5 why training presentation3
TRANSCRIPT
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Global Supply Management
5 Why Analysis
5 Why AnalysisJanuary 2, 2006
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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?
Power of Asking Questions
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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
Power of Asking Questions
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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
5 Why Analysis: ORing
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5-Why Analysis: O RingExample Path B
5 Why Analysis: ORing
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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