5 Why Training Presentation3

7/30/2019 5 Why Training Presentation3

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Global Supply Management

5 Why Analysis

5 Why AnalysisJanuary 2, 2006


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Global Supply ManagementJanuary 2, 20062Security Classification

5-Why Training Agenda

Where does 5-Why Fit within the PRR process

Understanding of 5-Why

Quick 5-Why Exercise as a group

Critique Sheet

5- Why Examples

Wrap Up/Discussion


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5-WHY

After a supplier has submitted an initial response and

containment plan (Step # 2 in the PRR process), a detailed

investigation is necessary to determine what caused the

problem. Step # 4 (Supplier determines the root cause)

requiresa 5-Why analysis to help in identifying the root causeof the problem.

Going back to one of the elements within the Purpose of a

PRRto facilitate problem resolution, 5-Why is the prescribed

tool for determining the root cause of the problem to facilitate

problem resolution.

Where does it fit within the PRR process?


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Is the powerful question own it!!


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SpeedLimit

StrictlyEnforced

NoReaction

HowFast

Are YouGoing?

CauseReaction

(Look at speedometer)

HowFast

Should

You BeGoing?

CauseReaction & Research(Look at speedometer;

Search for speed limit sign)

Power of Asking Questions


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Who are the best at asking questions tosolve problems?



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When working with people to solve a problem,

it is not enough to tell them what the solution is. They

need to find outand understandthe solution for

themselves. You help them do this by asking open-

ended, thought provoking questions.

Children!Why?

because they keep asking objective, open-ended questionsuntil the answer is simple and clear



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Close-Ended: Structures the response to be answeredby one word, often yes or no. Usuallygives a predetermined answer.

Example: Did the lack of standardization cause the incorrect setup?

Open-Ended: Leaves the form of the answer up to theperson answering which draws out morethought or research.

Example: How is setup controlled?

Close-Ended vs. Open-Ended Questions


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Benefits of Open-Ended Questions

Requires thought

Promotes additional research

Enhances problem solving skills

Does not assume there is one right answer

Avoids predetermined answers

Stimulates discussion

Empowers the person answering

In many circumstances, it is not only the answer itself,

but the process by which the answer was determined

that is important when asking an Open-Ended question


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Example 1:

What could have caused the tool to break?(Open-Ended, probing question forces the person to think about allpossibilities, not just PM)

Example 2: Would improving material flow help reduce lead times?(Good question but its still Close-Ended, focuses the person on materialflow as a means to reduce lead time. Is this the best improvement?)

Did the lack of a PM system cause this tool to break?

(Close-Ended question, can be answered by a yes or no, gives theperson a predetermined answer that PM is to blame)

What are some options on improving lead time?(Open-Ended, triggering more thought and research on all variablesimpacting lead time.)

Example 3: Is equipment capability causing the variation in your process?(Close-Ended, can be answered by a yes or no, focuses the person onequipment being the source of variation)

What could potentially cause variation in your process?(Open-Ended, triggering more thought and research, opens up possibilities

of variation with man, material & method, not just machine)

More Examples


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5 Why

Overview


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5-Why Analysis Three Paths

5-Why:

Specific problem: Why did we have the problem?

Problem not detected: Why did the problem reach the Customer?

System failure: Why did our system allow it to occur?


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5-Why AnalysisCorrective Action

with Responsibility Date

Define Problem

Use this path for

the specific A

nonconformance

being investigated

Root Causes

WHY? Therefore

WHY? Therefore

Use this path toinvestigate why theproblem was not

detected.WHY? Therefore B

WHY? Therefore WHY? Therefore

A

WHY? Therefore

Use this path toinvestigate the

systemic root cause(Quality System

Failures) WHY? Therefore

C

WHY? Therefore WHY? Therefore

B

Ref. No. (Spill, PR/R) WHY? Therefore

Date of Spill WHY? Therefore

Product / Process Delphi Location Content Latest Rev Date WHY? Therefore

C

Problem Resolution Complete Communicate to Delphi Date: Process Change Break Point Date: Implement System Change Date:

Lessons Learned:


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Root Cause Analysis

Delco fuse boxInsert example

What tool doWe use for this?


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Brainstorming


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Grasp the Situation

Part I Grasp the Situation Step 1: Identify the Problem

In the first step of the process, you become aware of a problem that may belarge, vague, or complicated. You have some information, but do not havedetailed facts. Ask:

What do I know?

Step 2: Clarify the Problem The next step in the process is to clarify the problem. To gain a more clear

understanding, ask:

What is actually happening?

What should be happening?

Step 3: Break Down the Problem

At this point, break the problem down into smaller, individual elements, ifnecessary.

What else do I know about the problem?

Are there other sub-problems?


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Grasp the Situation

Step 4: Locate the Point of Cause (PoC) Now, the focus is on locating the actual point of cause of the problem. You

need to track back to see the point of cause first-hand. Ask:

Where do I need to go?

What do I need to see?

Who might have information about the problem?

Step 5: Grasp the Tendency of the Problem To grasp the tendency of the problem, ask:

Who?

Which?

When?

How often?

How much?

It is important to ask these questions before asking Why?


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5-Why Analysis

Step 1: Problem Statement Is the problem statement clear & accurate?

Is the analysis on the problem as the customer sees it?

Step 2: Three Paths Are all three legs filled in?

Are there any leaps in logic? Can you ask one, two, or three more Whys?

Is there a cause-and-effect relationship in each path?

Can the problem be turned on and off?

Does the path make sense when read in reverse?

Do the whys relate to the actual error?

Does the non-conformance path tie to design, operations, dimensional issues,etc.?

Does the detection path tie to the customer, control plans, etc.?

Does the systemic path tie to management issues or quality system failures?


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5-Why Analysis

Step 3: Corrective Actions Is there a separate action for each root cause?

Is it possible to implement each corrective action?

Do corrective actions require Customer approval? If so, how will they becommunicated to the Customer?

Is there evidence to support verification of corrective actions?

Are corrective actions irreversible?If not, do actions address ongoingcontainment?

Is there a plan to standardize lessons learned across products, departments,etc?

Step 4: Lessons Learned

How could the problem have been foreseen? How will information be implemented?

On the line or in the plant?

At the point of detection?

Cross functionally at the Supplier?

Other products/plants?


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5-Why Analysis

Step 5: Overall Are there gaps or holes?

Are there things missed or not documented?

Do corrective actions address actions the Supplier owns?

How many iterations of 5 Why Analysis have there been?

Who prepared the 5 Why Analysis?

One person?

Sales representative ?

Clerk?

The best answer is a cross functional team that understand the product andprocess!


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Therefore Test


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5-Why Analysis

The problem is stated through

the eyes of the customerProblem

The first why is the main cause

Etc.

You have root cause if you

can demonstrate:

cause on, problem on

cause off, problem off

Root Cause

The second why is whatcauses the main cause

Etc.


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Cookies taste really badProblem

Used goose eggs rather thanchicken eggs

Recipe did not specify bird typeRoot Cause

Ingredients are wrong

Cookies are undercooked

5-Why Example

(Non-conformance)

5 Wh E l PPAP S b itt l


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PPAP submitted lateProblem

Test lead time not considered

No system to accurately assess

lead times of all PPAP elementsRoot Cause

Validation testing not complete

PPAP package not complete

5-Why Example - PPAP Submittal

(Non-conformance)

5 Wh E l PPAP S b itt l


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PPAP submitted lateProblem

No requirement to follow-up ontarget submittal dates

No standard system to managePPAP submittal timelinessRoot Cause

Did not know the targetsubmittal date had passed

Did not react to the target

submittal date

5-Why Example - PPAP Submittal

(Detection)

5 Wh E l B i Pl


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Did not meet the annual businessplan goal of a 10% increase in sales

Problem

Did not anticipate requiredresources

Did not develop a plan as to

how the goal would be reachedRoot Cause

Did not have adequateresources

Did not thoroughly evaluatemarket/competition

5-Why Example - Business Plan

(Non-conformance)

5 Wh E l B i Pl


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5-Why Example - Business Plan

(Detection)

Did not meet the annual businessplan goal of a 10% increase in salesProblem

Did not develop a plan to monitor

the status of reaching the goalRoot Cause

Did not know the goal was not

going to be met

Did not have alarms limitsidentified at strategic intervals

(monthly, quarterly, etc.)

Did not evaluate the status of

the goal until December

C S


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Flex Industries Case Study-Background

Jake Ryan is the Quality Manager at Flex Industries. Flex is a componentsupplier that manufactures metal stampings and light assembly products.The company has a reputation for supplying high quality parts on aconsistent basis. Seldom has there been a customer complaint. Flex hasQuality representatives called Customer Support Engineers (CSEs) at everycustomer assembly plant. The CSEs report any problems to Jake forinvestigation and follow-up.

At 7:00 a.m. this morning, Jake received a call from Janet, CSE at theWinding River Assembly Plant. Janet informed him that the customer hadfound five defective stabilizing brackets on second shift last night. Shechecked the remaining inventory and there were no defects in the remaining326 pieces. The manufacturing sticker on the back of the brackets indicatedthat they were made by the second shift operator. Normally, the stabilizing

bracket is fastened to the regulator motor with three rivets. The fivedefective brackets had only two rivets in them. The lower set of rivets on allfive brackets was missing a rivet. This was the first time that the problemoccurred.


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Background

GOOD BAD

Jake set-up containment procedures at the plant warehouse to sort for discrepant materials. As

of this morning, two more defective brackets had been found in the remaining 2019 pieces of

inventory at Flex.


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Cause Investigation

Jake went out to the floor to talk with the team leader of the two rivet lines

(East and West) and the area quality assurance auditor. He informed Sam(the team leader) of the quality problem and asked him to identify the linewhich runs the stabilizing bracket assembly. Sam directed Jake to the Eastline which runs Winding River assembly brackets only.

At the East Line, he spoke with Judy (the QA Auditor for the area) and askedto see the quality log sheets. Jake and Judy reviewed the Nov. 11th log

sheet and could not find anything out of the ordinary. He asked her to set-upin-house containment procedures to sort for any discrepant material in thefinished goods area.

Next, Jake tried to locate the second shift operator whose clock number wason the defective parts. Since that operator was gone, Jake spoke with thecurrent machine operator (Ben). He asked Ben about any recent difficulties

with the rivet machine. Ben said that he hadnt noticed anything out of theordinary. Ben also mentioned, however, that there had never been anyquality bulletins posted in the two years that this particular part has beenrunning.

Jake decided to stay in the area to watch the machine run for a while. Afterabout 15 minutes, he watched Ben dump rivets into the feeder bowl toprepare for the next run.


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Cause Investigation

Shortly after restarting rivet operations, Ben walked over to another riveterand came back with a steel rod. Ben poked around the rivet chute and thencontinued working. Jake approached Ben and asked him about the steelrod. Ben replied that from time to time the chute gets jammed and he has toclear it out. This happens two or three times during a shift. He didntmention this in his earlier conversation with Jake because the problem hasexisted ever since he started working with this machine. The previous

operator showed him how to clear the chute. All the rivet machines are likethis.

Jake called the Machine Repair Department and asked that someone look atthe rivet track. A slight gap in the track was found and removed, and Bencontinued to work.

Two hours later, Jake got a call from Ben saying that the track was still

jamming. As far as Jake could see, only rivets were in the bowl. Next, Jakelooked into the rivet supplier containers. There was some foreign material inthe blue container, but none in the red container. The label on the bluecontainer showed that it was from Ajax Rivet, Inc., and the label on the redcontainer indicated that it was from Franks Fasteners. Obviously, theforeign material was entering the rivet feeder bowl and jamming the track.


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Cause Investigation

Jake called Maintenance and requested that the bowl be cleaned. He alsoadded the cleaning operation to the preventive maintenance schedule on theequipment. He then called both Ajax Rivet, Inc. and Franks Fasteners. Heasked about the cleaning procedures on the returnable containers. Franksdid a full container purge and clean. Ajax just re-introduced the containersback into their system. When Jake asked why Ajax did not clean theircontainers, he was told that Ajax was not aware that such a policy was

needed. Upon further investigation, Jake learned that Franks Fasteners supplies

other major automotive companies. Since these companies require that allreturnable containers be cleaned, Franks instituted the purge as part of itspractice for all customers. Ajax Rivet, however, depends primarily on Flex asits major customer. No such policy has ever been required of them.


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Cause Investigation

Jake called the Material Control Department and requested thata container maintenance policy be drafted which would apply toall their suppliers. He also asked that a machine modificationbe developed to sense for the presence of rivets. Hopefully,this would error-roof the process.

Key Players Jake Quality Manager Janet CSE, Winding River Plant

Sam Team Leader, East Line

Judy QA Auditor, East Line

Ben Machine Operator


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The plant received a PR/R from a customer. (We use 5-WhyAnalysis to answer every PR/R.)

The PR/R states that the customer received Regular Cola in theright container (same for both products) with the Diet Cola label.The order called for Regular Cola.

The plant has two identical lines that are capable of running eitherof our two products. The lines are located immediately besideeach other. The only differences in the products are the syrup andthe labels.

The plant runs both lines 24 hours per day. There are three shifts

that run 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00p.m. to 7:00 a.m.

The date code indicates that the defective product wasmanufactured at 3:03 p.m.

Defective product has been contained and sorted.

Generic Information for 5-Why Example:Regular Cola Soft Drink vs. Diet Cola


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Bottling Process Flow for 5-Why

INSPECT

LIDSB

O

TT

L

IN

G

WATER

BOTTLES

SYRUP LABELS

Generic Information for 5 Why Real


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The plant received a PR/R from a customer. (We use 5-Why

Analysis to answer every PR/R.) The PR/R states that the customer received Mixed/Foreign

Material in Shipment.

The supplied part is an O Ring seal for oil filter.

A cutting operation produces the part to specified size. As the rawmaterial (cylindrical component) goes through the cuttingoperation, the irregular end-cuts are removed from the station.

Generic Information for 5-Why RealExample: O Ring Seal

Cutting Station

Matl Flow


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Missing o-ringon part number

K10001J

Parts missed the

o-ring installationprocess

Parts had to bereworked

Operator did not return

parts to the proper processstep after rework

No standardrework procedures

exist

WHY?

WHY?

WHY?

WHY?

Why did theyhave to rework?

This is still a systemic failure& needs to be addressed,

but its not the root cause.

Is this a good or badNon-Conformance leg?


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Missing threadson fastener partnumber LB123

Did not detect

threads weremissing

Sensor to detectthread presencewas not working

Sensor wasdamaged

No system toassure sensors areworking properly

WHY?

WHY?

WHY?

WHY?

What causedthe sensor toget damaged?

This is still a systemic failure& needs to be addressed,

but its not the root causeof the lack of detection.

Is this a good or bad Detection leg?

A d 5 Wh ill Y t th fi


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A good 5-Why will answer Yes to the five

PDCA questions:

PLAN

DOCHECK

ACT

1. Is the problem statementCLEARand ACCURATE?

2. Has the SYSTEMICroot cause(s) been

identified for all legs?

3. Has IRREVERSIBLECORRECTIVE ACTION(s)

been implemented forALL root causes?

4. Has a plan been identifiedto verify the

EFFECTIVENESSof all corrective

actions?

5. Has a plan been identifiedto STANDARDIZE and take

all lessons learned acrossproducts, processes,

plants, functional areas, etc.?

Understand the problem

Execute the PlanFollow-up

Standardize

A problem well definedis a problem half solved


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Is this a good Corrective Action plan?

A

Corrective Actionw/ Responsibility Date

Fastener P/N 10001

would not assemble

Burrs on the thread

Worn stamping

tool

Tool exceeded

recommended wear

life

PM interval not

adequate

PM failure; No system

to strategically set

PM intervals

WHY?

WHY?

WHY?

WHY?

WHY?

1. Replace worn tool(K. Jones)

2. Begin conducting PM on alldies after every run, minimum1 x / day, to collect history

(L. Burg)

A

6/1/03

6/1/03

3. Assess & adjust PM intervalsfor all dies based on history& mfg recommendations(B. Clark)

7/31/03

Plan

Plan

Do

Do/Act

Do/Act

4. Track PM completion %

to assure 100% conformance(C. Beckett)

6/1/03

6. Track FTQ at stamping tomonitor PM improvement

(S. Boland)

6/1/03

5. Check for burrs on threadsfor 60 days to verify c/a(M. Mendoeous)

6/1/03 -7/31/03

Check

Check

Check


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5-Why Critique Sheet

General Guidelines:A.)Dont jump to conclusions!; B.) Be absolutely objective. C.) Dont assume the answer isobvious. D.) If you are not thoroughly familiar with the process yourself, assemble a cross-functional team tocomplete the analysis.

Step 1: Problem Statement

Is the analysis being reported on the problem as the Customersees it?

Step 2: Three Paths (Dimensional, Detection, Systemic)

-Are there any leaps in logic?

-Is this as far as the Whys lead? Can you still ask one, two, three more whys)?

-Is there a true cause-and-effect path from beginning to end of each path? Is there statistical data/evidence to proveit? ---Can the problem be turned off and on?

-Does the path make sense when read in reverse from cause to cause? (e.g.We did this, so this happened, sothis happened, and so on, which resulted in the original problem.)

-Do the whys go back to the actual error?

-Does the systemic path tie back to management systems/issues?

-Does the nonconformance path ties back to issues such as design, operational, tiered supplier management,etc?

-Does the detection path ties back to issues such as protect the customer, control plans, etc?


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5-Why Critique Sheet (cont)

Step 3: Corrective Actions

-Does each corrective action address the root cause from a path?

-Is there a separate corrective action for each root cause? If not, does it make sense that the corrective actionapplies to more than one root cause?

-Is each corrective action possible to implement?

-Are there corrective actions that affect the Customer or require customer approval? How will they becommunicated to the Customer?

-Is there evidence and documentation to support the validity of the corrective actions?

-Are the corrective actions irreversible? If not, are there corrective actions in place that address containment?

Step 4: Lessons Learned

-How could this problem have been foreseen?

-How will this information be implemented:

a.) on the line or in the plant?

b.) at the point of detection?

c.) cross-functionally at the Supplier?

d.) other product/plants?

-Are there lessons learned for the Customer?

Step 5: Overall

-Do there seem to be big holes where ideas, causes,

corrective actions, or lessons learned are being avoided?

-Where things are missed or not documented?

-Do the corrective actions address the actions the supplier owns?

-How many iterations has the supplier gone through so far in preparing

this 5-why (It doesnt happen on the first try!)

-Who prepared the 5-why?

5 Wh A l i C l E l


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5-Why Analysis: Cola ExamplePath A

5 Wh A l i C l E l


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5-Why Analysis: Cola ExamplePath B

5 Wh A l i C l E l


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5-Why Analysis: Cola ExamplePath C

5 Why Analysis: ORing


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5-Why Analysis: O RingExample Path A



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5-Why Analysis: O RingExample Path B



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5-Why Analysis: O RingExample Path C


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5-Why Analysis: Green, Yellow, Red G: Can follow logic and flow of all 3 legs of 5 why's. The legs all

differentiate "What is the problem, why wasn't it detected, and whathappened systemically."

Y: All 3 legs filled out, some leaps of logic, needs minor corrections toimprove.

R: 1 or 2 legs missing, Leg 1 repeated as leg 2 or 3, not understandingwhat the different legs mean--typically missing what the systemic leg is.Poor answers on 2 or more legs.

Problem Case Audit Standards

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