number two with a bullet: going to the gemba prepared & presented by jack b. revelle, ph.d....

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Number Two with a Bullet:Going to the Gemba

Prepared & Presented by

Jack B. ReVelle, Ph.D.ReVelle Solutions, LLC

Santa Ana, CA

Let’s Look at Transportation Safetyin the Peoples’ Republic of China

About Dr. Jack B. ReVelle:

• A Consulting Statistician for ReVelle Solutions, LLC

• Author / Editor of: Quality Essentials: A

Reference Guide From A to Z Home Builder’s Guide to

Continuous Improvement

The QFD Handbook Manufacturing Handbook of

Best Practices Safety Training Methods Quantitative Methods for

Managerial Decisions

• B.S., Chemical Engineering• Ph.D., Industrial Engineering & Management• ASQ Fellow• IIE Fellow• IAE Fellow• 2012 ASQ Shainin Medalist•ASSE Senior Member 2

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Agenda - 1

• Background• Intro to Peoples’ Republic of China (PRC)• Translation Challenges• Arrangement of the Bullet Train• Quality Function Deployment (QFD) Project:

Step-by-Step• QFD Project Team • QFD Project Familiarization

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Agenda - 2

• Lack of Emphasis on Safety & Quality• The Accident• Going to the Gemba• Resulting Data• Data Collection & Analysis• Consolidating Multiple HOQs• QFD Project – Current Status• Corruption & Consulting

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Background

• QFD Symposiums – Beginning in 1989• QFD Symposiums – Attendees & exhibitors• QFD Capture – Software & representatives• Pertinent Websites

International TechneGroup Inc. (ITI) ReVelle Solutions, LLC

QFD InstituteTangshan Railway Vehicle Company, Ltd.

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Introduction to the Peoples Republic of China

• ITI & T-Solution - 2009• T- Solution - 2011• Tangshan Railway Vehicle Company – 2011• Tangshan Railway Vehicle Company – 2012

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ITI & T-Solution - 2009

• Visit to China sponsored by ITI • Provided 1-day Quality Function Deployment

(QFD) & QFD Capture orientation presentations in Shanghai & Beijing• Attended by over 100 persons from

manufacturing & academia• Introduced to T-Solution (TS) personnel

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T- Solution - 2011

• Agreed to 5-year exclusive contract with TS

• Introduced to Tangshan Railway Vehicle Company, Ltd. (TC)

• Established Statement of Work (SOW) in advance of initial visit to PRC

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Tangshan Railway Vehicle Co. – 2011

• Introduced to TC Management & QFD Project Team

• Introduced to Ministry of Railways (MoR) Delivery Requirements

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• Mission Statement

To provide world class railway transport equipment to our customers throughout the world

• Vision Statement

Become recognized as a world class enterprise in the field of railway transport equipment

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• November: MoR modified its delivery requirements to include a few additional specifications relative to safety& quality

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• 2012 Consultant’s Schedule: February: TC QFD project manager

planned 2012 consultant’s schedule March: TS VP-Administration cancelled all

future visits by consultant via email No further communication with TS Continued informal communication with TC

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Translation Challenges

• Example: “decomposition” vs. “deployment”• Customer verbatims

MoR delivery requirements Contract with TS Statement of Work (SOW)

• Rewording Customer needs & technical requirements Target values & functions

14总定员： 623+1 人，其中一等定员 56 人，二等定员567+1 人 Overall person number:623+1,First class number:56,Second class number:567+1

编组图和平面图

动车组总体布局 Overall Arrangement of Bullet Train

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MC01 车 Train MC01

一等定员： 56 人 First Class NO.56

Bullet Train Cars - 1

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MC08 车 Train MC08

二等定员： 70 人Second Class NO. 70


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TP02 车 Train TP02



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M03 车 Train M03



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T04 车 Train T04

定员： 88 人Rated passenger capacity:88


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TH05 车 Train TH05

二等定员： 57+1 人Second Class Rated passenger capacity:57+1


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QFD Project – Step-by-Step

• Initial introductions to TC QFD project team• QFD project team re-training• QFD project familiarization• Consultant emphasized lack of safety &

quality specifications • The accident occurred on July 23, 2011

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Initial Introductions to QFD Project Team

• Met with TC QFD project team leader & assistant leader as well as their bosses (the vice president of engineering & the chief engineer)

• Met with the team members, e.g., electrical, electronic, environmental & mechanical engineers (Note: No safety or quality engineers)

• Met with TS team leader & original translator• All initial & subsequent disconnects were due

to translation difficulties

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QFD Project Team Re-training

• Repeated QFD training previously provided in 2009 in Shanghai & Beijing

• Further translation difficulties• Requested TS provide professional

translator; denied as too costly• Many questions & delays arose due to

translation problems in conference room as well as by email between training sessions

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QFD Project Familiarization

• TC QFD project team shared MoR specs with Consultant, but specs noted that all customers requirements were of equal importance

• Consultant introduced concept of “Going to the Gemba” to TC QFD project team

• Consultant worked with TC QFD project team to create their plan for ” Going to the Gemba”

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What is the “Gemba?”- 1• Gemba ( 現場 ) is a Japanese term meaning

"the real place,“ e.g.: Japanese detectives call the crime scene the gembaJapanese TV reporters sometimes refer to

themselves as reporting from gemba In business, gemba refers to the place where value

is created

• The idea of gemba is that the problems are visible & that the best improvement ideas will result from “Going to the Gemba”

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What is the “Gemba?”- 2

• In manufacturing, safety & quality, the gemba is the factory floor. The idea is that if a problem occurs, engineers & managers must go there to understand the full impact of the problem, gathering data from all sources

• It can be any "site" such as a construction site, sales floor office or wherever the service provider interacts directly with the customer

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What is the “Gemba?”- 3

• Unlike focus groups & surveys, gemba visits are not scripted or bound by what one wants to ask

• The idea is that to be really customer-driven, you must go to the customer's gemba to fully understand his/her problems & opportunities, using all your senses to gather & process data

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Lack of Emphasis on Safety & Quality

• Review of MoR specifications revealed significant absence of safety & quality specs

• Consultant discussed missing specs with QFD project team

• QFD project team politely dismissed consultant’s concern for two reasons:MoR knows best No record of safety & quality problems to date

• That was on Friday; the accident occurred on Saturday

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The “Accident” - 1

Saturday, 23 July 2011

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The collision was the first fatal crash involving high-speed rail (HSR) in China

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When a moving bullet train hits a stationary train

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Chaos following the impact of two bullet trains

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Wenzhou, within Zhejiang Province, China

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• The accident, the first of its kind, had a profound impact on the development of high-speed rail in China

• Public confidence in high-speed rail eroded, leading to lower ridership & reduced profits

• Construction of high-speed rail lines in China was halted while the accident was under investigation

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• Speeds on other major high-speed rail lines in China were reduced. China's reputation in high technology was scrutinized internationally

• Railway signaling systems are designed to prevent any train from entering a stretch of track occupied by another train

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The “Accident” - 8• As of 31 July 2011, Chinese authorities had

failed to provide any logical explanation of why the safeguards built into the CTCS-2 signal technology had failed to work in the Wenzhou collision

• Various government announcements indicated: Defects in equipment (lightning strikes had

disabled devices) Defects in operating procedures (staff operated

signals in "manual mode")

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• But in the Wenzhou collision, Train D301 ran at high speed onto track occupied by Train D3115. This indicated a signal failure

• The 28 July 2011 announcement by the Beijing National Railway Research & Design Institute of Signals & Communication indicated that the signal equipment had a design flaw

• The Institute further said it would "shoulder responsibility" for the accident. This confirmed that the accident was a result of signal failure

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Going to the Gemba - 1

Customer Groups• Bullet train passengers• Bullet train maintenance personnel• Shopkeepers & residents located adjacent to

High Speed Rail (HSR) train tracks• MoR personnel

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• The TC QFD Project Team needed to obtain answers to many questions

• They requested the Consultant "give us some suggestions or samples on how to generate the survey format"

• The following questions & instructions were provided for use by the TC QFD Project Team while preparing to "Go to the Gemba"

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• Questions: Who are your direct & indirect customers? What are the sub-categories of each of the

primary categories? Where are these customers located relative to

the bullet train / high speed rail tracks? When are these customers available to meet with

TC personnel? How many customers are there in each

category?

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Which sub-categories can be observed directly in the Gemba?

Which sub-categories cannot be observed directly in the Gemba?

What activities or topics need to be seen & / or discussed when observing customers functioning in the Gemba?

What information must be learned about the customers who cannot be observed functioning in the Gemba?

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Going to the Gemba - 5 What media will be used to record customer

activities & responses? How will the media be stored & retrieved for

use by the TC QFD Project Team? Need to develop a written checklist of what to

observe & discuss for each sub-category of customers who can be directly observed & questioned

Need to develop a written checklist of questions to be asked of each sub-category of customers who cannot be directly observed & questioned

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Going to the Gemba - 6 Develop a process to visually record, i.e., video

tape these customers as they function in the Gemba These video records will be retained, edited &

studied to ascertain how these customers interact with the bullet train / high speed rail

The video records are expected to reveal important details of how customers interact with the bullet train / high speed rail in ways which direct / oral & indirect / written questioning will not

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Gemba Checklist (After Visit) - 1

• Record & file data gained from interviews File all photographs, questionnaires, trip

reports & any additional information in electronic format in the network project folder (to be set up on the engineering drive)

• Enter data in the Excel spreadsheet / database to facilitate quantitative & qualitative analysis

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Gemba Checklist (After Visit) - 2

• Whenever possible: Preferably mail a formal “Thank You”

letter to customers, or Alternatively, phone customer to thank

them for their time & valuable input

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Multiple Gembas

• First generation bullet trains• Bullet train stations• Shops & homes adjacent to train tracks• MoR offices

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Gemba Activity

• Determine questions• Determine who & what to observe• Determine what media to use

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Gemba Planning

• How many should go?• Who should go?• Which locations?• When to go?• What equipment to bring?

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Data Collection

• All four categories of customers were interviewed & / or observed by two-person TC QFD project team representatives

• Observations of activity were recorded with still photo & video cameras as well as audio tape recorders

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Resulting Data

• Accumulate data in central repository• Analyze data to establish “WHATs” for the

House of Quality (HOQ: customer wants & needs). This includes: Quantitative data Qualitative data

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Data Analysis

• Qualitative Data: Quantify with Thematic Content Analysis (TCA)

www.atlasti.com/demo.html (free download) Organize with Affinity Analysis Prioritize with Pareto Analysis

• Quantitative Data: Organize with Affinity Analysis Prioritize with Pareto Analysis

http://www.atlasti.com/demo.html

Reduces large collection of qualitative ideas into much smaller quantity of themes

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Affinity Analysis

Affinity Diagram

• Tool used to gather large amounts of qualitative data (ideas, opinions, issues) & organize it into groupings based on natural relationships between items.

• Largely a creative rather than a logical process

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Affinity Diagram

• Purpose: To identify meaningful categories so as to better organize ideas

• Uses brainstorming to organize input, i.e., decisions based on intuition / creative-type thinking

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Creatively

Categorize

Ideas

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• Uses Post-Its TM to rearrange apparently unrelated qualitative / language data into meaningful categories

• Offers high utility since various kinds of information are input from different sources:

Customer surveys

Customer complaints

Warranty / reliability problems

Affinity Diagram

Used to graphically plot frequency of occurrence of discrete (attribute) data as a vertical bar chart with greatest value on left side & least value on right side

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Pareto Analysis

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Pareto Analysis: Purpose

• Trying to solve every problem at the same time is as frustrating as it is futile

• Most cost effective & logical approach to problem prioritization & selection is to focus on the “worst-first,” i.e., identify the “critical / vital few” & temporarily set aside any work on the “trivial many”

• Provides step-by-step process necessary to efficiently identify leading problems, defects or errors

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Pareto Analysis: Example

0

50

100

150

200

250270

G E F B A D C O

100%

90

80

70

60

50

40

30

20

10

0

Def

ect

Fre

qu

ency

Cu

mu

lative Freq

uen

cy Percen

tage

Types of Defects

Cumulative % Line

80% 20% The 80-20 rule

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How to Consolidate Multiple HOQs into a Single Master HOQ - 1

• Begin construction of Master HOQ with four HOQs from Neighborhood of Quality (NOQ): MoR First Generation Bullet Train Passengers First Generation Bullet Train

Maintenance Personnel Shopkeepers & residents located adjacent

to HSR train tracks

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How to Consolidate Multiple HOQs into a Single Master HOQ – 2

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• For each HOQ: Identify & prioritize each WHAT Create & assess technical risk for each

HOW Develop Relationship Matrix Develop Conflict Matrix Conduct overall analysis Deploy critical WHATs & HOWs to

Master HOQ

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• Begin work on Master HOQ Organize deployed WHATs (using their

importance values) & HOWs (using their technical risk values)

Develop Relationship Matrix Develop Conflict Matrix

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Conduct overall analysis Shopkeepers & Residents Located

Adjacent to Railway Tracks HOQ MoR HOQ Passengers HOQ Maintenance Personnel HOQ

Develop Master HOQ

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• Complete process by obtaining agreement from TC design engineers about prioritization (order of importance) of Master HOQ HOWs

• In PRC, this is extremely difficult since the MoR considers each to be equally important

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QFD Project – Current Status• Without current official communications

between TS & / or TC, there is no way to know how far the project has progressed since February 2012, if at all

• It was unknown in 2012 whether problem source was: PRC Department of Transportation (DOT) PRC Ministry of Railways (MoR) Tangshan Railway Vehicle Company (TC) T-Solution, Ltd. (TS)

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Corruption & Consulting-1

• Situation clarified in Oct 2014 in Wall Street Journal article2010 – Chief Engineer at China’s Ministry of

Railways (MoR) sentenced to death for corruption & abuse of power by China’s Central Committee (CCC)

2011 – Deputy Chief Engineer removed from post & placed under investigation by CCC

2014 – Deputy Chief Engineer sentenced to death for taking $8 million in bribes

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Corruption & Consulting-2

• Resultant events: Funding by PRC’s MoR to TC for design &

development of second generation bullet train was cut off

Payment by TC to TS was stoppedConsulting funding was no longer availableConsulting engagements were terminated

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Conclusion

Comments

• What would you have done differently?

Questions

• What are your reactions?

number two with a bullet: going to the gemba prepared & presented by jack b. revelle, ph.d....

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