PRACTICAL PROBLEM SOLVING

Introduction This common problem solving process is used to analyze and solve any problem where the root cause in unknown. There are four major parts of the process: Grasp the Situation Cause nvestigation !roblem Correction !revention through "rrorproofing

Grasp the Situation #uring the first part of the process$ you: dentify the !roblem Clarify the !roblem %ocate the !oint of Cause &!oC' Cause Investigation n the second part of the process$ you: Conduct a ()*+hy, investigation to identify the root cause for the specific problem for why the problem was not detected for why the (system, allowed the problem to occur Pro !e" Correction n the third part of the process$ you: Take specific action to correct the problem. -t a minimum$ short*term temporary measures are re.uired to protect the customer. Prevention Thru Error proo#ing n the fourth part of the process$ you: Take specific action to make sure the problem cannot recur$ typically through error proofing Capture %essons %earned

PRACTICAL PROBLEM SOLVING MO$EL % &h' (unne!

G S R I A T S , P A T T I + O E N C A , S E I N V E S T I G A T I O N

!234%"5 #"6T 7 "# &%arge$ 8ague$ Complicated' !roblem Clarified -rea of Cause %ocated &here in the process is pro !e" occurring* !oint of Cause &!oC' -Go See. the pro !e" +hy1 / Cause Basic Cause)E##ect Investigation +hy1 0 Cause +hy1 9 Cause % &h'* +hy1 : Investigation o# Root Cause Cause +hy1 ) +hy did we +hy did it
have the problem1 get to the customer1

+hy did our (system, fail1

2oot Cause Corrective -ction %essons %earned

BASIC STEPS O( PRACTICAL PROBLEM SOLVING Part I / Grasp the Situation Step 01 Identi#' the Pro !e" n the first step of the process$ you become aware of a problem that may be large$ vague$ or complicated. ;ou have some information$ but do not have detailed facts. -sk: +hat do know1

Step 21 C!ari#' the Pro !e" The ne<t step in the process is to clarify the problem. To gain a more clear understanding$ ask: +hat is actually happening1 +hat should be happening1

Step 31 Brea4 $o5n the Pro !e" -t this point$ break the problem down into smaller$ individual elements$ if necessary. +hat else do know about the problem1 -re there other sub*problems1

Step 61 Locate the Point o# Cause 7PoC8 6ow$ the focus is on locating the actual point of cause of the problem. ;ou need to track back to see the point of cause first*hand. -sk: +here do need to go1 +hat do need to see1 +ho might have information about the problem1

Step %1 Grasp the Tendenc' o# the Pro !e" To grasp the tendency of the problem$ ask: +ho1 +hich1 +hen1 =ow often1 =ow much1

t is important to ask these .uestions before asking (+hy1,

Part II1 Cause Investigation Step 91 Identi#' and con#ir" the direct cause o# the a nor"a! occurrence: f the cause is visible$ verify it. f the cause is not visible$ consider potential causes and check the most likely causes. Confirm the direct cause based on fact. -sk: +hy is the problem occurring1 Can see the direct cause of the problem1 f not$ what do suspect as potential causes1 =ow can check the most likely potential causes1 =ow can confirm the direct cause1

Step ;1 ,se %<&h' investigation to ui!d a chain o# cause)e##ect re!ationships that !ead to the root cause: As41 +ill addressing the direct cause prevent recurrence1 f not$ can see the ne<t level of cause1 f not$ what do suspect as the ne<t level of cause1 =ow can check and confirm the ne<t level of cause1 +ill addressing this level of cause prevent recurrence1 f not$ continue asking (+hy1, until you find the root cause. Stop at the cause that must be addressed to prevent recurrence. -sk: =ave found the root cause of the problem1 Can prevent recurrence by addressing this cause1 s this cause linked to the problem by a chain of cause>effect relationships that are based on fact1 #oes the chain pass the (therefore, test1 f ask (+hy1, again$ will be into another problem1

4e sure you have used )*+hy nvestigation to answer these .uestions: +hy did we have the problem1 +hy did the problem get to the customer1 +hy did our (system, allow it to occur1

% &+= CA,SE INVESTIGATION

-bnormal 3ccurrence +hy1 7cause)e##ect re!ationship8

#irect Cause +hy1 7cause)e##ect re!ationship8

C
+hy1

Cause 7cause)e##ect re!ationship8

C
+hy1

Cause 7cause)e##ect re!ationship8

C
+hy1

Cause

2oot Cause

There#ore Test

Step >1 Ta4e Speci#ic Action to Address the Pro !e" ?se temporary measures to eliminate the abnormal occurrence until the root cause can be addressed. -sk: #oes it contain the problem until a permanent solution can be implemented1

mplement corrective actions to address the root cause to prevent recurrence. -sk: #oes it prevent the problem1

7ollow*up and check results. -sk: s the solution working1 =ow do know1

PRACTICAL PROBLEM SOLVING C+EC?LIST To be sure you have followed the problem solving model$ use this checklist as you complete the problem solving process. Grasp the situation AAA !ick*up the problem. AAA Clarify the problem. AAA 4reak down the problem. AAA %ocate the !oint of Cause &!oC'. AAA Grasp the tendency of the problem. Cause Investigation AAA dentify>confirm the direct cause. AAA -sk ) +hyBs to identify the root cause. AAA -sk ) +hyBs for (+hy the problem was not detected and reached the customer1, AAA -sk ) +hyBs for (+hy did the system allow the problem to occur1, Pro !e" Correction AAA mplement corrective actionC at a minimum$ implement temporary measures Prevention AAA "rrorproof the root cause. AAA Capture %essons %earned.

ACTIVIT=1 IN$,STRIES CASE ST,$= $irections1 ?se the !roblem Solving !rocess to evaluate the ndustries Case Study below and on the following pages. 2eview the )*+hy nvestigation results on !age //. ?se the worksheets on !ages /9 and /: to record your work. ?se only the information provided. #o not try to re*engineer the rivets or solve the technical problems in the case study. The purpose of this activity is to use the !roblem Solving model to organize the given data. IN$,STRIES CASE ST,$= Bac4ground Eohn #oe is the Fuality 5anager at G;H ndustries. G;H is a component supplier that manufactures metal stampings and light assembly products. The company has a reputation for supplying high .uality parts on a consistent basis. Seldom has there been a customer complaint. G;H has Fuality representatives called Customer Support "ngineers &CS"Is' at every customer assembly plant. The CS"Is report any problems to Eohn for investigation and follow*up. -t D:JJ a.m. this morning$ Eohn received a call from Eanet$ CS" at the +inding 2iver -ssembly !lant. Eanet 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 90@ pieces. The manufacturing sticker on the back of the brackets indicated that they were made by the second shift operator. 6ormally$ 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.

GOO$

BA$

Eohn set*up containment procedures at the plant warehouse to sort for discrepant materials. -s of this morning$ two more defective brackets had been found in the remaining 0J/L pieces of inventory at 7le<. Cause Investigation Eohn went out to the floor to talk with the team leader of the two rivet lines &"ast and +est' and the area .uality assurance auditor. =e informed Sam &the team leader' of the .uality problem and asked him to identify the line which runs the stabilizing bracket assembly. Sam directed Eohn to the "ast line which runs +inding 2iver assembly brackets only. -t the "ast %ine$ he spoke with Eudy &the F- -uditor for the area' and asked to see the .uality log sheets. Eohn and Eudy reviewed the 6ov. // th log sheet and could not find anything out of the ordinary. =e asked her to set*up in*house containment procedures to sort for any discrepant material in the finished goods area. 6e<t$ Eohn tried to locate the second shift operator whose clock number was on the defective parts. Since that operator was gone$ Eohn spoke with the current machine operator &4en'. =e asked 4uddy about any recent difficulties with the rivet machine. 4uddy said that he hadnIt noticed anything out of the ordinary. 4uddy also mentioned$ however$ that there had never been any .uality bulletins posted in the two years that this particular part has been running. Eohn decided to stay in the area to watch the machine run for a while. -fter about /) minutes$ he watched 4uddy dump rivets into the feeder bowl to prepare for the ne<t run.

Shortly after restarting rivet operations$ 4uddy walked over to another riveter and came back with a steel rod. 4uddy poked around the rivet chute and then continued working. Eohn approached 4uddy and asked him about the steel rod. 4uddy 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. =e didnIt mention this in his earlier conversation with Eohn because the problem has e<isted ever since he started working with this machine. The previous operator showed him how to clear the chute. -ll the rivet machines are like this. Eohn called the 5achine 2epair #epartment and asked that someone look at the rivet track. - slight gap in the track was found and removed$ and 4uddy continued to work. Two hours later$ Eohn got a call from 4uddy saying that the track was still jamming. -s far as Eohn could see$ only rivets were in the bowl. 6e<t$ Eohn 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 2iley 2ivet$ nc.$ and the label on the red container indicated that it was from 7riendlyIs 7asteners. 3bviously$ the foreign material was entering the rivet feeder bowl and jamming the track. Eohn called 5aintenance and re.uested that the bowl be cleaned. =e also added the cleaning operation to the preventive maintenance schedule on the e.uipment. =e then called both 2iley 2ivet$ nc. and 7riendlyIs 7asteners. =e asked about the cleaning procedures on the returnable containers. 7riendlyIs did a full container purge and clean. 2iley just re*introduced the containers back into their system. +hen Eohn asked why 2iley did not clean their containers$ he was told that 2iley was not aware that such a policy was needed. ?pon further investigation$ Eohn learned that 7riendlyIs 7asteners supplies other major automotive companies. Since these companies re.uire that all returnable containers be cleaned$ 7riendlyIs instituted the purge as part of its practice for all customers. 2iley 2ivet$ however$ depends primarily on G;H as its major customer. 6o such policy has ever been re.uired of them. Eohn called the 5aterial Control #epartment and re.uested that a container maintenance policy be drafted which would apply to all their suppliers. =e also asked that a machine modification be developed to sense for the presence of rivets. =opefully$ this would error* roof the process. ?E= PLA=ERS
Eohn Eanet Sam Eudy 4uddy Fuality 5anager CS"$ +inding 2iver !lant Team %eader$ "ast %ine F- -uditor$ "ast %ine 5achine 3perator

/J

5-WHY PROBLEM SOLVING PROCESS %<&h' Cause Investigation

Corrective Actions $ate

2eference 6o. AAAAAAAAAAAAAAA &Spill$ !2>2M' #ate: AAAAAAAAAAAAAAAAAAAA

$e#ine Pro !e"

Missing rivets on rac4ets shipped to custo"er &+=* Auto"ated rivet "achine did not p!ace rivet in position &+=* (eed!ine had o struction

,se this path #or the speci#ic noncon#or"ance eing investigated

Root Causes

,se this path to investigate 5h' the pro !e" 5as not detected
No reBuire"ent on contro! p!an to sa"p!e rac4ets continuous!'C on!' at set<up &+=*

&+=* (oreign "ateria! #ound in dunnage o structing #eed!ine &+=* Supp!ier had no "aintenance progra" #or dunnage &+=*
Not identi#ied on P(MEA as possi !e #ai!ure "ode eDcept at set<up

A < Revise pac4ing speci#ication #or dunnage to re#!ect no #oreign "ateria! reBuire"ent

Supp!ier not a5are o# reBuire"ent a out #oreign "ateria!

B E C < Revise scope o# P(MEA to inc!ude entire process #ro" doc4 to doc4

,se this path to investigate the s'ste"ic root cause

B < ,pdate P(MEA and Contro! P!an to re#!ect continuous sa"p!ing p!an #or rac4ets

Potentia! #ai!ure "ode not identi#ied on P(MEA &+=* (ai!ure "odes associated 5ith inco"ing dunnage not addressed &+=* Scope o# P(MEA !i"ited to "anu#acturing process on!'

B / Modi#' "achine to sense #or presence o# rivets

Lessons Learned1 0: Ma4e supp!ier part o# AP@P activities: 2: Ma4e P(MEAAs co"prehensive o# entire s'ste" //

5-WHY PROBLEM SOLVING PROCESS

%<&h' Te"p!ate to e used #or a!! %<&h' Investigations

%<&h' Ana!'sis
Re#erence No: FFFFFFFFFF 7Spi!!G PR)RH8 $ate1 FFFFFFFFFFFFFFFFFFFF
$e#ine Pro !e"
,se this path #or the speci#ic noncon#or"ance eing investigated
&+=*

Corrective Actions

$ate

Root Causes

&+=*

,se this path to investigate 5h' the pro !e" 5as not detected

&+=*

&+=*

B
&+=* &+=*

A
,se this path to investigate the s'ste"ic root cause
&+=* &+=*

&+=*

&+=*

B
&+=*

&+=*

Lessons Learned1

&+=*

/0

5-WHY PROBLEM SOLVING PROCESS

I=J IN$,STRIES &OR?S+EET

GRASP T+E SIT,ATION Activit' &Step' Identi#' the pro !e" &hat did the' 4no5* &hat did the' do*

C!ari#' the pro !e"

Brea4 do5n the pro !e"

!234%"5 #"6T 7 "# &%arge$ 8ague$ Complicated' !roblem Clarified -rea of Cause %ocated !oint of Cause &!oC' +hy1 / Cause +hy1 0 Cause +hy1 9 Cause +hy1 : Cause +hy1 )

Locate point o# cause 7geographic !ocation8 Grasp tendenc' o# the pro !e" 7&hat Buestions are 'ou as4ing*8

2oot Cause Corrective -ction %essons %earned

/9

5-WHY PROBLEM SOLVING PROCESS

CA,SE INVESTIGATION Activit' &Step' Identi#')con#ir" the direct cause As4 % &h'As to identi#' the speci#ic root cause associated 5ith the pro !e" As4 % &h'As #or 5h' the pro !e" 5as not detected and reached the Custo"er As4 % &h'As #or 5h' the -S'ste". a!!o5ed it to happen I"p!e"ent te"porar' "easures to protect the Custo"er I"p!e"ent corrective actions to prevent the pro !e" #ro" recurring (o!!o5<up and chec4 resu!ts
!234%"5 #"6T 7 "# &%arge$ 8ague$ Complicated' !roblem Clarified -rea of Cause %ocated !oint of Cause &!oC' +hy1 / Cause +hy1 0 Cause +hy1 9 Cause +hy1 : Cause +hy1 )

&hat did the' 4no5*

&hat did the' do*

2oot Cause Corrective -ction %essons %earned

/: