Root Cause Analysis Problem Identification and Tools. DIOSH March 2016

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1 Root Cause Analysis Problem Identification and Tools DIOSH March 2016

About IMEC Who we are: IMEC is a private, public

of Standards and Technology (NIST) What we do: IMEC

assistance, and leadership advisement to help

2 About IMEC Who we are: IMEC is a private, public partnership that operates through the National Institute of Standards and Technology (NIST) What we do: IMEC delivers customized training, hands on technical assistance, and leadership advisement to help manufacturers improve bottom line results Copyright Illinois Manufacturing Excellence Center. 2

Introduction Over 20 years focusing on Continuous Improvement efforts in manufacturing Lean Six Sigma ISO 9001 Lead Auditor ISO 13485 (Medical) Lead Auditor HACCP

3 Introduction Over 20 years focusing on Continuous Improvement efforts in manufacturing Lean Six Sigma ISO 9001 Lead Auditor ISO (Medical) Lead Auditor HACCP Certified B.S. Industrial Technology, NIU M.S. Industrial Management, NIU M.S. Information Systems, DePaul Ken Wunderlich IMEC Technical Specialist Copyright 2014 IMEC 3

4 Formulation of a problem is often far more essential than its solution, which may be merely a matter of mathematical or experimental skill. --Albert Einstein Copyright Illinois Manufacturing Excellence Center. 4 4

5 Using the Knowledge from the Team 1. Problem solving is best accomplished by a crossfunctional team 2. Fully describing the problem is the first, and most important, step in analyzing the causes of the problem 3. Focus on finding the true cause(s) before considering any solutions 4. Follow-up to verify the effectiveness of solutions/countermeasures to be sure you attacked the root cause 5. Share the knowledge with others 6. Reward the teams Copyright Illinois Manufacturing Excellence Center. 5

Process Management / Improvement Start Select

Collect Data Potential Causes Root Cause Propose

6 Process Management / Improvement Start Select Process Document Process Establish Measures Collect Data Potential Causes Root Cause Propose Solutions Select and Schedule Implement Solution Process Capable? Yes Process Control Control Chart No Update Documentation Collect Data Process Capable? 6

7 MODULE ONE: DEFINE THE PROBLEM 7

8 Design Solutions/Countermeasures Avoid The Silver Bullet A single fix for the problem Difficult for many people to consider alternatives Resources are wasted justifying it that should be used to consider better alternatives People become emotionally invested Almost always incomplete Usually wrong Copyright Illinois Manufacturing Excellence Center. 8

9 Inhibitors to Effective Problem Solving 1. Lack of agreement that there is a problem. 2. Problem is described incorrectly. 3. Problem-solving effort is expedited (focus on solution rather than cause). 4. Potential cause is misidentified as the root cause. 5. Countermeasures are applied, but not confirmed. 6. Knowledge is not shared with other lines, departments, factories or divisions. 7. Measurements and/or data are not available. Copyright Illinois Manufacturing Excellence Center. 9

10 ROOT CAUSE?

11 Containment comes FIRST Understand the problem. Turn off the water (Contain) Then what? Copyright Illinois Manufacturing Excellence Center. 11

12 Problem Solving as a Skill We don t know everything We don t know what we don t know. We can t do what we don t know. We need accurate data on which to decide what we know. We won t know until we measure. We don t measure what we don t value. We don t value what we don t measure. We can t not know what we do know. Copyright Illinois Manufacturing Excellence Center. 12

13 Problem Investigation/Understanding Stratification Does the problem exist on: All shifts OR Certain shifts All parts OR Certain parts All operators OR Certain operators etc. Copyright Illinois Manufacturing Excellence Center. 13

14 Problem Description What Changed? 1. Sudden Change 2. Change from Initial Start Up 3. The Should has Changed 4. One Time Occurrence All four types of problems have a deviation between what should be happening and what actually is happening. Process Standard Copyright Illinois Manufacturing Excellence Center. 14

15 MODULE TWO: GENERATE ALTERNATIVES 15

16 Process Mapping Steps Identify the process, its external inputs and customer outputs Identify the process suppliers and customers Identify all steps in the process graphically List key output variables at each step List key input variables and classify process inputs as controlled or uncontrolled Add process specifications for Input Variables Tough problems may require more detailed maps Copyright Illinois Manufacturing Excellence Center. 16

17 Evaluation Begin with the Standard what is supposed to be Flow Charting P? P P P Build a process flow to shoot an arrow Copyright Illinois Manufacturing Excellence Center. 17

18 MODULE THREE: SELECT AND EVALUATE (MEASURE) 18

19 Brainstorm 19

20 Fishbone Diagram for Test Failure Inspection Design Environment Documenation Tools Calibration Valve Yield Torque Safety Wire Stack Up Materials Inlet Protection Documentation Contamination Work Area Fluid FOD Control Rosan Fitting (C4A&B) Securing Method Solenoid Purge Process Test Stand Failed Functional Test Time Documentation Fluid Purity Torque Wrench Technique Technician Purge Process Training Templates Torque Test Equipment Product Flow Planning Tools Documentation Connectors Man Test Mfg. Process Copyright Illinois Manufacturing Excellence Center. 20

21 Selection Process N/3 Voting Concept A B C D Total Votes III II I 21

22 Problem Investigation/Understanding 5W2H Problem Description Who? What? Where? When? Why? How? How Many? Answer these questions to specify the information/data about the problem to make certain that all of the relevant information is recorded. Copyright Illinois Manufacturing Excellence Center. 22

23 23

24 Problem Investigation/Understanding 5W2H Problem Description Is the trend Staying the same? Getting worse? Getting better? Random? Copyright Illinois Manufacturing Excellence Center. 24

25 Root Cause Additional Tools Additional slides provide you a summary of some additional tools that are used in root cause analysis. These slides are located in the Nice to Know section of this presentation. 25

26 MODULE FOUR: IMPLEMENT SOLUTIONS 26

27 Check Sheets Data Collection Cause of Absenteeism Week 1 Week 2 Total per cause ///// /// 8 Too little responsibility Wrong person on job Poor training Poor budgeting Poor reward system Little feedback Low trust Low morale Internal competition Poor maintenance Difficult to operate Too little equipment Total # of problems 76 // // 4 /////// //////// 15 //// // 6 ///////////////// /////////////////// 36 ///// ////// 11 ///////////// ////////////// 27 ///////////// /////////////// 28 /// // 5 //// /// 7 /// // 5 / Copyright Illinois Manufacturing Excellence Center. 27

28 Thank You! March 2, 2016

29 Nice to Know Problem Identification and Tools DISOH March 2016

30 Closed Loop Problem-Solving Process Problem Identification & Definition Recognize the Team & Repeat the Process Problem Investigation & Understanding Share the Knowledge Root Cause Identification Control Plans/ Confirm Countermeasures Implement Countermeasures/ Solutions Design Countermeasures/ Solutions Copyright Illinois Manufacturing Excellence Center. 30

31 Pareto Chart # A b s e n c e s % 28 18% 27 17% 15 10% 11 8% 8 6% 7 5% 6 4% 5 3% 5 3% 4 2% % o f T o t a l Causes Rewards Morale Trust Training Feedback Responsibility Maintenance Budget Competition Operate Person Equipment Copyright Illinois Manufacturing Excellence Center. 31

32 Histogram f r e q u e n c y LSL USL f r e q u e n c y LSL USL Weight (g) Weight (g) This histogram shows what is likely to be a good situation. This histogram shows a process producing defects. The data shown is centered and falls between the specification limits. A very small % of the total production from this process could fall outside specifications. The data shown is centered, but some data falls outside specification limits. Variation due to common causes is too great. Copyright Illinois Manufacturing Excellence Center. 32

33 How to Create a Run Chart? 2. Draw horizontal and vertical axes 3. Plot data D o w n t i m e Mins March work days Copyright Illinois Manufacturing Excellence Center. 33

34 Root Cause Identification Problem Statement: Lathe bearings locked up. Corrective Action Person Responsible Target Completion Why? Lathe bearings ran dry. Why? Automatic oiler was not filled. Why? Access to automatic oiler is very difficult for the operator. Why? Operator has to lean over/under & kneel on machine covered with coolant & chips. Why? Oiler was buried when new controller was added during equipment upgrade. Why? Operators were not involved in machine upgrade decisions. Install interlock that shuts lathe down before oiler is empty Relocate oiler Cross functional teams of Maintenance, Operators & Engineering will do all machine upgrade projects. Name Maint Maint. Mfg, Mgr Engrg Mgr Copyright Illinois Manufacturing Excellence Center. 34 1/27 1/27 2/04

35 Design Solutions/Countermeasures Roadblocks you have probably never encountered! It is against our policy. The customer/supplier will never accept it. We don t have problems now, why change it? We ve always done it this way. It won t work. I already know It needs higher approval. It takes too long. Engineering/purchasing/quality doesn t like changes We can t tell the customer that we want a change now. It will cost too much. The boss won t like it. I don t want to do it that way. You are going to do it anyway. We ve tried that before. It takes education, training and patience to overcome roadblocks. Copyright Illinois Manufacturing Excellence Center. 35

36 Control Plans / Countermeasure Confirmation Prove that the solutions / countermeasures are effective Hold the gains Make the changes / improvements part of the way business is done Rely on standards, not memories Blue prints Work instructions Procedures Policies Copyright Illinois Manufacturing Excellence Center. 36

37 Creating Control Plans / Confirming Countermeasures 1. Decide on variable to control You get what you measure Office processes, manufacturing processes, managerial processes What is the cost of not meeting the standard? 2. Determine unit of measure Define it, no vague descriptions 3. Determine the standard without one there is no logical basis for decision making What are the requirements of the situation? 4. Determine measurement method Frequency & sample size Variable data is better than Go/No Go Copyright Illinois Manufacturing Excellence Center. 37

38 Verification: The infamous Audit The 8D format is designed to capture the issue, align the team, stop the bleeding, fix the issue, and finally verify the issue. So, what are you looking for: Countermeasures Training records vs. observation activity Data/Records Copyright Illinois Manufacturing Excellence Center. 38

39 Share the Knowledge Share the problem, root causes and solutions / countermeasures with associates, departments, functions, management, plants, divisions customers and suppliers Keep others from having to reinvent the wheel! Keeping tribal knowledge to yourself does not bring job security it sends jobs elsewhere Copyright Illinois Manufacturing Excellence Center. 39

40 Share the Knowledge Matrix Feed Information Forward and Backward to: Machining dept. in home plant Machining dept. in all divisions Maintenance dept. in home plant Method Message Responsible Date Dept. meeting Team Presentation Dept. meeting Team Presentation via Web Dept. meeting Team Presentation Findings of corrective action team Supervisor 02/04 Findings of corrective action team + applications elsewhere VP 02/06 Findings of corrective action team Mfg. Mgr. 02/04 Maintenance dept. in all divisions Engineering dept. in home plant Dept. meeting Team Presentation via Web Dept. meeting Team Presentation Findings of corrective action team + applications elsewhere VP 02/06 Findings of corrective action team Eng. Mgr. 02/04 Engineering dept. in all divisions Dept. meeting Team Presentation via Web Findings of corrective action team + applications elsewhere VP 02/06 Lathe suppliers Phone call/ Directions to suppliers Purchasing 02/10 Copyright Illinois Manufacturing Excellence Center. 40

41 Repeat the Process Post results to reinforce using the process. Make the process part of Management Review You get what you really measure! Management must control the process, but not overcontrol it Projects in process Projects completed New problems that will be assigned to teams Not every problem requires the process Prioritize projects Make resources available Review Plan, Do, Check, Act (Adjust) Copyright Illinois Manufacturing Excellence Center. 41

42 Rules for Problem Solving Success Containment means STOP -- Comes First Defect Root Cause is PHYSICAL A physical problem needs a physical corrective action Root Cause and Corrective Action have to match Any Corrective Action must have a switching action Verification is PHYSICAL proof Training is NOT a DEFECT corrective action Copyright Illinois Manufacturing Excellence Center. 42

43 Summary 1. Problem solving is best accomplished by a crossfunctional team 2. Fully describing the problem is the first, and most important, step in analyzing the causes of the problem 3. Focus on finding the true cause(s) before considering any solutions 4. Follow-up to verify the effectiveness of solutions/countermeasures to be sure you attacked the root cause 5. Share the knowledge with others 6. Reward the teams Copyright Illinois Manufacturing Excellence Center. 43

Root Cause Analysis for Learning Professionals

Root Cause Analysis for Learning Professionals Steve Hodgson, CPP, CPLP Director of Payroll Training American Payroll Association shodgson@americanpayroll.org Root Cause Analysis for Learning Professionals