5 why training_presentation

5 Why Analysis

5 Why Analysis

Prepared By Md Aminul Islam

Reliability Engineer

SADAF-SABIC,KSA

2 Security Classification

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


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) requires a 5-Why analysis to help in

identifying the root cause of the problem.

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

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?


Is the powerful question… own it!!


Speed Limit

Strictly Enforced

No Reaction

How Fast

Are You Going?

Cause Reaction

(Look at speedometer)

How Fast

Should You Be Going?

Cause Reaction & Research

(Look at speedometer; Search for speed limit sign)

Power of Asking Questions


Who are the best at asking questions to solve problems?



When working with people to solve a problem, it is not enough to tell them what the solution is. They need to find out and understand the solution for themselves. You help them do

this by asking open-ended , thought provoking questions.

Children! Why?

…because they keep asking objective, open-ended questions until

the answer is simple and clear



Close-Ended: Structures the response to be answered by one word, often “yes” or “no”. Usually gives a predetermined answer.

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

Open-Ended: Leaves the form of the answer up to the person answering which draws out more thought or research.

Example: “How is setup controlled?”

Close-Ended vs. Open-Ended Questions


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


Example 1:

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

Example 2: “Would improving material flow help reduce lead times?” (Good question but it’s still Close-Ended, focuses the person on material flow 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 the person 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 variables impacting 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 on equipment 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


5 Why Overview

?


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?


Corrective Action with Responsibility Date

Define Problem Use this path for

the specific

Root Causes A

nonconformance

being investigated

WHY? Therefore

Use this path to

investigate why the problem was not

detected.

WHY? Therefore

WHY? Therefore B

WHY? Therefore WHY? Therefore

A

Use this path to investigate the

systemic root cause (Quality System

Failures)

WHY? Therefore

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:


Delco fuse box Insert example

What tool do We use for this?


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 be large, vague, or complicated. You have some information, but do not have detailed 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, if

necessary. What else do I know about the problem? Are there other sub-problems?


◦ 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?”


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?


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 be

communicated to the Customer? ◦ Is there evidence to support verification of corrective actions? ◦ Are corrective actions irreversible?If not, do actions address ongoing

containment? ◦ 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?


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 and process!


5-Why Analysis

The problem is stated through the eyes of the customer Problem

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 what causes the main cause

Etc.


A good 5-Why will answer “Yes” to the five

PDCA questions:

PLAN

DO CHECK

ACT

1. Is the problem statement CLEAR and ACCURATE?

2. Has the SYSTEMIC root cause(s) been

identified for all legs?

3. Has IRREVERSIBLE CORRECTIVE ACTION(s) been implemented for

ALL root causes?

4. Has a plan been identified to verify the

EFFECTIVENESS of all corrective

actions?

5. Has a plan been identified to STANDARDIZE and take all lessons learned across

products, processes, plants, functional areas, etc.?

Understand the problem

Execute the Plan Follow-up

Standardize

“A problem well defined is a problem half solved”


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

Step 1: Problem Statement

Is the analysis being reported on the problem as the Customer sees 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 why’s)?

-Is there a true cause-and-effect path from beginning to end of each path? Is there statistical data/evidence to prove it? ---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, so this happened, and so on, which resulted in the original problem.)

-Do the why’s 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…?

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 action applies 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 be communicated 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 doesn’t happen on the first try!)

-Who prepared the 5-why?


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 what happened systemically."

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

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


THANK YOU

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