8D Problem Solving (Oshkosh).pdf
- 2. Learning Outline • Introduction to 8D • D1 – Problem Solving Team • D2 – Problem Description • D3 – Containment and Short-Term Corrective Actions • D4 – Root Cause Analysis (Definitions, Fishbone, 5 Why, etc) • D5 – Long Term Corrective Actions • D6 – Implementation & Verification of Long-Term Corrective Actions • D7 – Preventative Actions • D8 – Congratulate the Team & Conclusion 2
- 3. Introduction There is no method of improvement more effective than good problem solving A problem is an opportunity for improvement that: • You have proof is worth addressing • You can quantify the benefit of addressing • You can convince others is worth addressing Introduction 3 “Failure is simply the opportunity to begin again, this time more intelligently.” – Henry Ford
- 4. Introduction What to expect from your 8Ds: 1. Elimination of the problem 2. Permanent prevention of the problem 3. Prevention of similar problems 4. Overall improvement Introduction 4 problem improved performance Performance Time 8Ds are not about returning to the status quo before the problem. They are about improving on the status quo.
- 5. Common Misconceptions 8Ds are part of the punishment for failures. No! 8Ds and Corrective Actions are great opportunities to improve. 8Ds are Quality’s responsibility. No! Problem solving only works when the experts are involved. 8Ds are only for quality issues. No! Problem solving processes can be applied to any type of problem (cost, quality, delivery). Problem solving means 8D, 100% of the time. No! The 8D is a strong, formal corrective action process, not the only one. 8Ds are only able to prevent recurrence of the same failures. No! 8Ds should also address system weaknesses in order to prevent related failures. Introduction 5
- 6. 8D Form Two versions of the Oshkosh 8D are available (8D process is the same with both): Introduction 6 Excel spreadsheet on the OSN https://osn.oshkoshcorp.com/gsq-en.htm Reliance SCAR (issued by Oshkosh Supplier Quality)
- 7. 8D Pre-Work (D0) Before kicking off an 8D, you need to understand: Who is impacted? • Customer? Production line? End user? Etc. How significant is the impact? Is this an emergency? Does it need to be escalated? What is the scope of the problem (best guess)? Has this happened before? Introduction 7
- 8. 8D Pre-Work (D0) Pareto analysis is one very effective method to determine what problem deserves an 8D 0 10 20 30 40 50 60 70 80 90 Parts bent - short Parts bent backwards Cam locks installed incorrectly Missing weld Plate not installed Quantity of Rejects Pareto Chart (July 2019) Introduction 8
- 9. Problem Solving Process Introduction 9 Identify the team Define the problem Contain the problem Make short term correction Understand the process Analyze causes Identify root cause(s) Develop long term corrective actions Implement long term corrective actions Verify effectiveness Develop preventative actions Congratulate the team Investigate causes D1 Problem Solving Team D2 Problem Description D3 Containment and Short Term Corrective Actions D4 Root Cause Analysis D8 Congratulate the Team D5 Long Term Corrective Actions D7 Preventative Actions D6 Implementation and Verification of Long Term Corrective Actions D4 Root Cause Analysis
- 10. D1 – Problem Solving Team 10 D1 - Problem Solving Team
- 11. Identify the Team Teams are critical to problem solving! • No individual has the necessary knowledge or objectivity • Overcoming initial biases is difficult and typically requires a team • Getting buy-in is difficult as an individual Rule of thumb: Look for a team of 3 to 5 members. D1 - Problem Solving Team 11 8D Rule 1: If there’s no team, it’s not an 8D.
- 12. Identify the Team Team Champion • Person of authority in the organization • Does not actively participate in team meetings • Is responsible for the culture of problem solving Contributions: • Sets expectations • Removes roadblocks (i.e., politics and resources) • Guarantees positive recognition for the team D1 - Problem Solving Team 12 The team champion is responsible for the success of the whole 8D program.
- 13. Why do you think they fail? • Adoption of change • Lack of sponsor engagement • Too many priorities going on at same time • History of past failed changes • They can’t understand it • They can’t shape or influence • It attacks things they hold dear • It lacks direction • And many more reasons… 13 “70% of Projects or Initiatives Fail” McKinsey & Company 13
- 14. D1 – Summary Key Questions – Problem Solving Team: Reference Guide Questions D1 - Problem Solving Team 14 Does the team champion have the necessary influence? Will the team champion be an active member of the team? Does the team include the process experts? Does the team have a knowledgeable 8D facilitator? Does the team include the stakeholders? Is the team cross-functional?
- 15. Objective: Each person has 10 min to build an Origami Jumping Frog. Frog must jump at least 12”. Instructions are provided at origami.me/jumping-frog Materials are not provided. You’ll need to provide your own. The time limit for the build campaign is 10 minutes Frog must jump at least 12” Class Exercise – Origami Jumping Frog 15 D1 - Problem Solving Team 15
- 16. Class Exercise – Identify the Team Objective: Based on the initial problem statement from the customer (instructor), identify the best problem solving team Roles: 1. Team Champion 2. Team Leader 3. Team Members Note: Select from the roles to the right (or similar roles), not from your team members. • Production Manager • Operator 1 • Operator 2 • Operator 3 • Assembler • QA • Process Engineer – Operations • Process Engineer – Assembly • Quality Engineer • Quality Manager • Planner • Director of Quality • Purchasing Manager • Tool Room Manager • Maintenance Lead • Director of Operations • Sales Engineer • Company President D1 - Problem Solving Team 16 Team Exercise
- 17. D2 – Problem Description 17 D2 - Problem Description
- 18. Define the Problem D2 - Problem Description 18 “We fail more often because we solve the wrong problem than because we get the wrong solution to the right problem.” – Russell L. Ackoff “It's so much easier to suggest solutions when you don't know too much about the problem.” ― Malcolm Forbes “A problem well put is half solved.” ― John Dewey “If I had an hour to solve a problem, I'd spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.” ― Albert Einstein “If you define the problem correctly, you almost have the solution.” ― Steve Jobs “You don’t fix the problem until you define it.” — John W. Snow The definition of the problem, rather than its solution, will be the scarce resource in the future. ― Esther Dyson The problem definition step is the most critical of the whole problem solving process!
- 19. Define the Problem Specific problem statements are required for the root cause process. Problem descriptions should provide the answer to: What? Where? When? How Many? What? What is the part/product with the problem? Typically the part number, but could be the output of any process (on-time delivery rating, part cost, etc.) What is the specific problem? What is the requirement being violated? What is the actual value? What was the specific performance or test failure? Every problem statement should include both: • “Should Be” – What is the requirement? • “IS” – What is the actual condition? D2 - Problem Description 19
- 20. Define the Problem D2 - Problem Description 20 Where? Where was the problem detected and who detected it? At Oshkosh receiving inspection? At supplier final inspection? By the shift supervisor? At the quality gate? Etc. Where was the problem not detected? The problem is only present after paint? Complaints are only received from customers in cold climates? Etc. When? When did the problem occur? What is the scope of the problem? Shipment dates, lot numbers, batch numbers, PO numbers, date ranges, Etc. When is the problem not present? Is the problem only identified during humid months? Does the problem impact all lots or only some? Is the problem on-going or is it new? Etc. How many? How many parts/products/etc. are affected? How many parts? What percentage of parts?
- 21. Define the Problem Example A: 42.75" +/- 0.10 dimension out of specification on 271828 (Weldment Brackets) for 3 repeated shipments (reject dates 5/12, 5/13, 5/27 from supplier Quick Machine Co). Quantity of rejects: 27 out of 27 pieces. Rejected at Harrison Street assembly line on 5/30 because they did not fit. Two shipments have been received since 5/27 and do not have problem. Sample of 10 parts measures at 43.10“ to 43.15”. What? Where? 271828 Weldment Bracket Should Be: 42.75" Is: 43.10“-43.15” (Sample) Harrison Street assembly line When? How many? 3 repeated shipments from Quick Machine Co. 5/12, 5/13, 5/27 27 of 27 Class Discussion D2 - Problem Description 21
- 22. Define the Problem Vague problem definitions make the root cause process impossible! • Part is bad • Paint looks bad • Part doesn’t fit • Missing weld • Doesn’t work (Problem description submitted by JLG Aftermarket customer) D2 - Problem Description 22 8D Rule 2: Incomplete problem descriptions lead to bad solutions.
- 23. What is missing from these problem descriptions? – Supplier XYZ for Oshkosh Defense has an on-time delivery rating of 54.3% percent (multiple part numbers supplied). – From when to when? Is this a long term problem or only for the last month? – 38 of 38 pins in stock at IMT (all of the pins that were received in May) are long by .03 to .08. – What part number(s)? – Paint is chipped and scuffed on 274A274 brackets from the first production lot, found in supplier’s warehouse. – How many brackets are chipped and scuffed? Is this 2 parts or 1000 parts? – All 37 of the 274A274 brackets built in July have oil/grease contamination on all surfaces. – Where in the process are the parts? Are they in stock? Have they not been painted yet? Define the Problem Class Discussion Webex - Chat D2 - Problem Description 23
- 24. Good problem descriptions require good data. Get hands on the parts or vehicles with the problems Take photos Collect any available data – numerical inspection results, test results, performance (miles to failure or time to failure, etc.), historical results Document what you find Always update the problem description based on what is found during containment activities, as well as later in the 8D effort! Define the Problem Don’t forget to make sure that the “problem” you are solving actually is a problem. D2 - Problem Description 24
- 25. What the problem IS What else it might be but IS NOT WHO Who reported the problem? Who did not report the problem? Harrison Street assembly line Harrison Street receiving inspection Who is affected by the problem? Who is not affected by the problem that could have been? Harrison assembly line Other Oshkosh plants WHAT What is the product ID or reference number? What ID's or reference # are not affected that could have been? (similar parts or processes) P/N 271828 Weldment Brackets Other weldments from Quick Machine Co. What is (describe) the defect? What is not the defect? Do not fit 42.75” dimension measures 43.10”-43.15” Parts do not appear to be damaged WHERE Where does the problem occur? Where is it not occurring but could? Harrison Street assembly line N/A Where was the problem first observed? Where else might it occur? Harrison Street assembly line N/A WHEN When was the problem first reported? When was the problem not reported? First reported 5/30, shipment date 5/12 from supplier Shipments prior to 5/12 or since 5/27 When was the problem last reported? When might it reappear? Shipment date 5/27 Any future shipments WHY Why is this a problem? Why is this not a problem? Causes line delays and part scrap Problem has not been reported on 2 shipments since 5/27 Why should this be fixed now? Why is the problem urgent? Continued line delays and part scrap Risk of line stoppage if problem occurs again HOW How often is the problem observed? How often is it not observed? 27 out of 27 parts shipped between 5/12 and 5/27 Any parts shipped prior to 5/12 or since 5/27 How is the problem measured? How accurate is the measurement? Dimensional inspection of 42.75” using FARO arm FARO arm accuracy is approximately +/- .003" OTHER Can the problem be isolated? Replicated? Is there a trend? Has the problem occurred previously? Problem can be isolated to shipments dated 5/12 to 5/27 but cannot yet be replicated. This problem has not occurred previously. Define the Problem (IS / IS NOT example A) Instructions: – Do not make assumptions. – Define: – What the problem IS – What the problem could be but IS NOT – Investigate as needed to provide accurate/proven answers. – Highlight potentially key items. D2 - Problem Description 25
- 26. Define the Problem IS / IS NOT Problem Descriptions focus on the differences between what you would expect the problem to be and what the problem actually is. Benefits: – Kick-starts the investigation. – Provides direction for the investigation. – Ensures the problem is fully described and understood. What I expect the problem to be What the problem actually is D2 - Problem Description 26
- 27. D2 – Summary Key Questions – Problem Description: Reference Guide Questions D2 - Problem Description 27 What is the part number? What is the requirement that was violated? What is the nonconformance? Is the nonconformance description specific enough? Where was the nonconformance detected? What lot numbers/batch numbers/shipments are affected? Is the problem a single occurrence or intermittent? How many parts are suspect? What percentage of the parts does that represent? Based on the updated problem description, does the team composition need to change?
- 28. Class Exercise – Problem Description Objective: Create a problem description for an 8D • Investigate and create a full problem description • Do not make anything up, limit the problem description to what you can prove D2 - Problem Description 28 Team Exercise Customer Problem Description: “Defective Frog”
- 29. D3 – Containment and Short Term Corrective Actions 29 D3 - Containment and Short Term Corrective Actions
- 30. Contain the Problem Oshkosh manufactures safety critical vehicles. Effective containment of problems is critical to protective the customer. D3 - Containment and Short Term Corrective Actions 30
- 31. Contain the Problem Containment means identifying suspect parts/materials and preventing use until the nonconformance has been resolved or a short term corrective action has been put in place. Containment needs to occur along the whole pipeline of parts/materials/etc. Containment is focused on Product. D3 - Containment and Short Term Corrective Actions 31
- 32. Short Term Corrective Actions Short Term Corrective Actions We can’t always stop and wait for a full investigation, so we need a way to apply a band-aid until the problem is solved. • Short Term Corrective Actions are temporary band-aids that you use to give you time to investigate properly • Short Term Corrective Actions are focused on the Process. D3 - Containment and Short Term Corrective Actions 32
- 33. Short Term Corrective Actions Short term corrective actions are a quick and dirty fix (often actions that would not be acceptable as a permanent corrective action) Effective short term corrective actions are: 1. Contained At The Source And At Points Downstream In The Process 2. Implemented Immediately After Containment Is Complete 3. Proven Effective By Evidence Types of short term corrective actions: • Correct the immediate cause if it is known • Replace a worn tool • Re-train the operator • Repair the fixture • Rework parts Add an inspection or double check: • 100% inspection after operation • Review every PO before it is issued • CL1 or CL2 to protect the customer D3 - Containment and Short Term Corrective Actions 33
- 34. 8D Rule 3: Never stop after the short term fix, even if the symptoms go away. Short Term Corrective Actions It is tempting to stop the 8D after implementing a short term solution, because the symptoms are gone If you stop here, the problem will come back. D3 - Containment and Short Term Corrective Actions 34 Short Term Corrective Action
- 35. D3 – Summary Key Questions – Containment and Short Term Corrective Actions: Reference Guide Questions D3 - Containment and Short Term Corrective Actions 35 Containment When did the containment activities occur? Where were containment activities performed? Was any part of the pipeline missed? How many suspect/nonconforming parts were found at each area? What containment activities were performed? Does the problem description need to be changed based on findings in containment? Short Term Corrective Action(s) Is the short term corrective action being implemented immediately? Is the short term corrective action formally documented? Is there objective evidence that the short term corrective action effectively insulated the customer from the nonconformance?
- 36. D4 – Root Cause Analysis 36 D4 - Root Cause Analysis
- 37. Understand the Process Before beginning the root cause analysis process, you need to understand the current state of the process or processes where the problem occurred is necessary: Go see! • Watch the processes in action. Ask questions. Review process set-up, work instructions, documentation, tools, training requirements, etc. Utilize process experts • The people performing the processes (operators, etc.) are the experts, so make sure to use them Utilize process documents Map the process (using a tool like a flowchart) D4 - Root Cause Analysis 37 Do not try to solve problems on a process you don’t understand.
- 38. Understand the Process Flowcharts Flowcharts help you understand the current state of the processes where the problem might have occurred. Strict flow chart rules and conventions aren’t critical. Use a whiteboard or post-it notes to quickly map the process to make sure that it’s understood: Make sure inputs and outputs are understood (suppliers and customers). Identify all activities. Note the controls for each activity (e.g., work instructions, tribal knowledge, etc.). Make any other notes that are helpful for understanding the process. D4 - Root Cause Analysis 38 You are trying to understand the process, not determine a final root cause. Note everything that could potentially be relevant.
- 39. Understand the Process Flowchart example A A C B D4 - Root Cause Analysis 39
- 40. Comfort Control Competence Connection Because we experience a loss! Identifying what we lose and in what category, and then replacing that loss with a gain, or a find, or something new that helps to fill the void and move us closer to integration and resilience. Why do we struggle so much with change?
- 41. D4 – Root Cause Analysis (Definitions) 41 D4 - Root Cause Analysis
- 42. Definitions Problem Description Process/Design Root Cause Detection Failure Cause Systemic Root Cause (Like Parts, Similar Processes) Preventative Actions D4 - Root Cause Analysis 42
- 43. Definitions Process/Design Root Cause(s) – the direct process or design related cause(s) which led to the undesirable condition. Eliminating this cause(s) will prevent recurrences of the same failure. Example: Weld fixture design allows multiple setups of components on weld fixture. Only one of the setups can produce a conforming part. Systemic Root Cause(s) – the underlying systemic cause(s) which created or allowed the direct root cause(s) to occur. Eliminating this cause(s) will prevent related failures. Example: No defined process is in place to control the design of weld fixtures. Example: New product design process does not include a review of historical DFMEAs for probable failure modes. D4 - Root Cause Analysis 43 The Process/Design Root Cause is what is typically meant by “root cause”. Addressing it is the minimum requirement for an 8D.
- 44. Definitions Detection Failure Cause(s) – The reason why the earliest opportunity to catch the undesirable condition did not prevent the defect from progressing to the next step in the process. It should answer the question: “Why wasn’t it caught?” Example: Work instructions do not clearly identify the requirement for 100% inspection of the first piece for each production run. Contributing Cause – Generic term for important causes other than the root causes. In other words, watch for the phrase that: “It didn’t help that…” Example: Work instructions for welding process do not clearly define the required setup to produce conforming parts. D4 - Root Cause Analysis 44 8D Rule 4: Inspection cannot be the root cause. Inspection catches defects. It doesn’t prevent them.
- 45. Analyze – Investigate (Root Cause) The root cause investigation steps repeat themselves. It usually takes several repetitions of investigating and analyzing to start identifying root causes. The key is to use a method (5 Whys, etc.) and to write it down! If the analysis is not documented, then it will be impossible to review. Note: The Oshkosh supplier 8D procedure requires documentation of the root cause analysis. Investigate: Interview Gather data Test theories Analyze: 5 Whys Fishbone D4 - Root Cause Analysis 45 Don’t get frustrated. It takes effort and time to find the root cause. 8D Rule 5: Document your root cause analysis, every time.
- 46. Analyze – Investigate (Root Cause) Human Error – Operator Error Avoid the “Blame Game”. Blaming and training (or disciplining) people is quick and easy, but it does not lead to long-term improvement. Make sure to ask WHY they made the mistake. Not just if they made the mistake. Keep digging! The goal is to find the process/design or systemic root cause that led to the human error. 5 Whys D4 - Root Cause Analysis 46 8D Rule 6: Human error is not an acceptable root cause.
- 47. Section 47
- 48. Analyze – Investigate (Root Cause) Human Error – Operator Error • Three key steps for finding the root cause of human error: – Interview people in a non-confrontational way to find out why they made the mistake. Make it clear that you want to help them succeed, not punish them for failing. – Go see! Watch the process that failed as multiple people perform it (person who made the mistake and personnel who didn’t). – Ask a lot of questions! You can use the questions on the HERCA worksheet as a guide. 1 Is the process complex? Yes No 2 Is the process highly repetitive? Yes No 3 Is the operator being rushed? Yes No 4 Are there any ergonomic difficulties? Yes No 5 Are there any visual obstructions that make parts of the job hard to see? Yes No 6 Does the operator need to do anything out of the ordinary to complete the process? Yes No 7 Are the tools adequate to complete the process sucessfully? Yes No 8 Does the operator have all the tools needed to complete the job? Yes No 9 Is the tooling error proofed? Yes No 10 Is the tooling in good shape? Yes No 11 Is the equipment adequate to complete the process successfully? Yes No 12 Is the equipment in good shape? Yes No 13 Can the equipment settings be changed more than the process allows? Yes No 14 Are the process steps documented in a clear and easy to understand way? Yes No 15 Are the work instructions (or other process documentation) missing any steps/operations? Yes No 16 Are the work instructions (or other process documentation) up to date? Yes No 17 Do the work instructions (or other process documentation) indicate when to use each tool? Yes No 18 Do the work instructions (or other process documentation) indicate when to use each piece of tooling? Yes No 19 Do the work instructions (or other process documentation) indicate when to use each piece of equipment? Yes No 20 Is the workstation well laid out? (parts and tools easy to reach, adequate space to perform job, etc.) Yes No 21 Is the workstation organized? (everything has a designated place) Yes No 22 Is lighting in the workstation adequate? Yes No 23 Are there similar but different parts or tools in the workstation? Yes No 24 Is it possible to tell the status of each part in the workstation? Yes No 25 Are there any significant sources of distraction near the workstation? Yes No 26 Has the operator been trained on the job? Yes No 27 Has the operator been trained on the work instructions (or other process documentation) for the job? Yes No 28 Was the training adequate? Yes No 29 Does the job require any special qualifications/training that the operator does not have? Yes No 30 Is the operator qualified to perform the job? Yes No 31 Does the operator know how to verify their work? Yes No 32 Does the operator know what to do if something is out of the ordinary? Yes No 33 Does the operator perform the job regularly? Yes No Human Error Root Cause Analysis (HERCA) Worksheet D5 Problem Description The Corrective Action(s) need to make physical changes to the process The Corrective Action(s) need to make permanent changes to the tools, tooling, or equipment The Corrective Action(s) need to make permanent changes to the competency and training systems Next Steps Investigation Questions Investigate the competency and training system to identify the Process/Design Root Cause(s) Investigate the process further in order to identify the Process/Design Root Cause(s) Investigate the tools, tooling and/or equipment to identify the Process/Design Root Cause(s) Investigate the process documentation further to identify the Process/Design Root Cause(s) The Corrective Action(s) need to make permanent changes to the process documentation Investigate the workstation and/or work environment to identify the Process/Design Root Cause(s) The Corrective Action(s) need to make permanent changes to the workstation or work environment documentation Human Error Root Cause Analysis (HERCA) Worksheet D4 - Root Cause Analysis 48
- 49. D4 – Root Cause Analysis (Fishbone) 49 D4 - Root Cause Analysis
- 50. Fishbone Diagrams Fishbone Diagram 1. Break the diagram into 6 primary categories: Measurement, Materials, Environment, Manpower, Method, and Machine 2. For each category, brainstorm possible/likely causes 3. Analyze the causes, discuss whether causes can or can not be controlled Things to know: -This is a form of structured brainstorming. - It should be paired with another method to analyze possible causes that have been identified. -Do not argue about which category a specific cause belongs in. When to use: - Problem where you don't know where to start). D4 - Root Cause Analysis 50 Can be performed by drawing the diagram on a whiteboard and writing causes onto post-it notes.
- 51. Fishbone Diagrams Fixture warped Fixture warped Fixture assembled wrong Fixture holds wrong dim. Weld equip. not calibrated No fixture control Wrong fixture used Not enough clamps No WPS No Work Instructions Wrong WPS used No visual work instructions Weld performed out of sequence Component s assembled wrong Moved during weld Part tagged wrong Wrong sub- component s used Sub- component made from wrong material Wrong weld filler No control of which operator does which job Welder not AWS certified Operator not trained to this inspection Operator not trained to this weld Operator new to this area Gage out of cal. Different inspection method used Untrained inspector First piece not checked Measured at wrong location No weld table Cluttered weld booth Too much schedule pressure Damaged on floor 42.75” +/- .10 Dim. Is 43.10”-43.15” (27 of 27) D4 - Root Cause Analysis 51 Fishbone Diagram – Example A
- 52. Fishbone Diagrams Fishbone Diagram D4 - Root Cause Analysis 52 Fishbone diagrams are only a brainstorming method! Don’t stop once the fishbone diagram is complete. Each cause needs to be analyzed and investigated: • Identify the most likely causes and investigate/prove • Cross off causes that have been eliminated from consideration • Add possible causes that may come up Update the fishbone as you investigate You need to prove or disprove the possible causes that you identify.
- 53. Class Exercise – Fishbone Diagram Objective: Each group should develop a fishbone diagram of likely causes for the problem. Write the possible causes on post-it notes and place on the fishbone diagram Categories: D4 - Root Cause Analysis 53 Team Exercise Measurement Materials Method Environment Manpower Machine
- 54. D4 – Root Cause Analysis (5 Whys) 54 D4 - Root Cause Analysis
- 55. 5 Whys 5 Whys Start with the problem description and just keep asking “Why?” until you have reached the root cause. It can take less than, or more than, 5 Whys to reach the root cause Things to know: - Excellent "quick and dirty" method for problem solving. - Focus is critical. The 5 Whys can be derailed easily if questions are not answered carefully and logically. - Be specific! For each “Why?”, try to provide the most basic answer instead of jumping right to the root cause. When to use: - Problem that is likely to have few significant contributing causes. - Problem that is not highly complex or critical (should be used with other tools for difficult problems). 5 Whys D4 - Root Cause Analysis 55
- 56. 5 Why Example 56
- 57. 5 Whys Example A Problem: 42.75” dimension on bracket measures 43.10-43.15” on 27 of 27 for 3 repeated shipments. Why does the bracket measure 43.15”? – Components ‘A’ and ‘C’ were welded to component ‘B’ 43.15” apart from each other. Why were components ‘A’ and ‘C’ welded to ‘B’ too far apart? – The components were held in the fixture too far apart. Why were the components held in the fixture too far apart? – The components were assembled and clamped into the fixture too far apart. Why were the components assembled in the fixture too far apart? – The components can be assembled into the fixture in several different orientations. Why can the components be assembled into the fixture in several different orientations? – The fixture design allows several orientations instead of just one. Fixture Design Error (Process/Design Root Cause) Why was the fixture designed incorrectly? – Further investigation needed to reach systemic root cause… A C B 5 Whys C B A D4 - Root Cause Analysis 57
- 58. 5 Whys The “5 Whys Trap” One of the most common mistakes that is made on the 5 Whys is to answer a “Why?” incorrectly. Each answer must be backed up by logic and evidence. Two things to prove: 1. The answer to “Why?” is true. For example: Question: Why didn’t the operator know which specific fixture to use? Answer: The work instructions do not specify the required fixture number. Objective Evidence: The team examines the work instructions to prove that the fixture number is not referenced. 2. The answer to “Why?” is the actual cause. For example: Question: Why wasn’t the hose assembled correctly? Answer: The operator did not follow the work instructions. Objective Evidence: The team shows that following the work instructions will prevent the problem from occurring. D4 - Root Cause Analysis 58 If the answer to “Why?” is not apparent, keep investigating. Do not make assumptions!
- 59. 5 Whys Expanded 5 Whys Same process as the 5 Whys, except that more than one answer can be given for each “Why?” At each stage, determine which of the answers provided are legitimate and which can be ignored. Look for major contributing causes and detection failure causes as well as process/design and systemic root causes. Things to know: - Same basic process as the 5 Whys. - Careful reasoning is needed for marking causes as critical or non- critical. When to use: - Problem that is not highly complex or critical (should be used with other tools for difficult problems). D4 - Root Cause Analysis 59
- 60. 5 Whys Expanded 5 Whys example A: A C B D4 - Root Cause Analysis 60
- 61. D4 – Root Cause Analysis (Root Causes) 61 D4 - Root Cause Analysis
- 62. Root & Contributing Cause(s) Five questions to ask, to determine if you have found the Process/Design Root Cause (“the Root Cause”): D4 - Root Cause Analysis 62 1. If you fix it, will it prevent the problem from happening again? 2. Is it a process or design issue? • Are you changing anything with the process or the design to fix the root cause? If not, you need to keep digging. 3. Is it blaming a person or organization? • If the root cause is blaming someone, that means you need to keep digging. You need to ask WHY the person or organization made that mistake. 4. Can you fix it? 5. Do you want to fix it?
- 63. Root & Contributing Cause(s) Contributing causes: • Critical causes other than the root cause, which made the undesirable condition more likely to occur Problem Description Root Cause Problem Description Root Cause 5 Whys D4 - Root Cause Analysis 63 Watch for phrases like: “It didn’t help that…”
- 64. Root & Contributing Cause(s) Examples of weak root causes: • Operator error • Inattention • Failure to follow procedures • Operator wasn’t trained • I was busy • Machined wrong • Inspection failure • Wrong material selected • Machining error • Workmanship • Supplier error • Untrained operator • Job set-up wrong • Inspection didn’t catch it • No paperwork • Process not followed • Wrong part • Caused by supplier • Second check not performed • Management D4 - Root Cause Analysis 64 Class Discussion
- 65. D4 – Summary Is the root cause that was identified a problem with the process or design, not a symptom? Does the root cause blame someone or does it address the process or design? What method (5 Whys, fishbone diagram, etc.) was used to identify the root cause? Was the root cause proven by evidence/logic? Will eliminating the process/design root cause prevent recurrences of the problem? Is the root cause within the control of the team/organization? Are significant contributing causes and detection failure causes identified for correction? Do the process experts agree with the process/design root cause? D4 - Root Cause Analysis 65 Key Questions – Root Cause Analysis Reference Guide Questions
- 66. D5 – Long Term Corrective Actions 66 D5 - Long Term Corrective Actions
- 67. Correct the Root & Contributing Cause(s) Match the root cause to the corrective action: Root Causes: Corrective Actions: 1) Fixture allows several alignments 2) Work Instructions do not identify all steps 3) Planning process does not capture revision changes 4) Initial set-up of process not checked out G) Fire the QA person D) Update WI to require first piece inspection for all setups B) Re-write the work instructions to include all requirements C) Error-proof the fixture E) Re-write planning procedures to cover revision changes A) Fire the operator F) Re-train the operator D5 - Long Term Corrective Actions 67 Class Discussion Chat in Answers
- 68. Correct the Root & Contributing Cause(s) Long Term Corrective Action principles: • Always address the root causes (mitigate or eliminate) • Be specific • Be formally implemented (not a statement of intent or tribal knowledge) • Be verifiable (i.e., it is possible to audit the corrective action to verify implementation) There are always resource limitations: For cost/weight/time reasons, sometimes the root cause cannot be eliminated (e.g., adding inspection instead of changing the process) There are times when the corrective action can only decrease the likelihood of recurrence (e.g., adding better lighting and work instructions to a manual weld process, rather than changing to a robotic weld process) D5 - Long Term Corrective Actions 68 Always be honest on your 8Ds. If you cannot fix the root cause, be sure to record that fact. It will help if you deal with the problem if it happens again.
- 69. Correct the Root & Contributing Cause(s) Long Term Corrective Action questions: D5 - Long Term Corrective Actions 69 What are you going to change? Fixture Machine Procedure Work Instructions Policies Etc. What change are you going to make? Who is going to make the change? When will the change be made? How will you make sure the change was made correctly? How will you make sure the change worked?
- 70. Correct the Root & Contributing Cause(s) Example A: Corrective Action: Manufacturing Engineering will change the fixture to allow only one setup of components in the fixture. Fixture drawing 777A111 will be updated and fixture 777A111-1 will be reworked to meet the new requirements. Implementation Plan: W. Smith – Update 777A111, attach updated drawing as evidence – Due July 15 K. Ishikawa – Rework fixture 777A111-1, attach photos of fixture as evidence – Due July 29 G. Taguchi – Update welding PFMEA and Control Plan – Due Aug. 8 Verification Plan: Five different operators will set-up and run a sample part. The sample parts will be dimensionally inspected. D5 - Long Term Corrective Actions 70 A C B
- 71. D5 – Summary Do the long term corrective actions directly address the root causes? Do the corrective actions eliminate the root causes (prevent defects from occurring) or mitigate the root causes (decrease probability of occurrence or ensure detection)? Will the corrective actions be formally implemented or are they tribal knowledge or training? Are the corrective actions specific and auditable? What is the plan to verify that the corrective actions are effective? D5 - Long Term Corrective Actions 71 Key Questions – Long Term Corrective Actions Reference Guide Questions
- 72. D6 – Implementation and Verification of Long Term Corrective Actions 72 D6 - Implementation and Verification of Long Term Corrective Actions
- 73. Implementation Implementing Corrective Actions D6 - Implementation and Verification of Long Term Corrective Actions 73 When you implement a Corrective Action, you must make it permanent! Formally implement the Corrective Action • Verbal instructions, tribal knowledge, and/or one time training are not long-term fixes Questions to ask: • Will this corrective action still work if we hire someone or fire someone? • Will the corrective action still be in place in a month? In a year?
- 74. Implementation Update core documents including: • Work instructions – update with any changes to the process • Process Flow Diagram – update with any changes to the process • PFMEA – update with new/updated risks based on everything learned during the 8D AND with any changes to the process • Control Plan – update with any changes to the process D6 - Implementation and Verification of Long Term Corrective Actions 74
- 75. Implementation Getting buy in Always get buy in with the process owners (whoever performs the process day-to-day)! Many corrective actions fail because the team never gets buy in. Involve process experts. Make sure the process owners know what the problem was and how the corrective action will eliminate it. D6 - Implementation and Verification of Long Term Corrective Actions 75 8D Rule 7: Without buy in, even the best corrective action in the world will fail.
- 76. Implementation Effective methods for verifying implementation: Go see! Go witness the updated process. Ask questions, make sure that the updated process is understood by everyone using it. Use the 8D as an audit guide. Can you find evidence that they completed every action that the 8D said they would? Photos or other objective evidence. Take pictures of changes to processes or fixtures or other relevant items. Get copies of updated procedures, work instructions, and other documents. D6 - Implementation and Verification of Long Term Corrective Actions 76
- 77. Verify Effectiveness Effectiveness Verification answers the question: Did you eliminate the problem? The key requirement is objective evidence that the corrective actions have prevented recurrences of the problem. The method and length of the verification should be based on: Problem description (When? How Many?) Is it a rare problem (low percentage effected)? Would it be present on every batch/lot/job or does it happen sporadically? The strength of the correction action Is it physically changing the process or design (e.g., creation of a new fixture, error proofing, etc.)? Does it prevent the problem or only make it less likely (e.g., installing lighting, adding a checklist, etc.)? D6 - Implementation and Verification of Long Term Corrective Actions 77 Another way to think of effectiveness verification is: “Can I remove my short term fix, without having the problem re- occur?”
- 78. Fixed Mindset Growth Mindset • I’m only good at certain things • I give up when it gets too hard • I hate challenges • I take feedback/criticism personally • I don’t like what I don’t know • I can be good at anything • I try until I get the results I want • I embrace challenges • I welcome feedback/criticism • I like learning about things I don’t know Be aware of which mindset you’re in and the impact it has on your wellness Fixed vs. Growth Mindset
- 79. D6 – Summary Key Questions – Implementation and Verification of Long Term Corrective Actions: Were the corrective actions implemented as the team expected? Is there objective evidence that the corrective actions were implemented correctly? Has the short term corrective action been removed without causing problems? What objective evidence is available to prove the corrective actions effectively eliminated the problem? D6 - Implementation and Verification of Long Term Corrective Actions 79 Reference Guide Questions
- 80. Class Exercise – Corrective Actions Objective: Identify corrective action(s) for the process root cause(s) that was identified. • Develop a specific corrective action plan. • Identify the objective evidence needed to prove that the corrective action was implemented correctly. • Develop the effectiveness verification plan. D6 - Implementation and Verification of Long Term Corrective Actions 80 Team Exercise Poll Everywhere Note: You would document this plan in D5 (Long Term Corrective Actions). In D6 you would provide evidence that you executed the plan and that it was effective.
- 81. D7 – Preventative Actions 81 D7 - Preventative Actions
- 82. Preventative Actions The Preventative Actions step is where you have biggest impact. Preventative actions should address: • Systemic root causes • Like parts and similar processes D7 - Preventative Actions 82
- 83. Preventative Actions Prevent failures for similar parts and processes that could have the same, or similar, process/design problems. Example A: Identifying other fixtures that can allow multiple orientations of weldment components, similar to the 271828 bracket. Error-proofing fixtures that are identified. D7 - Preventative Actions 83 Addressing any like parts or similar processes is a necessary step in the 8D process and should be completed every time.
- 84. Preventative Actions Address systemic causes that were identified during the root cause investigation. Example A: Project developed to analyze and improve the current processes for the control of fixtures and the design of new fixtures. Project charter developed and approved on 6/21. (Note: Some projects may take a long time to address systemic or widespread issues. If a project charter or project plan is developed, the 8D does not need to wait on its completion.) D7 - Preventative Actions 84 8D Rule 8: If you want the 8D to have real impact, focus on the systemic corrective actions.
- 85. Communication plays a key role • Image courtesy of Efficient Thinking Solutions Change Leadership Change Management 85
- 86. D7 – Summary Key Questions – Preventative Actions: Have like parts and similar processes with similar process problems been addressed? Have any significant systemic root causes been identified? Should any larger scale continuous improvement plans be initiated (based on the systemic root causes)? D7 - Preventative Actions 86 Reference Guide Questions
- 87. D8 – Congratulate the Team 87 D8 - Congratulate the Team
- 88. Congratulate the Team Successfully completing an 8D is a big deal! The Team Champion should recognize the accomplishments of the team. • Personal recognition (in-person or via note) • Recognition during all-hands meetings • Awards (key contributor, etc.) D8 - Congratulate the Team 88 You provide the 8D team with recognition so that they will volunteer to be on the next one.
- 89. D8 – Summary Key Questions – Congratulate the Team and Wrap-up: Has the team received recognition for improvements made to the process and system? Was the 8D process treated as a continuous improvement activity? Has the 8D process been documented so that it can be used to help resolve future problems? D8 - Congratulate the Team 89 Reference Guide Questions
- 91. Conclusion Discipline is key to problem solving 1. Follow the process step by step. Don’t skip steps! 2. Ensure that each step is completed correctly before moving on. 3. Document your process. You will not be successful the on the first try with every 8D. Documenting your work means that you will not have to start over at the beginning if a solution doesn’t work. Conclusion 91 Pencil whipping 8Ds leads to solutions that are ineffective, expensive, or both.
- 92. Conclusion A few final notes: • It takes practice to become a skilled problem solver. • Make sure to get feedback from other skilled problem solvers. • Don’t be discouraged if your 8D isn’t perfect. Ask yourself: “Did I make a permanent improvement to the process or system?” • Reach out if you need assistance, Oshkosh has people who can help. Conclusion 92
- 93. Questions? Conclusion 93 8D Rule 1: If there’s no team, it’s not an 8D. (D1) 8D Rule 2: Incomplete problem descriptions lead to bad solutions. (D2) 8D Rule 3: Never stop after the short term fix, even if the symptoms go away. (D3) 8D Rule 4: Inspection cannot be the root cause. Inspection catches defects. It doesn’t prevent them. (D4) 8D Rule 5: Document your root cause analysis, every time. (D4) 8D Rule 6: Human error is not an acceptable root cause. (D4) 8D Rule 7: Without buy in, even the best corrective action in the world will fail. (D6) 8D Rule 8: If you want the 8D to have real impact, focus on the systemic corrective actions. (D7)