( to

lin) common case variation to an" &articlar sorce.2 S&ecial Casevariation reslts from events hich are occrring otside the &rocess. ,ore/am&le( a relativel" maRor change in tem&eratre or hmidit" coldcase signicant variation 1&oints otside control limits2 in the &rocess.


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4D

>rainstor$in#- %o( to= 'he folloing rles are im&ortant to brainstorming sccessfll"E

A leader shold ta)e control of the session( initiall" dening the&roblem to be solved ith an" criteria that mst be met( and then)ee&ing the session on corse. !e or she shold encorage an

enthsiastic( ncritical attitde among brainstormers andencorage &artici&ation b" all members of the team. 'he sessionshold be annonced as lasting a /ed length of time( and theleader shold ensre that no train of thoght is folloed for toolong. 'he leader shold tr" to )ee& the brainstorming on sbRect(and shold tr" to steer it toards the develo&ment of some

&ractical soltions. Partici&ants in the brainstorming &rocess shold come from as

ide a range of disci&lines ith as broad a range of e/&erience as&ossible. 'his brings man" more creative ideas to the session.


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4D

>rainstor$in#-%o( to= Irainstormers shold be encoraged to have fn brainstorming(

coming & ith as man" ideas as &ossible( from solidl" &ractical onesto ildl" im&ractical ones in an environment here creativit" iselcomed.

3deas mst not be criticised or evalated dring the brainstormingsession. Criticism introdces an element of ris) for a gro& member in&tting forard an idea. 'his sties creativit" and cri&&les the freernning natre of a good brainstorming session.

Irainstormers shold not onl" come & ith ne ideas in abrainstorming session( bt shold also ;s&ar) oJ; from associationsith other &eos ideas and develo& other &eo&les ideas.

A record shold be )e&t of the session either as notes or a ta&erecording. 'his shold be stdied sbse7entl" for evalation. 3t canalso be hel&fl to Rot don ideas on a board hich can be seen b" allbrainstormers.


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4D

Indiid!al s4 Gro!p >rainstor$in# Irainstorming can either be carried ot b" individals or gro&sE

Indiid!al )rainstor$in# tends to &rodce a ider range of ideas thangro& brainstorming( bt tends not to develo& the ideas as eJectivel"(&erha&s as individals on their on rn & against &roblems the" cannotsolve. 3ndividals are free to e/&lore ideas in their on time ithot an"

fear of criticism( and ithot being dominated b" other gro& members. Gro!p )rainstor$in# develo&s ideas more dee&l" and eJectivel"( as

hen diclties in the develo&ment of an idea b" one &erson are reached(another &erson;s creativit" and e/&erience can be sed to brea) themdon. Gro& brainstorming tends to &rodce feer ideas 1as time is s&entdevelo&ing ideas in de&th2 and can lead to the s&&ression of creative bt

7iet &eo&le b" lod and ncreative ones. 3ndividal and gro& brainstorming can be mi/ed( &erha&s b" dening a

&roblem( and then letting team members initiall" come & ith a iderange of &ossibl" shallo soltions. 'hese soltions cold then beenhanced and develo&ed b" gro& brainstorming.


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4D

De/ne Scope Of Tea$ Select tea$ $e$)ers and f!nctions

De/ne roles and responsi)ilities

Identify eternal c!sto$er needs@

epectations and re"!ire$ents

Identify internal c!sto$er needs@epectations and re"!ire$ents

Co$plete preli$inary st!dies

Identify costs@ ti$in# and constraints Identify doc!$entation process and $et%od

Deelop inesti#ation plan

4D


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4D

Tea$ Or#aniation Cross-f!nctional

Design Hngineering 1'"&icall" the leader2

Balit" Assrance

Prchasing

anfactring Hngineering

aterial Control

SalesLar)eting

Htc.

+articipation appropriate for p%ase )ein# cond!cted

Reso!rces - Tea$ de/nes eeds

S%o!ld inole c!sto$er or s!)contractorparticipation ?not al(ays feasi)le

4D


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4D

Roles In A Tea$ Seeral roles need to )e esta)lis%ed for t%e tea$4 T%ese roles

are= Leader@ C%a$pion@ Record eeper ?Recorder@ +articipantsand ?if needed Facilitator4

eader-Gro& member ho ensres the gro& &erforms its dties andres&onsibilities. S&o)es&erson( calls meetings( establishes meeting

timeLdration and setsLdirects agenda. Da"-to-da" athorit"( res&onsible foroverall coordination and assists the team in setting goals and obRectives.

Re!ord "eeper-#rites and &blishes mintes.

Parti!ipantsE

@es&ect each others ideas.

Kee& an o&en mind.

Ie rece&tive to consenss decision ma)ing.


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4D

Inp!ts To Tea$ ,ield service re&orts

Problems and isses re&orted from 3nternal cstomers

3nternal evalations sing srrogate cstomers

@oad tri&s 1e.g.E Strts2

anagement comments andLor direction Government re7irements andLor reglations

Contract revie

3n&t from higher s"stem level or &ast B,D &roRects

edia commentar" and anal"sis

Cstomer letters and sggestions'hings gone @ightL#rong re&orts

Dealer comments

,leet o&erator comments

4D


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4D

>asic Tea$ R!les Tea$ $!st deelop t%eir o(n #ro!nd r!les

Once develo&ed( ever"one mst live b" them

Grond @les are an aid to Mself-managementM

'eam can modif" or enhance the rles as the" contine to meet

Deter$ine if t%ere s%o!ld )e a $eetin#

Decide (%o s%o!ld attend

+roide adance notices

*aintain $eetin# $in!tes or records

Esta)lis% #ro!nd r!les +roide and Follo( an a#enda

Eal!ate $eetin#s

Allo( O interr!ptions

4D


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4D

.%at s i$portant 1 %or# a &ea#

Core 'eam Strctre

'eam Pre&aration

4D C t d


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4D-Case std"

#hat criteria old "o choose in selecting ateam that shold solve the &roblema of a tan)that as &rodced in % factor"( tested in %factor" bt hen arrived at the beneciar"( it as

loo)ing li)e in the gre $

4D C St d


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4D-Case Std"

#ho shold be the leader of theteam $ 3s this man a good leader $

5D


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5D

Descri)e t%e +ro)le$

Describe the &roblem in measrableterms. S&ecif" the internal or

e/ternal cstomer &roblem b"describing it in s&ecic terms.

S&ecif" the internal L e/ternal

cstomer &roblem b" identif"ing in7antiable terms the #ho( #hat(#hen( #here( #h"( !o( !o an"

1*#+!2 for the &roblem.

+D


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+D

Descri)e t%e +ro)le$ Problem denition is the basis of &roblem

solving. 'he denition is sed dringbrainstorming sessions to identif" rootcases in ste& + and main 1&otential2cases in ste& . Potential cases are thosemost li)el" cases that a&&ear on thesrface to be the sorce of the &roblem. A&otential case ma" be the root case btmst be s&&orted b" evidence.

+D


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+D

Descri)e t%e +ro)le$

Part of the &roblem solving &rocess is to identif" the rootcase of the &roblem and nderstand h" it e/isted in

the rst &lace. Onl" then can a &ermanent soltion bechosen and im&lemented. to ma)e certain the &roblemill never srface again. 'he root case is the reasonthe &roblem e/ists. #hen it is corrected or removedfrom the s"stem( the &roblem ill disa&&ear. 3t is

im&ortant to im&rove or nderstanding of toda";stechnolog" to ma)e &ossible the &lanning re7ired toachieve 7alit" and &rodctivit" brea)throghs fortomorro and into the ftre.

+D


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+D

C!sto$er Co$plaints an" &roblems arise from cstomer com&laints. An

internal cstomer com&laint cold involve onede&artment com&laining that the" cannot se the

ot&t of another de&artment. An e/ternal cstomercom&laint cold involve a cstomer com&laining toa dealer that a transmission Mshifts fnn"M.

,re7entl" the rong &roblem is solved and thecstomer com&laint is not addressed. 3t is ver"im&ortant that the cstomer com&laint be clearl"nderstood. 'he onl" method to ensre this is tohave direct cstomer contact.

+D


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+D

C!sto$er Co$plaints ,or internal cstomers( it is advisable to have

re&resentatives from the com&laining organi0ationas &art of the &roblem solving team. 3n man" cases

this a&&roach is the onl" a" a &roblem can trl"be solved.

H/ternal cstomer com&laints t"&icall" re7iredirect intervies to nderstand h" the cstomeris not satised. 3t is not nsal for a cstomercom&laint to be misre&resented b" a com&an"re&orting s"stem that classies &roblems in&rearranged standard categories.

+D


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+D

Operational De/nition of t%e +ro)le$ 3t is im&ortant that the &roblem be described in terms that %ae t%e

sa$e $eanin# to eeryone4'his is best achieved throgh ano&erational denition.

An operational de'nition !onsists of eri'able !riteria thathae the sa#e #eaning to the produ!tion worers* #anager*

!usto#er* engineer* bu+er* te!hni!ian* tea# #e#bers* et!,*and are used for past* present and future !o#parisons andanal+sis,

Sometimes &roblems are mista)enl" described in terms of s"m&tomsE achine is don de to electrical &roblem. >o bac)& machine or alternative

available.

'he scra& rate has increased from from to ++.

Cstomer arrant" claims on engine com&onent is 4+.

,ailre of drabilit" tests of a transmission com&onent at *=(=== miles illdela" lanch.

+D


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+D

Sy$pto$s s4 Ca!ses 3t is not ncommon for &roblems to be re&orted as s"m&toms.

ore e/am&les areE noise( on t or)( no &oer( machine don(bro)en tool( head fro0e &( contaminated( rogh srface(&orosit"( shortage of &arts( rattles( 7alit" &roblem( orn ot(

line sto&&ed( not to s&ecication( labor &roblem( management&roblem( too mch variation( etc.

'he &roblem solving team mst se a s"stematic a&&roach todene the real &roblem in as mch detail as &ossible. Adenition of the &roblem can best be develo&ed singa&&roaches that organi0e the facts to get a com&arative

anal"sis. 'hese a&&roaches do this b" as)ing hat is againsthat is not. 'hen the" dra distinctions from this com&arison(testing these against the &roblem denition and forming astatement or descri&tion of the &roblem hich mst be resolved.

+D


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+D

+ro)le$ Solin# Syste$atic approac%es to pro)le$ solin#=

Isiness as a S"stem 1Isiness as a Process2

Anal"tical &roblem solving

Process o

+ro)le$ analysis $et%odolo#ies= *#+!

Stratication Com&arative anal"sis

Similarit" anal"sis

+D *#+! Anal"sis


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+D-*#+! Anal"sis

It is so$eti$es diJc!lt to de/ne t%e pro)le$ and sort o!treal dierences4 T%e /rst@ $ost i$portant step@ %o(eer@ itto deter$ine t%at t%e c!sto$er co$plaint is f!lly!nderstood4

;.5H = #ho$ 3dentit" cstomers com&laining

#hat$ 3dentit" the &roblem ade7atel" and accratel"

#hen$ 'iming - #hen did the &roblem start$

#here$ ocation - #here is it occrring$

#h"$ 3dentif" )non e/&lanations

!o$ 3n hat mode or sitation did the &roblem occr$

!o an"$ agnitde - Bantif" the &roblem

To red!ce t%e ris& of $a&in# (ron# decisions@ considerationand analysis of potential pro)le$s in adance (ill proidecontin#ency actions to $aintain control and protect t%ec!sto$er4

+D *# +! Anal"sis


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+D-*#-+! Anal"sis

.%o$ - 3dentit" individals associated ith the &roblem. Characteri0ecstomers ho are com&laining. #hich o&erators are having diclt"$

.%at$ - Describe the &roblem ade7atel". Does the severit" of the&roblem var"$ Are o&erational denitions clear 1e.g. defects2$ 3s themeasrement s"stem re&eatable and accrate$

.%en$ - 3dentif" the time the &roblem started and its &revalence in

earlier time &eriods. Do all &rodction shifts e/&erience the samefre7enc" of the &roblem$ #hat time of "ear does the &roblem occr$

.%ere$ - 3f a defect occrs on a &art( here is the defect located$ Alocation chec) sheet ma" hel&. #hat is the geogra&hic distribtion ofcstomer com&laints$

.%y$ - An" )non e/&lanation1s2 contribting to the &roblem shold bestated.

Ho($ - 3n hat mode or sitation did the &roblem occr$ #hat &rocedresere sed$

Ho( *any$ - #hat is the e/tent of the &roblem$ 3s the &rocess instatistical control$

+D Stratication anal"sis


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+D-Stratication anal"sis

Strati/cation Analysis deter$ines t%eetent of t%e pro)le$ for releant factors4 3s the &roblem the same for all shifts$

Do all machines( s&indles( /tres have the same

&roblem$ Do cstomers in varios age gro&s or &arts of the

contr" have similar &roblems$

'he im&ortant stratication factors ill var" ith

each &roblem( bt most &roblems ill haveseveral factors. Chec) sheets can be sed tocollect data.

+D Stratication anal"sis


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+D-Stratication anal"sis

Strati/cation Analysis deter$ines t%e etent of t%epro)le$ for releant factors4

Hssentiall" this anal"sis see)s to develo& a Pareto diagramfor the im&ortant factors. 'he ho&e is that the e/tent of the&roblem ill not be the same across all factors. 'he

diJerences can then lead to identif"ing root case. #hen the *#+! and Stratication Anal"sis are &erformed( it

is im&ortant to consider a nmber of indicators. ,or e/am&le(a cstomer &roblem identied b" arrant" claims ma" alsobe reected b" varios in-&lant indicators. Sometimes(

cstomer srve"s ma" be able to dene the &roblem moreclearl". 3n some cases anal"sis of the &roblem can bee/&edited b" correlating diJerent &roblem indicators toidentif" the &roblem clearl".

+D Describe the &roblem


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+D-Describe the &roblem

3t has been said that there are no ne &roblems( onl" diJerentmanifestations of old &roblems. 3n &roblem denition( it is often sefl to7antif" the &roblem in similar sitations. 'he criteria to match similarsitations ill var" ith the t"&e of &roblem. 3dentif"ing eJective matchesand evalating the &resence of the &roblem &rovides sefl information togenerate &otential cases and &ossible &roblem soltions. 3f the similarit"anal"sis identies a com&arable sitation here the &roblem does not e/ist(the anal"sis can focs on the diJerences in here the &roblem is occrringand here it is not occrring.

Once the t"&es of anal"sis have been com&leted( it is sometimes &ossibleto divide the &roblem into se&arate &roblems. 3t is easier to address thesesmaller &roblems becase feer root cases are involved. 3n the ideal case(a single root case old be res&onsible for each &roblem. 3f the &roblem is

se&arated( diJerent teams ma" be re7ired to address each &roblem. All three elements of the &roblem denition are not sed for ever" &roblem.

!oever( collectivel" the diJerent anal"ses &rovide a com&rehensibledescri&tion. o are develo&ing a Ms&ecicationM of the &roblem4

+D 3SL3s not 7estions


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+D-3SL3s not 7estions

IS IS not

#hat $ #hat is the obRect"o have &roblemsith $

#hat cold beha&&ening bt isnot $

#here $ #here is the &roblem

in the &rodct orservice $

#hen $ At hat ste& of the&rocess "o rst sathe &roblem $

!o big $ !o mch of theservice or &rodct isaJected b" thedeJect $

!o man" &rodctscold have the defectbt did not

+D Describe the &roblem Bestions


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+D-Describe the &roblem Bestions

.%at Type of +ro)le$ Is It1 Field co$plaint

'!ality i$proe$ent

*an!fact!rin# i$proe$ent

Co$ponent desi#n

La)o!r B +ersonnel

S!pplier B 0endor

Cost i$proe$ent

Sol!tion i$ple$entation

Cross f!nctional

Researc%

Safety

Descri)e t%e +ro)le$ '!estions

Other Bestions Can "o list all of the resorces and docments hich might hel& "o s&ecif" the &roblem

more e/actl"$

Do "o have more than 4 &roblem$ Can this sitation be se&arated into smaller &arts$

3s L 3s >ot

3s there an" evidence this &roblem srfaced before$

+D-Describe the &roblem in terms


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of *#

.%o@ .%at@ .%en@ .%ere@ .%y@ Ho(@ Ho( *any #hat is the e/tent of the &roblem$

!as the &roblem been increasing( decreasing or remainingconstant$

3s the &rocess stable$

#hat indicators are available to 7antif" the &roblem$ Can "o determine the severit" of the &roblem$ Can "o

determine the varios costs of the &roblem$ Can "oe/&ress the cost in &ercentages( dollars( &ieces( etc.$

Do e have the &h"sical evidence on the &roblem in hand$

!ave all sorces of &roblem indicators been identied andare the" being tili0ed$

!ave failed &arts been anal"0ed in detail$

+D


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+D

.%at is i$portant 1 Des!ribe the Proble#

* #h"

Problem Statement

Anit" Diagram

3s L 3s >ot

Problem Descri&tion

+D Case Std"
http://www.quality-one.com/corrective-action/5-why/http://www.quality-one.com/corrective-action/5-why/


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+D-Case Std"

A storage tan)( designed for or)ingat + bar in&t &ressre( is modiedb" adding a no00le in the in&t &i&e(

in order to ma)e an niform lling ofthe tan). After the change( theo&eration manager decided to s&eed

& a little the &rocess( groving thein&t &ressre at bar. Please denethe event that ma" ha&&en1=D2 andits root cases.

D+ *#h"


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D+-*#h"

* #h" is a &roblem solving techni7e &ioneered b" 'o"otaotor Cor&oration. 'he * #h" conce&t is sim&le. If pro)le$solers as& t%e "!estion K.%y1 /e ti$ess!ccessiely@ t%e root ca!se (ill present itself )y t%e9t% or ;t% .%y4Often( the *th #h" &oints directl" at the

management s"stems and &ractices alloing the &roblem toe/ist.

* #h" is not a dedctive brainstorming techni7e. 'he *#h" &rocess for @CA1@oot Case Anal"sis2 re7ires thateach #h" be s&&orted b" data or facts. 'he &rocess is a

team activit"( re7iring members to or) at each level ithdisci&line to obtain s&&orting data. 'he )non or collectedfacts from each #h" lead to the ne/t #h" as the &rocesscontines( conclding hen the root case is fond.

D+ *#h"
http://www.quality-one.com/core-competencies/http://www.quality-one.com/core-competencies/


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D+-*#h"

'he 'hree-legged * #h" is a techni7e sedto follo three related &aths. T%e p!rposeof t%e T%ree-le##ed ; .%y is to arrieat t%e root ca!se leel@ (%ere ener#y

%as )een epended incorrectly res!ltin#in a fail!re c%ain. 'he failre chain ends atthe s"m&tom or eJect e/&erienced b" thecstomer. 'he 'hree-legged * #h" begins

ith a &roblem s"m&tom and ends ith threese&arate conclsions for im&rovement.

D+-*#h"


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D+-*#h"

T%e T%ree Le#s are= @oot Case 1Hnerg"

isa&&ro&riation2

Iarrier or Control 1Balit" Control2 S"stemic Case 1anagement2

+D-*#h"


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+D-*#h"

,indings from each leg can crossover beteen &aths.'he develo&ment of sbse7ent legs reslt in a moredetailed e/&lanation of here( hen and ho the&roblem occrred. Prevention of ftre &roblems areaddressed in all three legs( ith the folloingE

Avoidance of the s&ecic root case throgh SPC1Statistical Process Control and Process Ca&abilit"2or Hrror L ista)e Proong1Po)a o)e2

Po)a o)e of the &rocess res&onsible for the &roblem

Hstablishment of Standard #or) Practicestomaintain consistenc"

+D-Case Std"
http://www.quality-one.com/improvement/spc/http://www.quality-one.com/core-competencies/http://www.quality-one.com/core-competencies/http://www.quality-one.com/core-competencies/http://www.quality-one.com/core-competencies/http://www.quality-one.com/improvement/spc/


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+D-Case Std"

Please give a Po)a o)e e/am&leta)ing into accont a command&annel that cold trigger a ver"

n&leasant reaction if someone iscoming inside and thin)ing Rst toM&la" ith the bttonsM

6D


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6D

I$ple$ent and 0erify S%ort-Ter$Correctie Actions

Dene and im&lement those

intermediate actions that ill &rotectthe cstomer from the &roblem ntil&ermanent corrective action is

im&lemented. Verif" ith data theeJectiveness of these actions.

D


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D

I$ple$ent and 0erify - Interi$?Contain$ent Actions Dene and 3m&lement containment

actions to isolate the eJect of the&roblem from an" internal L e/ternalcstomer ntil corrective action isim&lemented.

Verif" the eJectiveness of thecontainment action.

D


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D

Containment-Action obRective Dene and 3m&lement containment

actions to isolate the eJect of the

&roblem from internal and e/ternalcstomers ntil corrective action isim&lemented.

Verif" the eJectiveness of the

containment action1s2.

D


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D

Contain$ent actions-3 'he main obRective of this &art of the &roblem

solving &rocess is to isolate the eJects of the&roblem b" im&lementing containment actions.

A &roblem ma" be &oor 7alit"( marginal&rodct design( or a &rocess or s"stem that isn&redictable. A containment action ma" besto&&ing &rodction of a )non sorce of a

&roblem( or not shi&&ing an" &arts orassemblies ntil the sorce of the &roblem isidentied.

D


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D

Contain$ent actions-3 Once a &roblem has been described( immediate actions

are to be ta)en to isolate the &roblem from thecstomer. 3n man" cases the cstomer mst be notiedof the &roblem. 'hese actions are t"&icall" local fxes4

Co$$on contain$ent actions incl!de= 4== sorting of com&onents

Cars ins&ected before shi&ment

Parts &rchased from a s&&lier rather than manfactred in-

hose'ooling changed more fre7entl"

Single sorce

D


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D

Contain$ent actions- 5Unfort!nately@ $ost contain$ent actions (ill

add si#ni/cant cost 1X2 to the &rodct. !oever( it isim&ortant to &rotect the cstomer from the &roblem ntil&ermanent corrective actions can be veried and

im&lemented.ost interim actions are te$porary s%ort ter$actionsta)en ntil a &ermanent corrective action is dened(im&lemented and veried. 'he danger of man" interimcorrective actions is that the" are considered to be a &ermanentsoltion to the &roblem. 3t mst be remembered that the" aret"&icall" Mband-aidsM. 3t is a mista)e to vie containment actions

as a soltion to the &roblem. Containment actions t"&icall"address the eJect. 'he" shold be considered Mimmediate rst-aidM to be revieed and removed as 7ic)l" as &ossible.

D


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D

Contain$ent actions-6 Containment actions can and often shold &roceed in &arallel ith

the root case determination investigation. Dring the &eriod inhich containment actions are ta)ing &lace( man" sefl thingsmst be &rsed as a rst ste& in nding the root case. 'hesethings incldeE Hstablishing an investigative &lan

Obtaining baseline data

3nitiating an on-going control s"stem

Develo&ing a follo-& and commnications s"stem

Correcting &rodcts alread" &rodced

Start s"stematic investigations Condct s&ecial stdies and statistical e/&eriments


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D Case Std"

A tan) containing sl&hric acid ascorroded and a s&ill is the reslt. 'hes&ill is small so the o&eration

manager decided to eld a metalsheet over the s&ill hole.

#old this be an immediate

corrective action $ #h" $ #hat arethe ste&s that mst be folloedbefore ma)ing the elding $ #hatare the immediate control ste&s $

D


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D

nteri# Contain#ent A!tion Verication of HJectiveness

9D


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9D

De/ne +RI*AR, CAUSESTHROUGH ROOT CAUSESAAL,SIS

3dentif" all &otential cases hichcold e/&lain h" the &roblemoccrred. 'est each &otential case

against the &roblem descri&tion anddata. 3dentif" alternative correctiveactions to eliminate root case.

D


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D

Identify all potential ca!ses(%ic% co!ld eplain (%y t%epro)le$ occ!rred4

Isolate and erify t%e root ca!se)y testin# eac% potential ca!sea#ainst t%e pro)le$ description

and test data4 Identify alternatecorrectie actions to eli$inateroot ca!se4

D-@oot case of a failre


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D @oot case of a failre

D


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D

T(o Root Ca!ses Root Cause of .ent (/!!ur or

/!!urren!e)

#hat s"stem alloed for the event tooccr$

Root Cause of .s!ape

#hat s"stem alloed for the event toesca&e ithot detection$

D


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D

De/ne and 0erify Root Ca!se?s-3 An investigation into all identied &otential cases

is necessar" for eJective &roblem solving. A caseand eJects diagram can be sed to brainstorm all

&otential cases of the described &roblem. 'heteam shold decide on hat CNH diagram1s2 is tobe sedE *( Process ,lo andLor stratication. 'hemore detailed the CNH diagram( the higher thechances the root case ill be inclded on the CNH

diagram. An eJective CNH diagram ill incldein&t from all team members and ill be discssedin detail.

D


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D

De/ne and 0erify Root Ca!se?s-3

An" e/isting data shold be revieed for cles to &otentialcases. ,rther data collection ma" be re7ired to investigateadditional cases.

3f the &roblem has not &reviosl" been seen( a timeline

anal"sis shold &rovide signicant data. 'he timeline illidentif" events occrring abot the time the &roblemdevelo&ed. 3f enogh docmentation is available( &otentialcases can be frther identied. ,or e/am&le( if a neo&erator as &t on a &rocess or if a ne s&&lier begans&&l"ing &arts. 3nvestigation into the events occrring at thesame time the &roblem as discovered cold lead to severalim&ortant &otential cases.

M#hat Changed$M M#hen$M are im&ortant 7estions.

D


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D

De/ne and 0erify Root Ca!se?s-5 A techni7e sed e/tensivel" in anal"tical &roblem

solving is a com&arison anal"sis. 'his anal"sis loo)sat hat is and hat is not in the &roblem

descri&tion. Potential cases can be discovered b" condcting a

srve". I" srve"ing the cstomer ho hasitnessed the &roblem( more &otential cases canbe highlighted.

As)ing M#h"Mre&eatedl" is eJective in driving the&rocess toard root case and generating morecom&lete nderstanding of the case and eJect.

D


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D

De/ne and 0erify Root Ca!se?s-6 Once the &roblem has been described and the

&otential cases identied( the team shold beevalated. Are the right members on the team to

investigate the &otential cases$ Are technicaladvisors re7ired to assist in an" s&ecial stdies$Do ne team members need to be added$ 3s theathorit" to &rse the anal"sis of the &otentialcases ell dened$ All these 7estions mst be

ansered to ensre the team ill be sccessfl ininvestigating the &otential cases and determiningthe root case.

D


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De/ne and 0erify Root Ca!se?s-6

'he case and eJect diagram is sed to identif" the&otential cases to be investigated. #hat is the&robabilit" that a &otential case cold be res&onsible forthe &roblem$ 3dentif" all &otential cases that cold have

been &resent and ma" have cased the &roblem. Once all &otential cases have been agreed &on( choose

several &otential cases to investigate. 3f onl" one&otential case is investigated( a lot of time ma" be lostif that &otential case &roves not to be the cl&rit. 'o

e/&edite a soltion( investigate several &otential casesat the same time 1Parallel actions on several &otentialcases2.

D


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De/ne and 0erify Root Ca!se?s-9 3f the &roblem is a manfactring &rocess( begin to

establish a stable &rocess. Once the &rocess is stable(denition of the &otential case ill be claried.

3f design cases are identied( screening e/&eriments ma"

hel& identif" the )e" variables hich are aJected b"sbse7ent &rocesses. Design changes ma" be a&&ro&riate.

,or or ve &otential cases shold be identied toinvestigate. 3dentif"ing several &otential cases forces theteam to address mlti&le &ossibilities rather than searching

endlessl" for a single case. An im&licit &art of &roblemanal"sis is investigating &otential cases in &arallel ratherthat in series.

D


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Si Steps Of Inesti#ation State ho the &otential case cold have reslted in the

described &roblem.

Hstablish hat t"&e of data can most easil" &rove or dis&rovethe &otential case. Develo& a &lan on ho the std" ill be

condcted. 3dentif" the actions on an action &lan. Pre&are the re7ired materials to condct the std". 'raining

ma" also be re7ired.

Collect the re7ired data.

Anal"0e the data.


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Identify Alternate Sol!tions Generate a Case N HJects diagram.

Srve" the cstomer.

3dentif" similar &roblem1s2 &reviosl" solved.

Avoid im&lementing the interim actions for&ermanent actions Lsoltions.

Consider ne and crrent technolog" for the

soltion. 3ncor&orate the soltion into ftre &rodcts4

D


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Identify +otential Ca!ses Dene the eJects for case and eJect diagram1s2.

Pre&are a *( Process or Stratication case N eJects diagram for eacheJect 1"o ma" ant to se a combination2.

'eam members shold each assme their activit" cases the &roblem andas) themselves E!o cold hat 3 do &ossibl" generate the &roblem$

Pre&are a time line anal"sis if the &roblem as not ala"s &resent.3dentif" hat changed hen.

Perform a com&arison anal"sis to determine if the same or a similar&roblem e/isted in related &rodcts or &rocesses. 3dentif" &ast soltionsand root cases hich ma" be a&&ro&riate for the crrent &roblem.

3dentif" the to& fe &otential cases. Develo& a &lan for investigating

each case and &date the action &lan. Hvalate a &otential case against the &roblem descri&tion. Does a

mechanism e/ist so that the &otential case cold reslt in the &roblem$

D


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Analye +otential Ca!ses- Identify Root Ca!se Analye +otential Ca!ses

Use t%e iteratie process to analye eac% potential ca!se4

!"&othesis generationE !o does the &otential case reslt in the &roblem$

DesignE #hat t"&e of data can most easil" &roveLdis&rove the h"&othesis$

Pre&arationE Obtain materials and &re&are a chec) list.

Data CollectionE Collect the data.

Anal"sisE


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De/nin# t%e /e ele$ents ofprod!ction= ObRects of ProdctionE aterialsE @a( ,inished(

Semi-nished( 3n-&rocess

Agents of ProdctionE Peo&le( achines( 'ools(Qigs( achine 'ools( 3ncidental Devices( 3ns&ectionH7i&ment( 'he Hnvironment( etc.

ethodsE Processing S"stem( oad N Ca&acit"

Ialance( Processing Conditions S&aceE eft to @ight( ,ront to Iac)( 'o& to Iottom

'imeE Process 'ime( Prodction 'ime( 'as) 'ime

D- &rocess Phenomena


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&

D


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+o&a ,o&e Deices@ Syste$s Inspection +o&a ,o&e Syste$s

Control Syste$s

!alt the o&erations( and re7ire feedbac) and actionbefore &rocess can resme.

.arnin# Syste$s


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+o&a ,o&e Deices Are Iilt ithin the Process

3n General !ave o Cost

!ave the Ca&acit" for 4== 3ns&ection

@emember SBC is &erformed otside the&rocess hich adds cost and allosdefects to esca&e the s"stem.

D-S"stems for = defects $


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"

D-Case Std"


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"

Please describe- in "or o&inion- as"stem ith = defects.

D


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.%at is i$portant 1 RCA?Root Ca!se Analysis and

Escape +oint

DiJerences and Changes @oot Case 'heories

Verication

Process ,lo Diagram

Hsca&e Point

D-@CA
http://www.quality-one.com/corrective-action/rca/http://www.quality-one.com/corrective-action/rca/


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@CA 1@oot Case Anal"sis2 is not a method or &rocessitself( bt a class of &roblem solving methods aimedat identif"ing the root case of &roblems or events.@CA is an" strctred a&&roach that identies factorsreslting in the &roblem otcome inclding

s"m&toms( eJects or conse7ences. 'he &ractice of @CA is based in the belief that

&roblems are &ermanentl" solved b" addressing theroot case( rather than addressing obvios

s"m&toms. Conter measres directed at the rootcase are more li)el" to &revent &roblemreoccrrence.

D-@CA


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'here ma" be several eJective measres that addressthe root cases of a &roblem. De to this fact( @CA isoften &erformed iterativel" and is fre7entl" sed as acontinos im&rovement tool. @CA is reactive(identif"ing events or cases( revealing &roblems and

solving them. Anal"sis is done after a &roblem hasoccrred. ,HA1,ailre ode and HJects Anal"sis2 isthe sage of @CA to forecast or &redict &robabilit" ofevents before the" occr. @CA and ,HA are relatedand similar bt se&arated b" their &lace in the Prodctor Process life c"cle. ,HA is sed &rior to &rodct or&rocess lanch hereas @CA is sed after.

D-@CA
http://www.quality-one.com/development/fmea/http://www.quality-one.com/development/fmea/


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'he root case of an" &roblem is fond at the&oint of creation. 'he root case is never ano&erator error or a bro)en tool. 'he s&ecics of aroot case occr at the conversion of a &rodct or

service from one state to a ne desired state.'his conversion mst be measrable and t"&icall"re7ire &ro&er energ" sage. H/am&les of energ"inclde( bt are not limited to force( tem&eratreor motion. 'he incorrect a&&lication of energ" is

the &oint at hich the root case can be fond.'he root case can onl" be )non if it can betrned on and oJ at ill.

D-@CA


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'he @CA &rocess is selected de&ending &onman" factors sch as cltre and )noledgeof &roblem solving tools. Balit"-One hasdecades of e/&erience in determining the

&ro&er tools and techni7es for &roblemsolving sited to "or s&ecic needs. B-4 isthe leader in 'raining and ,acilitating themost eJective @CA techni7es available. #e

s&eciali0e in 8D1Hight Disci&lines of ProblemSolving2( * #h"and Si/ Sigma.

D-@CA
http://www.quality-one.com/corrective-action/eight-disciplines/http://www.quality-one.com/corrective-action/5-why/http://www.quality-one.com/improvement/six-sigma/http://www.quality-one.com/improvement/six-sigma/http://www.quality-one.com/corrective-action/5-why/http://www.quality-one.com/corrective-action/eight-disciplines/


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User B Operator Safety-)asedRCA

Accident Anal"sis

Occ&ational Safet" and !ealth +rod!ction-)ased RCA

Balit" Control

anfactring

D-@CA


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+rocess-)ased RCA Isiness Processes

Fail!re-)ased RCA

,ailre Anal"sis in Hngineering andaintenance

Syste$s-)ased RCA

Change anagement

@is) anagement

S"stems Anal"sis

D-@is) Iased 3ns&ection


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@is) Iased 3ns&ection cold establishthrogh com&le/ 7antitativeanal"sis the &rinci&al cases of the

nonconformit". @3I is an American based ins&ection

method develo&ed b" AP3 1American

Petrolem 3ndstr"2



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An ins&ection strateg" based on ris) avoids theinade7acies of the traditional a&&roach. 'heconce&t of ris) ta)es into accont( not onl" the&robabilit" of failre( bt also the conse7encesof failre. 'hese ma" encom&ass conse7ences interms of lost &rots( re&air and re-Rsticationcosts( hman casalties and environmental clean& costs. Sch a strateg" ensres that ins&ectioneJort is targeted a&&ro&riatel" to o&timi0e costs

and benets( and &rovides an aditabledemonstration that this has been done ith dediligence.



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3n some cases( initial trnarond ins&ection &lanningis based on 7alitative ris) ran)ing 1B@@2. #hereas(7antitative ris) assessment attem&ts to &erform a&recise nmerical evalation of the ris) e/&osrere&resented b" e7i&ment( 7alitative ris)-based

ins&ection 1@I32 &lanning &rovides a means ofma)ing a ris) categori0ation. 'herefore( 7alitative@I3 &lanning &rovides a sefl methodolog" forcorrectl" targeting ins&ection e/&enditre to

com&onents of the &lant here it ill be mosteJective in ma/imi0ing the safet" of &lant &ersonneland minimi0ing the cost e/&osre to failre.



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A 7alitative @I3 methodolog" &resents( to an e/&ert std"team( each of the factors inencing the li)elihood ofe7i&ment failre and each of the factors inencing theconse7ences of that failre in the event it ere to occr.Iased on the std" teams combined e/&ertise( Rdgments arethen made as to the magnitde of each factor( for each item(according to a &re-determined scheme. 'he reslt of sch anassessment is an evalation of ris) categor" 1or ran)ing2 foreach item( the severit" of hich then dictates the a&&ro&riatere7ired eJectiveness of the ins&ection res&onse.

3n cases here the assessment &rocedre for determining the

magnitde of an" of the factors inencing either li)elihood orconse7ences of failre( re&lace e/&ert Rdgment b"nmerical rles( the a&&roach is termed semi-7antitative.



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@is) Iased 3ns&ectionE is a conse7ent develo&ment of traditional

maintenance strategies that minimi0esmaintenance e/&enses(

belongs to the )noledge based methodologiesfocssing on safet" and &lant availabilit" ondemand b" increasing on-stream time de to lesstrn-arond time and a conse7ent redction ofne/&ected failres(

is a s"stematic tool that hel&s sers to ma)einformed bsiness decisions regarding ins&ectionand maintenance e/&enses(



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@is) Iased 3ns&ectionE identies Y#ea) PointsM and YIad ActorsM(

enables evoltion from a YIandage A&&roachM to asstaining reliabilit" cltre(

is a recogni0ed a" toards YIest 3n Class PerformanceM

and YO&erational H/cellenceM( means fostering re&lacement strateg"(

is measring ris) as a )e" &erformance indicator(

im&lies &rioriti0ation in maintenance eJorts(

e/tends ins&ection intervals here local athorities

recogni0e @is) Iased 3ns&ection 1@I32( and allos determination of e/ternal alternative ins&ection

methods to avoid internal entr"



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Obtainable eJectsE 3dentication of #ea) Points

Asset Policies

@e&lacement Strateg" ess internal ins&ectionsE

3ncreased 3ns&ection 3ntervals

Alternative 3ns&ection ethods


153/204D-@is) Iased 3ns&ection


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S%ort description of $et%odolo#y Step 3=De/ne pro)a)ility of fail!re

,ailre &robabilit" rles have been develo&ed sch thatdata re7irements are minimi0ed as mch as &ossible.Generall"( data re7ired can be obtained from PN3D

and P,D draings( &i&ing and valve s&ecications(&rocess mass balance data etc.( ith onl" minimalre7irement to reference design draings( &i&ingisometrics etc. 'he &rinci&le is that sch detailed datashold onl" need to be revieed for more detailedanal"sis if deemed a&&ro&riate folloing ris) ran)ingsing the standard easil" a&&lied rles. aRor featresincldeE



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S%ort description of $et%odolo#y Step 3=De/ne pro)a)ility of fail!re

'o &robabilities of failre are derived for &ressre vessels and &i&eor)(&robabilities of failre de to internal damage and de to e/ternal damage.

#here a&&ro&riate failre &robabilities are dened in terms of remaining life

here the life is calclated according to an assessed or measred

degradation rate( a life in service( and a degradation tolerance. ,or damage mechanisms for hich a remaining life is not a&&ro&riate( sch as

Stress Corrosion Crac)ing( a failre &robabilit" score is derivedaccording to ho the actal &rocess conditions com&are ith&ermissible &rocess conditions for the materials in 7estion.

,ailre &robabilit" rles address a ide variet" of degradation mechanisms

gro&ed nder the folloingE #all thinning mechanisms e.g. Corrosion Crac)ing mechanisms e.g. Stress Corrosion Crac)ing

echanical damage e.g. ,atige

etallrgical Damage e.g. Hmbrittlement



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S%ort description of $et%odolo#y Step 5=De/ne conse"!ence of fail!re

'hree categories of failre conse7ence areassessed.

Safet"E to/ic( re( e/&losion( &ressre andtem&eratre ha0ards

HnvironmentE &olltion ha0ard to srronding&o&lation or landsca&e

IsinessE instant and longer term eJects on&rodction



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S%ort description of $et%odolo#y Step 6=De/ne $aintenanceBinspection eectieness

@I3L@I rles allo for ins&ection eJectiveness in a&&ortioningcondence grades to each e7i&ment item. 3n the rst instancethese grades are ta)en to be the same as the &lants e/istingins&ection grades. 3n eJect the grading re&resents condencein the crrent and ftre condition of an item( condence isloest if there is no ins&ection evidence and highest if there islots of a&&ro&riate ins&ection evidence or ell behaveddegradation. aRor featres incldeE ,or an" given ris) ran)ing( items graded high ill be allocated longer

ins&ection intervals than items graded lo condence. Probabilities of detection are not sed in the standard methodolog" bt

can be ta)en accont of in 3ns&ection Vale Anal"ses.



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S%ort description of $et%odolo#y Step 9=Ris& $iti#ation $et%odolo#y

3ns&ection alone is not scient to mitigate ris)(action arising ot of ins&ection is also re7ired.

'hrogh se of Condence Grading and remainingall thic)ness measrements etc.( allos forinformation on )non condition of items and thisis then sed to inence &erceived ris). ,ore/am&le( a all thic)ness measrement can besed to rene Rdgments on historical corrosion(this is renement of &erceived ris).



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S%ort description of $et%odolo#y Step ;=Fitness for p!rpose and re$ainin# life eal!ation

#ithin HS@ 'echnolog"s @I3L@I methodolog" tness for&r&ose is re&resented b" either remaining life or failressce&tibilit". @emaining lives in the rst instance arecalclated according to assessed or measred corrosion rates(design corrosion alloances( time in service( and &resence andcondition of an" &rotective coatings. 3n almost all instancessch a basic remaining life can be e/tended throgh se ofim&roved determination of corrosion alloance e.g. throghmore detailed a&&lication of design codes( nite element

anal"sis etc( or throgh more in de&th corrosion assessment( orthrogh better corrosion rate trending from all thic)nessmeasrements.



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S%ort description of $et%odolo#y Step :=Inspection strate#y

3ns&ection activities are assigned in terms ofdamage needing to be chec)ed for as follosE

#all thinning ins&ection. Crac)ing ins&ection.

echanical damage ins&ection.

etallrgical damage ins&ection.

3nternal visal ins&ection 1an activit" intended to chec)

for more than one t"&e of damage categor" andassigned in instances of either lo condence andLorhigh ris)2.



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S%ort description of $et%odolo#y 3ns&ection fre7encies are assigned for each of the

above activities as the soonest of to calclated datesas follosE

A fre7enc" obtained from a loo)& table according

to ris) ran) and condence grade 1here the ris) isdened b" the overall failre conse7ences and thefailre li)elihood ran) for the t"&e of damage2.

A &ercentage of the remaining life calclated for the

t"&e of damage( here the &ercentage is obtainedfrom a loo) & table according to the derived overallfailre conse7ence ran)ing.



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S%ort description of $et%odolo#y Cost and )ene/t analysis

,ield e/&erience re&orts that good 7alit" andthorogh @I3L@I ill reslt in more ecient

ins&ection schedling throgh hich high ris) itemscan be concentrated on sing better ins&ectionhilst ins&ection re7irements are rela/ed on loerris) items. HS@ 'echnolog" has e/&erience ofcalclating the im&act of @I3L@I &rogrammes( the

reslts can be dramatic. 3n &ractice the sccess ofan" cost benet anal"sis de&ends ver" mch on thedata that can be obtained from the &lant.



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S%ort description of $et%odolo#y-P@OIAI33'- CO>SHBCH A'@3%



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S%ort description of $et%odolo#y-3ns&ectionschedle



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S%ort description of $et%odolo#y- AP3 @I3matri/

;D


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0erify Correctie Actions Conrm that the selected corrective

actions ill resolve the &roblem for

the cstomer and ill not casendesirable side eJects. Dene otheractions( if necessar"( based on

&otential severit" of &roblem.

*D


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C%oose@ 0erify and I$ple$ent CAo)Nectie=

'hrogh &re-&rodction test

&rograms 7antitativel" conrm thatthe selected corrective actions illresolve the &roblem for the

cstomer( and ill not case an"ndesirable side eJects.

Dene contingenc" actions( ifnecessar"( based &on @is)

*D


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C%oose@ I$ple$ent 0erify Correctie Actions-3 I" far the most critical ste& in the &roblem-solving &rocess is to verif"

that the soltion ill in fact eliminate the &roblem. 3n addition( it isoften the most diclt ste&. 'he most common method to evalate a&roblem soltion is to ait for im&lementation of the soltion( then seeif the &roblem goes aa". !oever( too mch time ma" be lost beforeconclsive information is available. Verication( here ever &ossible(shold come before im&lementation.

Several a&&roaches to verication are available. 3n engineering( designverication and &rodction validation testing &rovides signicantinformation. 3n the short term( a benchLlab test can be sed to verif". 3nsome cases d"namometer testing can &rovide verication. ong termone can monitor eet res&onse. ,or manfactring( verication is b" in-

&lant indicators. SPC can verif" the elimination of the &roblem.Sometimes scra& rate re&orts and conformance adits &rovideinformation. Sometimes a designed e/&eriment is &art of verication4

*D


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C%oose@ I$ple$ent and 0erify Correctie Actions-5 #hatever verications "o choose( a detailed verication L action &lan

is re7ired to otline ho ill be ta)ing hat actions b" hen. 'heaction &lan shold sho hat data or statistics ill be collected andanal"0ed( ho is res&onsible and mst trac) actal &rogress andschedled com&letion. 'he action &lan is the detailed D"namic recordof all &hases of the &roblem solving &rocess.

Good &roblem soltion veries the cstomer is satised ith thesoltion. 3f &ossible( involve the cstomer in choosing soltions.

All verication of the &roblem soltion ill re7ire decision anal"sis.Decision anal"sis is &art of the cost and timing consideration of thesoltion. Decisions aJecting cost mst inclde eJects on 7alit"(ftre &roblem recrrence and com&lete elimination of the &roblem. 3naddition( management and o&erating &rocedres ma" be involvedhen choosing

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