77 Lewis Root Cause - 77 MORS

Root Cause Analysis: Tools of Lean Six Sigma
78th MORS Symposium (MORSS)
Solving Tomorrows Problems Today And Resolving Yesterdays Problems As Well.
78th
Tutorial Presentation for the MILITARY OPERATIONS RESEARCH SOCIETY Symposium 21 24 June 2010 Marine Corps University, Quantico, Virginia Presented by Kenneth W. Lewis, Ph.D., 23 June 2010 @ 1215 Hours US Army Logistics University Fort Lee, VA 78th MORS Symposium (MORSS)
PREMISE: All human beings look forward to achieving goals. Goals might be Big or Small, Tangible or Intangible, Physical, Mental, Emotional, Career Oriented, Status Oriented, Finance Oriented, Military Oriented, Politically Oriented, Or Otherwise. Regardless, all human beings look forward to achieving goals. Goals are easier to grasp if they are SMART GOALS.
SMART Goals are Specific Measureable Attainable Realistic Timely Who? What? Which? Where? Why? are answerable. How much? How many? How often? You can plan your steps to actually achieve that goal. You have the will and the ability to work towards achieving that goal. That goal is Grounded within a timeframe.
So let us consider the GOAL as the desired end state of some plan, process or procedure
Some carefully executed plan Some ingeniously produced widget Some thoughtfully offered service Some successful emergency response

That plan might be Operation Eagle Claw April 1980 That Product or Widget might be the V-22 Osprey Tilt-Rotor Aircraft 1984 to Present That Program might be Space Shuttles Challenger January 1986 or Columbia February 2003 That Service might be the JCIDS or CBA process March 2002 That Emergency Response might be The BP Gulf Coast Oil Spill Disaster of 2010 They all represent some military related examples of plans, products, procedures, which have been executed, produced, implemented with some desired outcome or GOAL.

Recent Problems: Haiti Earthquake Disaster and Recovery Capability Gap British Petroleum Oil Disaster and Recovery Capability Gap in the Gulf Coast US Army Velcro Capability Gap
BP oil leak: now partner company says firm was "reckless" as public relations disaster gets worse Photo: EPA/US COAST GUARD
History of the previous slide recalls that the actual outcomes did not align with the desired or expected outcomes. There was Discrepancy Discord Separation between the actual and desired end state or goal. What you see is what you get. Flip Wilson, Comedian What you get is not what you expected. Discrepancy What did you expect?
There was VARIABILITY!

- Behavior Not True to Type Aberrant Subject to Change (Merriam-Webster)
The Inquisitive OR Analyst will look at the actual outcome, compare it to the desired outcome or goal, and then begin to ask WHY? WHY? WHY? WHY? WHY? The answer to WHY? lies in the Root Cause that led to that variability of the GOAL. So we begin the journey of finding the WHY by conducting a
Root Cause Analysis

A part of the Six Sigma process that seeks to identify problematic causes of operational failures so that a solution can be put in place which will solve that problem and/or prevent reoccurrence of that problem.
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Abstract: Variability = Descrepancy between Observed and Desired Outcomes. Variability in plans, products, services is inevitable. Variability is problematic when variability is not explainable. variability results in an unsatisfactory outcome. Identification of root causes of variability allows us to minimize variability associated with outcomes, maximize likelihood of achieving satisfactory outcomes, create and implement action plans to maintain desired outcomes. Review of Six Sigma Tools will help Identify root causes of variability, Provide remedies to potential problems due to variability, Improve quality of desired outcomes of plans, products, or services. Prevent future incidents
Source: Walker (2000)IELD DEMONSTRATION WORKSHOP ON ROOT CAUSE ANALYSIS FOR MARINE CASUALTIES AND ENVIRONMENTAL INCIDENTS
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Brief Overview of Six Sigma

Question: What is the Six Sigma Foundation? Answer: To improve business or enterprise processes by using the DMAIC approach to problem solving.
Process Steps: 1) 2) 3) 4) 5) Defining Opportunities (What is Important?) Measuring Performance (How are we doing?) Analyzing Opportunity (What is Wrong or What is currently happening?) Improving Performance (What needs to be done?) Controlling Performance (How do we sustain performance?)
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The DMAIC Methodology
Brief Overview of Six Sigma Tools

Improvement teams use the DMAIC methodology to root out and eliminate the causes of defects: D - Define a problem or improvement opportunity. M - Measure process performance. A - Analyze the process to determine the root causes of poor performance; whether the process can Redesign determine be improved or should be redesigned. I - Improve the process by attacking root causes. C - Control the improved process to hold the gains.
Source:
http://www.asq.org/learn-about-quality/six-sigma/overview/dmaic.html
Define Measure Analyze

Modify Design?
Improve Control
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Brief Overview of Lean Six Sigma
Lean Six Sigma is distinguished from other quality systems by several themes: Focus on the customer rather than process, inputs, or outputs. Data- and fact-driven management: with an emphasis on measurement of quantitative data. Process is the key vehicle of success. monitoring the input, throughput, and output Proactive management. Implementing Six Sigma in an organization requires a high level of management buy-in. The work is delegated, but accountability is not. Emphasis on root causes: digging down beyond proximal causes to find what is really going on. Creating sustained changes, with control mechanisms in place to ensure changes are sustained over the long term. Source: What is Six Sigma?, Pete Pande and Larry Holpp, McGraw-Hill, 2002.
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Root Cause Analysis: Tools of Lean Six Sigma Definitions:
Root Cause Analysis (RCA)

A structured evaluation method that identifies the root causes for an undesired outcome (event) and the actions adequate to prevent recurrence.
Event or the Problem

A real-time occurrence describing one discrete action, typically an error, failure, or malfunction. Examples: pipe broke, power lost, lightning struck, person opened valve, etc
Cause (Causal Factor)

Root cause analysis should continue until organizational factors have been identified, or until data are exhausted. The antecedent behavior that led to the observed final behavior.
Source: www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf
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Proximate Cause(s)
The event(s) that occurred, including any condition(s) that, existed immediately before the undesired outcome, directly resulted in its occurrence and, if eliminated or modified, would have prevented the undesired outcome. Also known as the direct cause(s).
Root Cause(s)
One of multiple factors (events, conditions or organizational factors) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated, or modified would have prevented the undesired outcome. Typically multiple root causes contribute to an undesired outcome.
Condition
Any as-found state, whether or not resulting from an event, that may have safety, health, quality, security, operational, or environmental implications.
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Organizational Factors
Any operational or management structural entity that exerts control over the system at any stage in its life cycle, including but not limited to the systems concept development, design, fabrication, test, maintenance, operation, and disposal. Examples: resource management (budget, staff, training); policy (content, implementation, verification); and management decisions.
Contributing Factor(s)
An event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence.
Barrier
A physical device or an administrative control used to reduce risk of the undesired outcome to an acceptable level. Barriers can provide physical intervention (e.g., a guardrail) or procedural separation in time and space (e.g., lock-out-tag-out procedure).
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Overview of Steps in Root Cause Analysis Clearly define the undesired outcome. Conduct 5 Whys analysis to identify root causes. Create an event and causal factor tree. Gather data, including a list of all potential causes. Check your logic and eliminate items that are not causes. Generate solutions that address both proximate causes and root causes. Source: www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf
18 78th MORS Symposium (MORSS)

Root Cause Analysis Techniques for this Presentation
Identify the Problem Identify the Key Performance Parameters or Indicators Apply the 5 Whys Technique Apply the Ishikawa Fishbone Cause and Effect Chart Technique Apply the Pareto Chart Technique Apply the Failure Modes and Effects Analysis Technique Apply the Control Plan or Action Plan
+ 8 Tutorial Assignments
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Assignment #1
Identify a recurring military problem related to:

1) Personnel assignment, discipline or other personnel services 2) Intelligence collection and processing 3) Operations and Planning 4) Logistics Planning, Development and Distribution 5) Military / Civil Affairs 6) Computer and Electronic Information Processing and Evaluation 7) Training and Operations Exercise Coordination 8) Allocating Resources to Defense Strategies and The Army Plan 9) Analysis
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Assignment #2
Identify those key performance parameters or indicators used to measure success or failure of the plan, product or service related to that recurring military problem related to:

Assignment #3
Use the 5 Whys? technique to Identify the root cause of that recurring military problem related to:
The 5 Why's Root Cause Analysis Technique By repeatedly asking the question "Why" at least five times, you can peel away the layers of symptoms which can lead to the root cause of a problem. Why? Why? Why? Why? Why?
Source: http://www.emsstrategies.com/dd020106article.html
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Five Whys? Chain of Causation Example Problem: Injuries occur with great frequency.
Effects Injury Fall Wet Surface Leaky Valve Seal Failure Caused by Caused by Caused by Caused by Caused by Causes Fall Wet Surface Leaky Valve Seal Failure Poor Maintenance
Source: Quality Progress: October 2008
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Five Whys? Chain of Causation Example Problem: The Kingdom of Liberty and Freedom was lost.
Effects Loss of Kingdom Loss of Battle Loss of Rider Loss of Horse Loss of Shoe Loss of Nail Caused by Caused by Caused by Caused by Caused by Caused by Causes Loss of Battle Loss of Rider Loss of Horse Loss of Shoe Loss of Nail ?????????
Can you do this with the Army Velcro Problem?

5-Whys Exercise - Jefferson Memorial, Washington, DC - True Story Problem: Excessive amounts of seagull droppings were requiring the monument to be pressure washed much more frequently than other memorials, causing erosion and deterioration of the granite.
Inquiry: How Might We Stop the Seagulls from Swarming around the Jefferson Memorial? Source: Terry Madden (2005)
http://74.125.93.132/search?q=cache:jjmZJ8xd3z0J:www.irmi.com/conferences/crc/handouts/crc25/workshops/cuttingedgesafetyapplyinglean.pdf+root+caus e+analysis+jefferson+memorial&cd=6&hl=en&ct=clnk&gl=us
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5-Whys Exercise - Jefferson Memorial, Washington, DC - True Story
Possible Solutions: Elaborate system of spikes and nets (high- cost solution) Loud noises to chase off the birds (and tourists) Kill the birds Or, lets ask why? several times... Source: Terry Madden (2005)
http://74.125.93.132/search?q=cache:jjmZJ8xd3z0J:www.irmi.com/conferences/crc/handouts/crc25/workshops/cuttingedgesafetyapplyinglean.pdf+root+cau se+analysis+jefferson+memorial&cd=6&hl=en&ct=clnk&gl=us
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5-Whys Exercise - Jefferson Memorial, Washington, DC True Story (cont.) Source: Terry Madden (2005) The Jefferson Memorial is requiring excessive power washes. Why? Because seagulls are swarming to the monument and depositing large amounts of droppings. Why? Because they are feeding on an unusually large amount of spiders living under the roof line. Why? Because the spiders are feeding on an unusually high number of midge flies as they hatch throughout the day. Why? Because midge fly larva is literally caked under the roof line of the memorial. Why?
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5-Whys Exercise - Jefferson Memorial, Washington, DC True Story (cont.) Source: Terry Madden (2005)
Root Cause... As it turns out, the lights that illuminate the memorial were set to come on automatically 20 minutes before dusk. This twilight condition created a ideal condition for midge flies to mate.
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5-Whys Exercise - Jefferson Memorial, Washington, DC True Story (cont.) Source: Terry Madden (2005)
Solution: The automatic lights were reset to reduce the twilight condition Result: Fewer midge flies Fewer spiders Fewer seagulls Less droppings Fewer power washings Slower Deterioration of the Jefferson Memorial
Jefferson Memorial Slide Show

http://www.slideshare.net/gibsonjunkie/jefferson-memorial
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Assignment #4
Identify those categories of causation that contribute to the variability in outcome of the plan, product or service of that recurring military problem related to:
Causal Categories:
Categories Man Machine Material Method Measurement Mother Nature Categories Machine Method Measurement Material People Environment Categories Equipment Process People Material Management Environment
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Other Causal Categories:

Categories Method Machine Material Management Manpower Categories Doctrine Organization Training Materiel Leadership and Education Personnel Facilities Categories Political Element Military Element Economic Element Social Element Information Element Infrastructure Element Physical Environment Element Time Element
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CONTEMPORARY OPERATIONAL ENVIRONMENT VARIABLES (PMESII-PT) Political. Describes the distribution of responsibility and power at all levels of governance or cooperation. Military. Explores the military capabilities of all relevant actors in a given operational environment. Economic. Encompasses individual behaviors and aggregate phenomena related to the production, distribution, and consumption of resources. Social. Describes the cultural, religious, and ethnic makeup within an operational environment.
https://rdl.train.army.mil/soldierPortal/atia/adlsc/view/public/10536-1/FM/20/chap1.htm;jsessionid=hGfGJ2qZ3C3hghQGGP88HvSSXhcKsc3pYQ1KB62r1TLw7b1yy9vb!467865
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CONTEMPORARY OPERATIONAL ENVIRONMENT VARIABLES (PMESII-PT) Information. Describes the nature, scope, characteristics, and effects of individuals, organizations, and systems that collect, process, disseminate, or act on information. Infrastructure. Is composed of the basic facilities, services, and installations needed for the functioning of a community or society. Physical Environment. Defines the physical circumstances and conditions that influence the execution of operations throughout the domains of air, land, sea, and space. Time. Influences military operations within an operational environment in terms of the decision cycles, operational tempo, and planning horizons. (FM 3-0)
https://rdl.train.army.mil/soldierPortal/atia/adlsc/view/public/10536-1/FM/20/chap1.htm;jsessionid=hGfGJ2qZ3C3hghQGGP88HvSSXhcKsc3pYQ1KB62r1TLw7b1yy9vb!467865
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The Fishbone Diagram Root Cause Analysis Technique:

Causal Categories resemble the skeleton of a fish. The failure event or problem is stated in the box to the right. Major causes are usually summarized as Methods, Measurements, Machines, Materials, and People. Under each category, identify potential causes for the problem relating to the category. For example: Incorrect parts being delivered to the assembly area is a potential cause for the Materials category.
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Ishikawa Fishbone Diagram - Wikipedia
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Fishbone Diagram Example
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The nail was lost.
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The wreckage that was left after the RH-53 Sea Stallion Helicopter and MC-130 Aircraft collided in the desert during Operation Eagle Claw April 25, 1980. (Courtesy photo)
Source: http://www.hurlburt.af.mil/news/story_media.asp?id=123095779
Operation Eagle Claw Remembered Operation Eagle Claw remembered the members from the 8th Special Operations Squadron who died in the fatal accident during Operation Eagle Claw were (from left to right) Capt. Richard Bakke, Tech. Sgt. Joel Mayo, Capt. Lyn McIntosh, Capt. Hal Lewis and Capt. Charles McMillan. (Courtesy photo)
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Recent Problems: Haiti Earthquake Disaster and Recovery Capability Gap British Petroleum Oil Disaster and Recovery Capability Gap in the Gulf Coast US Army Velcro Capability Gap
BP oil leak: now partner company says firm was "reckless" as public relations disaster gets worse Photo: EPA/US COAST GUARD
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43
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British Petroleum Oil Spill Disaster 2010
Equipment
Process
People The BP Blowout Preventer Device Failed
Management
Environment
Material
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Assignment #5
Use your chosen categories of causation to construct a Fishbone Cause and Effect Diagram for that recurring military problem related to:

Creating A Cause-and-Effect Diagram Place the problem in the square to the right and construct a fish vertibrae with 5, 6, or 7 extensions. The 6 basic categories are easily remembered from the anagram "5 ME".
Source: http://thequalityweb.com/cause.html
MAN METHOD -
Does the operator have the proper training, experience, and ability to perform the function? Are the work instructions available and up-to-date? Do they reflect the best method to perform the task? Are the proper tools available? Are the process parameters specified clearly? Does the machine have the capability to produce the product as specified? Does the machine have the ability to produce the product on a consistent basis? Are there regular routine maintenance and preventative maintenance tasks? Are they performed according to schedule? Are the correct materials available for the process? What is the quality of the material used in the process? Is there more than one supplier and does quality vary with different suppliers? What types of material problems could exist? Are the measurement instruments adequate for the process? Are they maintained correctly and regularly calibrated? Are the measurement instruments affected by environmental conditions such as temperature, vibration, dirt, etc.? Is the manufacturing environment affected by temperature, humidity, dust and dirt, power fluctuations or seasonal differences?
MACHINE -
MATERIAL -
MEASUREMENT -
ENVIRONMENT -
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People Machines Measurements
Training Communication
Fixtures
ed nc ot l rie s n el pe tor s w . ex ra a rs In e d e op ine oth a tr as
to e le no bl b A em tly ke s o c as rre a-y co e in ok p
n of tio ck ica La un een d m w an s. m t rs er e co b te bl s m te se as
Incorrectly Assembled Parts
Not verified at Standard Work Charts incorrect process Incorrect parts delivered to line
Methods
Materials
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The Pareto Chart Analysis Technique
Source: http://www.schools.utah.gov/sars/servicesinfo/module4/04pchart.pdf
Pareto Chart - Named after Vilfredo Pareto, a 19th century economist who postulated that a large share of wealth is owned by a small percentage of the population. The descending bar chart is used to separate the vital few from the trivial many. Based on the Pareto Principle which states that 80 percent of the problems come from 20 percent of the causes.
A Pareto Chart can answer the following questions: o What are the largest issues facing our team or business? o What 20% of sources are causing 80% of the problems? o Where should we focus our efforts to achieve the greatest improvements?
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When is the Pareto Chart useful? The Pareto analysis technique is used primarily to identify and evaluate nonconformities Pareto Charts convey information in a way that enables you to see clearly the choices that should be made, they can be used to set priorities for many practical applications. Some examples are: o Process improvement efforts for increased unit readiness o Skills you want your division to have o Customer needs o Suppliers o Investment opportunities

Consider the following example: Your business was investigating the delay associated with processing credit card applications. You could group the data into the following categories and their frequencies of occurrence.
Step 1
Construct a Frequency Chart
Step 2 Order the categories according to

descending frequency.
Category No address Illegible Current customer No signature Other Total
Frequency 9 22 15 40 8 94
Category No signature Illegible Current customer No address Other Total
Frequency 40 22 15 9 8 94
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Step 3 and Step 4

Compute Relative Frequencies and Cumulative Relative Frequencies Category No signature Illegible Current customer No address Other Frequency 40 22 15 9 8 Percentage 43% 23% 16% 10% 8% Cumulative Percentage 43% 66% 82% 92% 100%
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Step 5 Draw the descending bar chart and the cumulative line graph together
Pareto Chart of Category
90 80 70 60 50 40 30 20 10 0
100 80 60 40 20
Frequency
Category
No
Frequency Percent Cum %
a gn Si
e tur
Ille
le gib
40 42.6 42.6
22 23.4 66.0
to us C nt e r r Cu
er
r dd A No
s es
r he Ot
15 16.0 81.9
9 9.6 91.5
8 8.5 100.0
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Percent

Things to look for on your Pareto Chart: In most cases, two or three categories will tower above the others. These few categories which account for the bulk of the problem will be the high-impact points on which to focus. If in doubt, follow these guidelines: 1. Look for a break point in the cumulative percentage line. This point occurs where the slop of the line begins to flatten out. The factors under the steepest part of the curve are the most important. 2. If there is not a fairly clear change in the slope of the line, look for the factors that make up at least 60% of the problem. You can always improve these few, redo the Pareto analysis, and discover the factors that have risen to the top now that the biggest ones have been improved. 3. If the bars are all similar sizes or more than half of the categories are needed to make up the needed 60%, try a different breakdown of categories that might be more appropriate.

Assignment #6
Using your chosen categories of causation and associated frequencies of occurrences construct a Pareto Chart for that recurring military problem related to:
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The District 11 Southern Region (SR) Auxiliary Strategic Plan for 2007-2008: The District 11 of the Southern Region (SR) reviewed its Strategic Plan of 2005-6: Issues of review included:
Problems Unavailable fuel for Patrols Coast Guard Training to serve the Sector needs AUX Structure Alignment Communication AUX Officer Training
Issues Operations Issues Human Resource Issues Organizational Management Issues Technology Issues Facilities Issues
- With the Management tools of SWOT Analysis (Strengths Weaknesses Opportunities Threats) - Balanced Score Card - Pareto Chart Analysis
Source: DISTRICT 11 (SR) AUXILIARY STRATEGIC PLAN 2007-2008
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Pareto Chart Analysis Findings: Weaknesses in Coast Guard Operations 1. New Boat Crew requalification requirements 2. Poor bottom to top chain of communications 3. Old, poorly maintained facility equipment 4. Poor direction for MOM (Marinetime Observation Mission) patrols 5. Members on limited income find it hard to participate 6. Limited planning and goals
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Pareto Chart Analysis Findings Weaknesses in Coast Guard Human Resources 1. Average age of the member is over 50 2. Low membership participation (80/20 rule) 3. Poor emphasis on member retention 4. Poor mentoring 5. AP status requires too much time 6. Members dont follow chain of leadership 7. Poor recruitment of youth 8. No plan in flotillas for new members 9. Need more emphasis on Elected Officer training at flotilla and Division 10. Need more qualified coxswains 11. Too much paperwork 12. Too many levels in the organization
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Pareto Chart Analysis Findings Weaknesses in Coast Guard Organizational Management 1. Poor communication by leaders 2. Staff officers are not effective 3. Flotillas struggle to survive with poor focus on increasing membership 4. Poor inter-flotilla communications 5. Members get positions based on popularity not ability 6. Low/no funding for staff 7. Excessive levels of leadership 8. Too much paperwork/forms and reports required
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Pareto Chart Analysis Findings Weaknesses in Coast Guard Technology/Facilities 1. Not enough facilities 2. Communications with older age members is challenging 3. Not enough emphasis to members to view web sites for communications 4. POMS to fragile 5. Emphasis on E learning not available to all members 6. No FAQ on web sites 7. Inputting of data into AUXDATA is by a volunteer member and may not be inputted or slow to input 8. CG is reluctant to pay damage claims 9. CG will not furnish boats in this district increasing wear-tear on member boats
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Coast Guard Study Findings
Using the SWOT analysis, it was found that the top area weakness was OPERATIONS. The second weakness was poor bottom to top CHAIN of COMMUNICATIONS.
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Failure Modes and Effects Analysis (FMEA) Also called: potential failure modes and effects analysis; failure modes, effects and criticality analysis (FMECA). Description Failure modes and effects analysis (FMEA) is a step-by-step approach for identifying all possible failures in a design, a manufacturing or assembly process, or a product or service.
Source: http://www.asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html
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Types of FMEA System - focuses on global system functions Design - focuses on components and subsystems Process - focuses on manufacturing and assembly processes Service - focuses on service functions Software - focuses on software functions
Source: http://www.npd-solutions.com/fmea.html
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FMEA Procedure 1. Describe the plan/process/product/program and its functions. 2. Populate the FMEA table with necessary identification information. 3. Identify the function or functions associated with the plan/process/product/program. 4. Identify the failure mode, i.e., what could go wrong.
http://www.npd-solutions.com/fmea.html
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FMEA Procedure (cont.) 4. Identify Failure Modes. A failure mode is defined as the manner in which a component, subsystem, system, process, etc. could potentially fail to meet the design intent. Examples of potential failure modes include:
Corrosion Hydrogen embrittlement Electrical Short or Open Torque Fatigue Deformation Cracking Breakage
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FMEA Procedure (cont.) 5. Identify potential EFFECTS of each failure mode. Examples of failure effects include:
Injury to the user Inoperability of the product or process Improper appearance of the product or process Odors Degraded performance Noise Death
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FMEA Procedure (cont.) 6. Assign a SEVERITY rating from the SEVERITY scale indicating the magnitude of the failure effect. 1 = not severe. 10 = catastrophic.
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FMEA Procedure (cont.) Severity Scale

Rating 10 9 8 7 Description Extremely dangerous Very dangerous Dangerous Definition (Severity Scale) Failure could cause death of a customer (patient, visitor, employee, staff member, business partner) and/or total system breakdown. Failure could cause major or permanent injury and/or serious system disruption with interruption in service. Failure causes minor to moderate injury with a high degree of customer dissatisfaction and/or major system problems requiring major repairs or significant re-work. Failure causes minor injury with some customer dissatisfaction and/or major system problems. Failure causes very minor or no injury but annoys customers and/or results in minor system problems that can be overcome with minor modifications to system or process. Failure causes no injury and customer is unaware of problem however the potential for minor injury exists; little or no effect on system. Failure causes no injury and has no impact on system.
6 5 4 3 2 1
Moderate danger Low to Moderate danger Slight danger No danger
Source: Goodman (1996)
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FMEA Procedure (cont.) 7. Identify the causes for each failure mode. A failure cause is defined as a design weakness that may result in a failure. Examples of potential causes include:
Improper torque applied Improper operating conditions Contamination Erroneous algorithms Improper alignment Excessive loading Excessive voltage
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FMEA Procedure (cont.) 7. Assign an OCCURRENCE rating from the OCCURRENCE scale indicating the magnitude of the failure cause. 1 = Virtually certain not to occur. 10 = Virtually certain to occur.
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FMEA Procedure (cont.) Occurrence Scale

Rating 10 9 8 7 6 5 4 3 2 1 Description Certain probability of occurrence Failure is almost Inevitable Very high probability of occurrence Moderately high probability of occurrence Moderate probability of occurrence Low probability of occurrence Remote probability of occurrence Potential Failure Rate Failure occurs at least once a day. 1 in 5 Failure occurs every 3 or 4 days. 1 in 10 Failure occurs once per week. 1 in 50 Failure occurs once per month. 1 in 100 Failure occurs once every 3 months. 1 in 500 Failure occurs once per year. 1 in 1000 Failure almost never occurs; no one remembers last failure.
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FMEA Procedure (cont.) 8. Identify Current Controls (design or process). Current Controls (design or process) are the mechanisms that prevent the cause of the failure mode from occurring or which detect the failure before it reaches the customer. Detection is an assessment of the likelihood that the Current Controls (design and process) will detect the Cause of the Failure Mode or the Failure Mode itself, thus preventing it from reaching the Customer.
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FMEA Procedure (cont.) Examples of Current Controls (design or process) might include: Temperature Gauge Early Warning System Two Proofreaders Bank Notice that your account is below a certain amount Lexus Rear View Camera when in reverse
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FMEA Procedure (cont.) 8. Assign a DETECTION rating from the DETECTIBILITY scale indicating the magnitude of the failure effect. 1 = Virtually certain to Detect. 10 = Virtually certain not to Detect.
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FMEA Procedure (cont.)

Detection Scale
Rating 10 9 8 7 6 5 Description No chance of detection Very Remote / Unreliable Remote Definition There is no known mechanism for detecting the failure.
4 3 2 1
The failure can be detected only with thorough inspection and this is not feasible or cannot be readily done. The error can be detected with manual inspection but no process is in place so that detection left to chance. There is a process for double-checks or inspection but it is Moderate not automated and/or is applied only to a sample and/or chance of relies on vigilance. detection High There is 100% inspection or review of the process but it is not automated. Very High There is 100% inspection of the process and it is automated. Almost Certain There are automatic shut-offs or constraints that prevent failure.
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FMEA Procedure 9. Compute Risk Priority Numbers (RPN). The Risk Priority Number is a mathematical product of the numerical Severity, Occurrence, and Detection ratings: RPN = (Severity) x (Occurrence) x (Detection) RPN values may range from 1 to 1000. The RPN is used to prioritize items than require additional quality planning or action.
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FMEA Procedure (cont.) 10. Determine Recommended Action(s) to address potential failures that have a high RPN. - Assign Responsibility and a Target Completion Date for these actions. - Indicate Actions Taken. After these actions have been taken, re-assess the severity, probability and detection and review the revised RPN's. - Update the FMEA as the design or process changes, the assessment changes or new information becomes known.
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FMEA Example
Function Potential Failure Mode Potential Effects of Failure Dissatisfied Customer S Potential Cause(s) of Failure O Current Process Controls D R P N 200 CRIT (S x O)
Dispense amount of cash requested by customer
Does not dispense cash
Out of Cash
Internal low cash alert Internal jam alert
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Machine jams Incorrect entry to demand deposit system Discrepancy in cash balancing Dispenses too much cash Bank loses money Discrepancy in cash balancing Takes too long to dispense cash Customer is somewhat annoyed 3 6 Bills stuck together Denominations in wrong trays Heavy computer network traffic Power interruption during transaction
10
240
24
Power failure during transaction
None
10
160
16
Loading procedure (ruffle ends of stack) Two-person visual verification None
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12
3 7
4 10
72 210
18 21
None
10
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http://www.asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html
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Reliability Analysis Quick Subject Guide
Source: http://www.weibull.com/basics/fmea.htm
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Assignment #7
Conduct a FMEA for that recurring military problem related to: ex: British Petroleum Blowout Preventer
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FMEA Procedure (cont.)
The Failure Mode and Effects Analysis Approach actually provides a very nice segue into the last technique known as Quality Control or Action Plan.
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Control Techniques
Quality Control -To effectively maintain new standard methods, you really need to: Verify the results and validate that changes adhere to all operating and compliance policies. Document the new methods in such a way that people will find them easy to use, and provide training to everyone who will use the new methods. Monitor implementation and make regular course corrections. Summarize your learning and share them with co-workers involved in similar projects, with customers, and with managers who need to know the final outcome. Think about what should be taken on next in the process to further improve the sigma level(s).
http://www.thequalityweb.com/controlsixsig.html
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Control Techniques 1. Control charts 2. Data Collection 3. Flow diagrams 4. Charts to compare the before and after, such as frequency plots, Pareto charts, etc. 5. Quality Control Process Chart 6. Establishing Standardization (Control Plan)
http://www.thequalityweb.com/controlsixsig.html
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Assignment #8
Write a Quality Control Action Plan that will provide documentation and instructions on how to maintain the new found quality of your solution to that recurring military problem related to:
A Tutorial Review
We detected and identified a problem. We identified key performance parameters or indicators for that problem. We conducted a 5 Whys? analysis to identify the root cause of that problem. We identified categories of causation for variability of that problem. We constructed a Fishbone Cause and Effects Chart for that problem. We performed a Pareto Chart Analysis of causes of that problem. We conducted a FMEA related to that problem. We identified some fixes to that problem with the FMEA table. We created a Quality Control plan or Action Plan for the maintenance of the quality of the solution(s) to that problem.
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Root Cause Analysis: Tools of Lean Six Sigma CLOSING: -We have devised a way to minimize variability. -We have a better perspective on making sure the desired outcome and the actual outcome are one in the same. -We have defeated the battle against discrepancy. -Our plans, products, processes, programs and procedures will yield our desired results and help us achieve our SMART goals. - Operation Eagle Claw, the JCIDS process, the OSPREY, the Space Shuttles Challenger and Columbia programs were not vainly wasted. -So thanks to Root Cause Analysis
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For quality of the nail, the shoe will not be lost.
87
For quality of the shoe, the horse will not be lost.
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For quality of the horse, the rider will not be lost.
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For quality of the rider, the battle will not be lost.
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For victory in battle, the kingdom will not be lost.
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For protecting the kingdom, freedom and liberty will never be lost.
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And all for the quality of a nail...
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Source http://www.guardian.co.uk/environment/2010/jun/20/gulf-oil-spill-bp-lying
Well, . Almost. Anybody got a nail?

The root cause of success.
Go forth into the world rejoicing in the spirit of Quality and accomplishing your desired Goals. Thanks be to Quality!
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Solving Tomorrows Problems Today And Resolving Yesterdays Problems As Well.

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Thank You! Questions ??
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77 Lewis Root Cause - 77 MORS

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Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Solving Tomorrows Problems Today And Resolving Yesterdays Problems As Well.

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

There was VARIABILITY!

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Root Cause Analysis

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Brief Overview of Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Brief Overview of Six Sigma Tools

Define Measure Analyze

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Root Cause Analysis: Tools of Lean Six Sigma Definitions:

Root Cause Analysis (RCA)

Event or the Problem

Cause (Causal Factor)

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma Definitions:

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma Definitions:

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Identify a recurring military problem related to:

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Root Cause Analysis: Tools of Lean Six Sigma

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Source: Quality Progress: October 2008

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

Can you do this with the Army Velcro Problem?

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)

Root Cause Analysis: Tools of Lean Six Sigma

78th MORS Symposium (MORSS)