Transcript landscape Powerpoint Template

5 Why Analysis
January 2, 2006
Global Supply Management
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
Where does it fit within the PRR process?

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)
requires a 5-Why analysis to help in identifying the root cause
of the problem.

Going back to one of the elements within the Purpose of a
PRR “to facilitate problem resolution”, 5-Why is the prescribed
tool for determining the root cause of the problem to facilitate
problem resolution.
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Is the powerful question… own it!!
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Power of Asking Questions
Speed
Limit
Strictly
Enforced
How
Fast
Are You
Going?
No
Reaction
Cause
Reaction
(Look at speedometer)
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How
Fast
Should
You Be
Going?
Cause
Reaction & Research
(Look at speedometer;
Search for speed limit sign)
Global Supply Management – January 2, 2006
Power of Asking Questions
Who are the best at asking questions to
solve problems?
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Power of Asking Questions
Children!
Why?
…because they keep asking objective, open-ended questions
until the answer is simple and clear
When working with people to solve a problem,
it is not enough to tell them what the solution is. They
need to find out and understand the solution for
themselves. You help them do this by asking openended , thought provoking questions.
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Close-Ended vs. Open-Ended Questions
Close-Ended:
Structures the response to be answered
by one word, often “yes” or “no”. Usually
gives a predetermined answer.
Example: “Did the lack of standardization cause the incorrect setup?”
Open-Ended:
Leaves the form of the answer up to the
person answering which draws out more
thought or research.
Example: “How is setup controlled?”
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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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More Examples
Example 1:
“Did the lack of a PM system cause this tool to break?”
(Close-Ended question, can be answered by a “yes” or “no”, gives the
person a predetermined answer that PM is to blame)
“What could have caused the tool to break?”
(Open-Ended, probing question forces the person to think about all
possibilities, not just PM)
Example 2:
“Would improving material flow help reduce lead times?”
(Good question but it’s still Close-Ended, focuses the person on material
flow as a means to reduce lead time. Is this the best improvement?)
“What are some options on improving lead time?
(Open-Ended, triggering more thought and research on all variables
impacting 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 on
equipment 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)
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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 Analysis
Corrective Action
with Responsibility
Date
Define Problem
Use this path for
the specific
nonconformance
being investigated
WHY?
A
Root Causes
Therefore
WHY?
Use this path to
investigate why the
problem was not
detected.
WHY?
Therefore
WHY?
Therefore
B
Therefore
WHY?
Therefore
A
WHY?
Use this path to
investigate the
systemic root cause
(Quality System
Failures)
Therefore
WHY?
Therefore
C
WHY?
Therefore
WHY?
Therefore
B
Ref. No. (Spill, PR/R…)
WHY?
Date of Spill
Product / Process
Therefore
WHY?
Delphi Location
Content Latest Rev Date
Therefore
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 box
Insert example
What tool do
We 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 be
large, vague, or complicated. You have some information, but do not have
detailed 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, if
necessary.
» 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 be
communicated to the Customer?
– Is there evidence to support verification of corrective actions?
– Are corrective actions irreversible?If not, do actions address ongoing
containment?
– 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 and
process!
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Therefore Test
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5-Why Analysis
Problem
The problem is stated through
the eyes of the customer
The first why is the main cause
The second why is what
causes the main cause
Etc.
Etc.
You have root cause if you
can demonstrate:
• cause on, problem on
• cause off, problem off
Root Cause
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5-Why Example
(Non-conformance)
Problem
Cookies taste really bad
Cookies are undercooked
Ingredients are wrong
Used goose eggs rather than
chicken eggs
Root Cause
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Recipe did not specify bird type
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5-Why Example - PPAP Submittal
(Non-conformance)
Problem
PPAP submitted late
PPAP package not complete
Validation testing not complete
Test lead time not considered
Root Cause
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No system to accurately assess
lead times of all PPAP elements
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5-Why Example - PPAP Submittal
(Detection)
Problem
PPAP submitted late
Did not react to the target
submittal date
Did not know the target
submittal date had passed
No requirement to follow-up on
target submittal dates
Root Cause
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No standard system to manage
PPAP submittal timeliness
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5-Why Example - Business Plan
(Non-conformance)
Problem
Did not meet the annual business
plan goal of a 10% increase in sales
Did not thoroughly evaluate
market/competition
Did not have adequate
resources
Did not anticipate required
resources
Root Cause
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Did not develop a plan as to
“how” the goal would be reached
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5-Why Example - Business Plan
(Detection)
Problem
Did not meet the annual business
plan goal of a 10% increase in sales
Did not know the goal was not
going to be met
Did not evaluate the status of
the goal until December
Did not have alarms limits
identified at strategic intervals
(monthly, quarterly, etc.)
Root Cause
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Did not develop a plan to monitor
the status of reaching the goal
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Flex Industries Case StudyBackground

Jake Ryan is the Quality Manager at Flex Industries. Flex is a component
supplier that manufactures metal stampings and light assembly products.
The company has a reputation for supplying high quality parts on a
consistent basis. Seldom has there been a customer complaint. Flex has
Quality representatives called Customer Support Engineers (CSE’s) at every
customer assembly plant. The CSE’s report any problems to Jake for
investigation and follow-up.

At 7:00 a.m. this morning, Jake received a call from Janet, CSE at the
Winding River Assembly Plant. Janet informed him that the customer had
found five defective stabilizing brackets on second shift last night. She
checked the remaining inventory and there were no defects in the remaining
326 pieces. The manufacturing sticker on the back of the brackets indicated
that they were made by the second shift operator. Normally, the stabilizing
bracket is fastened to the regulator motor with three rivets. The five
defective brackets had only two rivets in them. The lower set of rivets on all
five brackets was missing a rivet. This was the first time that the problem
occurred.
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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 line
which runs the stabilizing bracket assembly. Sam directed Jake to the East
line which runs Winding River assembly brackets only.
At the East Line, he spoke with Judy (the QA Auditor for the area) and asked
to 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-up
in-house containment procedures to sort for any discrepant material in the
finished goods area.
Next, Jake tried to locate the second shift operator whose clock number was
on the defective parts. Since that operator was gone, Jake spoke with the
current machine operator (Ben). He asked Ben about any recent difficulties
with the rivet machine. Ben said that he hadn’t noticed anything out of the
ordinary. Ben also mentioned, however, that there had never been any
quality bulletins posted in the two years that this particular part has been
running.
Jake decided to stay in the area to watch the machine run for a while. After
about 15 minutes, he watched Ben dump rivets into the feeder bowl to
prepare for the next run.
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Cause Investigation



Shortly after restarting rivet operations, Ben walked over to another riveter
and came back with a steel rod. Ben poked around the rivet chute and then
continued working. Jake approached Ben and asked him about the steel
rod. Ben replied that from time to time the chute gets jammed and he has to
clear it out. This happens two or three times during a shift. He didn’t
mention this in his earlier conversation with Jake because the problem has
existed ever since he started working with this machine. The previous
operator showed him how to clear the chute. All the rivet machines are like
this.
Jake called the Machine Repair Department and asked that someone look at
the rivet track. A slight gap in the track was found and removed, and Ben
continued 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, Jake
looked into the rivet supplier containers. There was some foreign material in
the blue container, but none in the red container. The label on the blue
container showed that it was from Ajax Rivet, Inc., and the label on the red
container indicated that it was from Frank’s Fasteners. Obviously, the
foreign 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 also
added the cleaning operation to the preventive maintenance schedule on the
equipment. He then called both Ajax Rivet, Inc. and Frank’s Fasteners. He
asked about the cleaning procedures on the returnable containers. Frank’s
did a full container purge and clean. Ajax just re-introduced the containers
back into their system. When Jake asked why Ajax did not clean their
containers, he was told that Ajax was not aware that such a policy was
needed.
Upon further investigation, Jake learned that Frank’s Fasteners supplies
other major automotive companies. Since these companies require that all
returnable containers be cleaned, Frank’s instituted the purge as part of its
practice for all customers. Ajax Rivet, however, depends primarily on Flex as
its 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 that
a container maintenance policy be drafted which would apply to
all their suppliers. He also asked that a machine modification
be developed to sense for the presence of rivets. Hopefully,
this would error-roof the process.
 Key Players

–
–
–
–
–
Jake
Janet
Sam
Judy
Ben
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Quality Manager
CSE, Winding River Plant
Team Leader, East Line
QA Auditor, East Line
Machine Operator
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Generic Information for 5-Why Example:
Regular Cola Soft Drink vs. Diet Cola
 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 “Regular Cola in the
right 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 either
of our two products. The lines are located immediately beside
each other. The only differences in the products are the syrup and
the 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 11:00
p.m. to 7:00 a.m.
 The date code indicates that the defective product was
manufactured at 3:03 p.m.
 Defective product has been contained and sorted.
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Bottling Process Flow for 5-Why
BOTTLES
WATER
SYRUP
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B
O
T
T
L
I
N
G
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LIDS
INSPECT
LABELS
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Generic Information for 5-Why Real
Example: “O” Ring Seal
 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 raw
material (cylindrical component) goes through the cutting
operation, the irregular end-cuts are removed from the station.
Cutting Station
Mat’l Flow
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Is this a good or bad
“Non-Conformance” leg?
Missing o-ring
on part number
K10001J
WHY?
Parts missed the
o-ring installation
process
WHY?
Why did they
have to rework?
Parts had to be
reworked
WHY?
Operator did not return
parts to the proper process
step after rework
WHY?
No standard
rework procedures
exist
This is still a systemic failure
& needs to be addressed,
but it’s not the root cause.
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Is this a good or bad “Detection” leg?
Missing threads
on fastener part
number LB123
WHY?
Did not detect
threads were
missing
What caused
the sensor to
get damaged?
WHY?
Sensor to detect
thread presence
was not working
WHY?
Sensor was
damaged
WHY?
No system to
assure sensors are
working properly
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This is still a systemic failure
& needs to be addressed,
but it’s not the root cause
of the lack38of detection.
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A good 5-Why will answer “Yes” to the five
PDCA questions:
“A problem well defined
is a problem half solved”
ACT
PLAN
Standardize
Understand the problem
5. Has a plan been identified
to STANDARDIZE and take
all lessons learned across
products, processes,
plants, functional areas, etc.?
1. Is the problem statement
CLEAR and ACCURATE?
2. Has the SYSTEMIC
root cause(s) been
identified for all legs?
CHECK
Follow-up
4. Has a plan been identified
to verify the
EFFECTIVENESS
of all corrective
actions?
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DO
Execute the Plan
3. Has IRREVERSIBLE
CORRECTIVE ACTION(s)
been implemented for
ALL root causes?
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Is this a good Corrective Action plan?
Corrective Action
w/ Responsibility
Plan
Fastener P/N 10001
would not assemble
A
Do
1. Replace worn tool
(K. Jones)
6/1/03
Do/Act
2. Begin conducting PM on all
dies after every run, minimum
1 x / day, to collect history
(L. Burg)
6/1/03
Do/Act
3. Assess & adjust PM intervals
for all dies based on history
& mfg recommendations
(B. Clark)
7/31/03
WHY?
Burrs on the thread
WHY?
Worn stamping
tool
WHY?
Tool exceeded
recommended wear
life
Check
4. Track PM completion %
to assure 100% conformance
(C. Beckett)
WHY?
PM interval not
adequate
Plan
WHY?
PM failure; No system
to strategically set
PM intervals
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Date
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Check
5. Check for burrs on threads
for 60 days to verify c/a
(M. Mendoeous)
A
Check
6. Track FTQ at stamping to
monitor PM improvement
(S. Boland)
6/1/03
6/1/03 7/31/03
6/1/03
Global Supply Management – January 2, 2006
5-Why Critique Sheet

General Guidelines: A.) Don’t jump to conclusions!; B.) Be absolutely objective. C.) Don’t assume the answer is
obvious. D.) If you are not thoroughly familiar with the process yourself, assemble a cross-functional team to
complete the analysis.

Step 1: Problem Statement
Is the analysis being reported on the problem as the Customer sees 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 why’s)?
-Is there a true cause-and-effect path from beginning to end of each path? Is there statistical data/evidence to prove
it? ---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, so
this happened, and so on, which resulted in the original problem.)
-Do the why’s 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 action
applies 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 be
communicated 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 doesn’t happen on the first try!)
-Who prepared the 5-why?
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5-Why Analysis: Cola Example –
Path A
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5-Why Analysis: Cola Example –
Path B
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5-Why Analysis: Cola Example –
Path C
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5-Why Analysis: “O”Ring
Example – Path A
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5-Why Analysis: “O”Ring
Example – Path B
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5-Why Analysis: “O”Ring
Example – Path C
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Problem Case Audit Standards

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 what
happened systemically."
– Y: All 3 legs filled out, some leaps of logic, needs minor corrections to
improve.
– R: 1 or 2 legs missing, Leg 1 repeated as leg 2 or 3, not understanding
what the different legs mean--typically missing what the systemic leg is.
Poor answers on 2 or more legs.
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