Root Cause Analysis (RCA) The Boeing Problem Solving Model … · 2019-11-28 · Presented By...
Transcript of Root Cause Analysis (RCA) The Boeing Problem Solving Model … · 2019-11-28 · Presented By...
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Presented By
Jennifer MacKay
Associate Technical Fellow, The Boeing Company
1
Root Cause Analysis (RCA) &The Boeing Problem Solving Model (BPSM)
Bridging the ‘Problem Solving’ Skills Gap
Author, 11/26/2019, Filename.ppt | 1
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Why Root Cause Analysis?
“At the core of all industry is the desire to make money. Anything that negatively impacts this goal is usually
attacked by performing root cause analysis.”ARMS Reliability - 2018
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Presentation Outline
Section 1
Section 2
Section 3
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Section 1
Jen & The Boeing Company
• Enterprise Overview
• My Work Environment
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The Boeing Company Headquarters: Chicago, IL
Commercial
Defense, Space, & Security
• The world's largest aerospace company • Over 140k employees in more than 65 countries• Leading manufacturer of commercial jetliners and defense, space and security systems• America’s biggest manufacturing exporter
Global Services
The Boeing Company
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The Boeing Company
Jen
’s D
esk
Everett, WAUSA
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Jen’s Factory Desk – 777 Moving Line
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777 Airplane Program777-300 Extended Range
Three million parts in a 777 provided by more than 900
suppliers from 17 countries around the world
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Jennifer MacKayAerospace Application
Boeing employee since 1991
Associate Technical Fellow in Root Cause Analysis (RCA)
RCA Instructor > 1,500 engineers, technicians, and quality investigators
RCA Mentor, Consultant, & Champion
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Former SPEEA President: Society of Professional Engineering Employees in Aerospace (SPEEA)
Former IFPTE Vice President: International Federation of Professional and Technical Employees (IFPTE)
Former CESO Delegate: Council of Engineers and Scientists Organization (CESO)
Former SRLC Executive Board Member: Spokane Regional Labor Council
Former SAWDC Member: Spokane Area Workforce Development Council
Jennifer MacKayActivist Application
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Why do you care?
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Companies want
Skilled Problem Solvers
Companies cant’ find Skilled Problem Solvers
SKILLS GAPin the
Problem SolvingSkill-Set
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Section 2
The Skills Gap
• Definition / Studies
• Bridging the Gap
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What is a Skills Gap?
https://static.googleusercontent.com/media/edu.google.com/en//pdfs/skills-of-the-future-report.pdf
Forbes: A skill gap is a gap between what employers want or need their
employees to be able to do, and what those employees can actually do when they walk into work.Forbes article “The Most Serious Skill Gap Of All” 8/18/2016
Bloomberg: Skills companies want in top talent but can’t find. Skills that are
important but in short supply. Bloomberg’s annual “Employers Survey” https://www.bloomberg.com/graphics/2016-job-skills-report/ 2015 & 2016
Economist: The gap between what students learn in school and what they do in
real life. Economist Intelligence Unit report “Driving the skills agenda” https://static.googleusercontent.com/media/edu.google.com/en//pdfs/skills-of-the-future-report.pdf 2015
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More Wanted – Harder to Find
More Wanted – Easier to Find
Less Wanted – Harder to Find
Less Wanted – Easier to Find
Bloomberg's 2015 MBA rankings. Surveyed 1,320 job recruiters at more than 600 companies. They chose their top 5 most important skills and the 5 hardest to find skills from a list of 14 skills.
The Sweet Spot
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Most people think that
they are a good problem
solver by nature.
“… believe that they have
become very good at
given skills without
receiving formal
education in them.”
https://static.googleusercontent.com/media/edu.google.com/en//pdfs/skills-of-the-future-report.pdf
No Problem…
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Disconnect
Structured Problem-Solving
Vs.
Winging-It
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Section 3
The BPSM & Apollo RCA
• MacKay application
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BPSMThe Boeing Problem Solving Model
Boeing Problem Solving ModelThe Boeing Problem Solving Model provides a structured approach to continuous improvement through problem solving.
•Principle based
•Applies to problems of any size and scope
•Works for all aspects of the business
Authored by Corrective Action & Preventive Action PRO-6490 & BPI-6022
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Problem Solving Tool Box
5-Why’s
Apollo Root Cause Analysis (ARCA)
Fishbone Diagram (Cause & Effect)
Fault Tree Analysis
Brainstorming
6-Sigma (DMAIC)
Toyota’s 8 Steps
Accelerated Improvement Workshop (AIW)
Failure Modes & Effects Analysis (FMEA)
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Define / Describe the ProblemStep 1
1
2
3
4
5
DEFINE and DESCRIBE the
Problem or Opportunity
Identify ROOT
CAUSES
Identify and VALIDATE
PROPOSED Solutions
IMPLEMENTthe
Solutions
SUSTAIN the
Gains Boeing
Problem Solving
Model
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Step 1: Define & Describe the Problem
BPSM • Containment
• Investigation
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Ask What,
When,
Where,
& Significance Questions = Problem Statement
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MacKay IntegrationStep 1: Define & Describe the Problem
Investigation: Design/Plan/Build ‘As-Designed’ Condition:
• Engineering Drawings, PL/DL’s, 3D Models• Specifications (Boeing & Regulatory)• Tool Designs• All Levels: Raw Mtl, Dtl, Assy & Instl
‘As-Planned’ Condition: • Accurate• Sufficient• In the Proper Sequence• Mfg Plans & Tool Use Instructions
‘As-Built’ Condition:• Interview Witnesses & SME’s• Observe the Process – Monitor Several AP’s• Data Collection & Review
Historic: RH/LH, Tool Units, 1st /2nd shift Real-Time: Metrology &
Detail Part MeasurementsAsk What, When, Where, & Significance Questions
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Identify Root CausesStep 2
1
2
3
4
5
DEFINE and DESCRIBE the
Problem or Opportunity
Identify ROOT
CAUSES
Identify and VALIDATE
PROPOSED Solutions
IMPLEMENTthe
Solutions
SUSTAIN the
Gains Boeing
Problem Solving
Model
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Step 2: Identify Root Causes
Root Cause Analysis (RCA): The process of identifying the root causes of a detected or potential nonconformity or other undesirable situation utilizing one or more RCA methods or tools (e.g., Cause and Effect Diagram, 5-Why Analysis, Cause Tree). PRO-6490
BPI-4024
1
2
3
4
5
DEFINE and DESCRIBE the
Problem or Opportunity
Identify ROOT
CAUSES
Identify and VALIDATE
PROPOSED Solutions
IMPLEMENTthe
Solutions
SUSTAIN the
Gains Boeing
Problem Solving
Model
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ARCAThe Apollo Root Cause Analysis Methodology
Gano, Dean L. “Apollo Root Cause Analysis – A New Way of Thinking” Apollonian Publications, 1999, 2003
“There is no such thing as a single right answer.Rather, Solutions are found in an infinite set of causes.”
Event Based - Most problems do not have one right answer,
– multiple root causes thus multiple solutions.
Dean L. Gano
Gano, Dean L. “Apollo Root Cause Analysis – A New Way of Thinking” Apollonian Publications, 1999, 2003
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DefinitionCause-Mapping
Cause-Mapping:A root cause analysis tool that provides a visual explanation of why an incident occurred. It connects individual cause-and-effect relationships to reveal the system of causes within an issue.
Begin with the Problem, what it is that you want to fix. This becomes your starting point or Primary Effect.
Then map the reasons why the problem occurred as ‘causes’ on your Cause-Map.
To explore both action and condition contributors, differentiate your causes as Action Causes or Conditions Causes.
Action Causes are those actions that occurred (or failed to occur) that caused the problem while Condition Causes are those conditions already in place that allowed those Actions to happen.
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“Things don’t just happen, they are made to happen.”John F. Kennedy
MacKay IntegrationStep 2: Root Cause Analysis
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Example: 777 Wing Majors- Wing Skin Panel Scrap
Condition Why
The tool can physically
be used in an up-side-
down condition.
Action Why
Mechanic applied Drill
Starts at incorrect
locations
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Action Causes & Condition Causes
Any manual task that can possibly be done incorrectly – will be done incorrectly
Even highly skilled top performers can simply ‘have a bad day’.
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Collaborative Approach:Cross-Functional / Formal Workshop - Invite those who…
• Know the most about the problem• Can best help you implement your solutions
Streamlined Approach:Perform initial investigation and create the a Cause Map draft on your own, work 1-on-1 with SME’s as needed to finalize the cause map– No formal workshop.
Tip: Resources are usually limited so be judicious when planning workshops. Hold several half-day sessions in lieu of full-day workshops.
The Cause-Mapping Exercise
Cause Maps can be created with pen & paper, sticky notes on a white-board, or with software applications such as PowerPoint, Visio, Excel, or RealityCharting®.
My personal Cause-Mapping tool of choice is RealityCharting®.
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How far back should you go?
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Apollo’s Reasons to Stop
Desired Condition
More Information Needed
Lack of Control
Other Cause Paths
More Productive
Potential Solution
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Identify Potential SolutionsStep 3
1
2
3
4
5
DEFINE and DESCRIBE the
Problem or Opportunity
Identify ROOT
CAUSES
Identify and VALIDATE
PROPOSED Solutions
IMPLEMENTthe
Solutions
SUSTAIN the
Gains Boeing
Problem Solving
Model
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Step 3: Identify & Validate Proposed Solutions
Each Cause Path without a StopShould have a Potential Solution
• Local SME’s – Subject Matter Experts• Internal Research & Development• Benchmarking
Lack of Control
Desired Condition
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Down-Select
Down-select until you have a Solution Set you have confidence in.
(2) Selected & Implemented(7) Potential Solutions Identified
Employ Tools to Help select and prioritize:• Return on Investment (ROI)• Impact & Changeability Analysis
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Implement SolutionsStep 4
1
2
3
4
5
DEFINE and DESCRIBE the
Problem or Opportunity
Identify ROOT
CAUSES
Identify and VALIDATE
PROPOSED Solutions
IMPLEMENTthe
Solutions
SUSTAIN the
Gains Boeing
Problem Solving
Model
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Most Difficult Step• Relying on Multiple Organizations with
differing hierarchy & priorities
• Extensive Implementation Time Frame
• Employee Movement / Attrition
Implementation Effort & Cost Varied: Simple, Efficient, Inexpensive
Complex, Revolutionary, Capital Expense
Tracking is Key
MacKay IntegrationStep 4: Implement Solutions
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RCA Project Repository
• Single point of visibility
• Common metrics and reporting
• Searchable: Accessible to anyone searching for ideas that can be replicated
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Sustain the GainsStep 5
1
2
3
4
5
DEFINE and DESCRIBE the
Problem or Opportunity
Identify ROOT
CAUSES
Identify and VALIDATE
PROPOSED Solutions
IMPLEMENTthe
Solutions
SUSTAIN the
Gains Boeing
Problem Solving
Model
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Step 5: Sustain the Gains
Non-Conformance Generated Projects:• Built-In Verification System• Formal Validation Sign-Off
Process Improvement Projects• 30/60/90 Day Post-Implementation
Review
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MacKay IntegrationStep 5: Verify / Validate Outcome
Sustaining the Gains- Validation:
One way to express the importance of the Validation step, is to share with you an experience I had when I failed to follow-up:
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BPSMThe Boeing Problem Solving Model
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https://collab2.web.boeing.com/sites/rcapm/RCA_Present/_layouts/15/start.aspx#/SitePages/Home.aspx.https://collab2.web.boeing.com/sites/rcapm/RCA_Present/_layouts/15/start.aspx#/SitePages/Home.aspx
Our longest running Non-Conformance Issues BCA-Wide
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In-Service Quality Issues
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RCA Resource all Commercial Programs
Renton Waste Water Treatment Plant – Capacity Issue
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Supplier Quality & Supply Chain ME Support: External Supplier RCA Training and Workshop Facilitation
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Engineering Process Problems 777 Program-Wide
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BPSM/RCCA
A: BPSM Basics 78983
Required
1-Hr Web Based
B: BPSM Application 78984
Recommended
8 or 16-hr Instructor Led
RCA Cause Mapping
A: PE110 Cause Mapping
Recommended
8-Hr Instructor LedJennifer MacKay - expand pool
Project
Management
A: PE101
Recommended
6-Hour Instructor LedSusan Murphy
Mastery
Trained: Complete the curriculum
Practitioner: Lead a formal RCA
Facilitator: Facilitate multiple projects to the
satisfaction of a Facilitator or BDE
Boeing Designated Expert
Obtain Industry RCA Training & Certification
Apollo RCA / ARMS Reliability
Growing the Problem Solving Skill SetCurriculum Flow
CF105: Curriculum Flow for Integrated Problem Solving Levels
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Summary
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Companies want Skilled Problem Solvers
Boeing Job Classifications • Engineering • Information Technology (IT)• Contracts & Pricing• Environment, Health, & Safety• Facilities
Key Competency:
Provides technical solutions to complex problems that require ingenuity and creativity.
Copyright: <a href='https://www.123rf.com/profile_semisatch'>semisatch / 123RF Stock Photo</a>
“Can you tell us about a time when you had to solve a
complex problem?”
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For every Action or Inaction that caused a problem
A Condition existed that allowed it to happen Questions?