A-Summary-of-Apollo-Root-Cause-Problem-Solving

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					A Summary of Apollo Root Cause Problem Solving
Holly Duckworth Master Black Belt TRW Automotive 4/16/2008

Method Credited to…
Based upon the book: “Apollo Root Cause Analysis”, Dean L. Gano, 2nd ed., Apollonian Publications, Yakima, Washington, 2003.

Problem Solving Techniques




Problem Resolution -- to help identify and rectify an identified problem – a “special cause” situation  8-D problem solving Process Improvement -- to identify and implement improvements proactively – a “common cause” situation  Six Sigma process improvement  8-D Problems solving can be used within a six sigma project to solve special cause issues

PDCA
Act Implement the change, if appropriate. Make all needed systems changes to formalize Plan

Act Check

Plan Do

Plan for a change needed to solve the problem/improve the process

Check Check the impacts of the proposed change.

Do Test change on a small scale. Collect data.

8-D Problem Solving
The Eight Disciplines* (8-D) are:
Team Formation Problem Description Interim Corrective Action Root Cause Identification Choosing/Verifying Permanent Corrective Action Implementing Permanent Corrective Action Preventing Problem Recurrence Recognizing the Team We will focus on the unique root cause identification tools in this lecture

*Generally attributed to Ford Motor Company

Root Cause Identification




We always start with understanding the EFFECT  However, in each problem there is usually a series of effects and causes Example:

Effect
Injury Fall Wet Floor Mopping Mud in Aisle

Cause
Fall Wet Floor Mopping Mud in Aisle No mat at door

Root Cause Identification


What we also find is that every EFFECT is caused by a combination of CONDITIONS and ACTIONS  Conditions – Causes that exist prior to an action  Actions – Momentary causes that bring the condition and effect together

Action: Match Strike
Condition: Ignition Contact Condition: Fuel-Dry Brush Condition: Oxygen

Effect: Brush Fire

Defect and Systemic Root Cause


The effect is an employee slips and falls  The defect root cause is the employee walking across a wet floor  The condition is the wet floor  The action is the employee walking on the wet floor  The systemic root cause is the employee choosing the at-risk behavior and/or the janitor not marking the wet floor

Cause and Effect Diagrams


We might use a “fish bone” diagram, but only to brainstorm possible causes (conditions and actions)
People Materials Equipment

Effect

Methods

Measurement

Environment

Cause and Effect Diagrams


But the important tool in Apollo Root Cause Problem Solving is the Condition/Action Chart Action: Employee
Action: Employee walks on wet floor

chooses to ignore wet floor sign
Condition: “At risk” behavior not corrected

Effect: Employee Slips and Falls

Action: Janitor mops up mud
Condition: Wet floor Condition: Muddy floor

Action: No mat placed at door Condition: No side walk to walk on

Condition/Action Analysis


Let’s walk through an example…

Condition: Battery is dead

Effect: Car doesn’t start

Condition: Car is out of gas

Condition: Starter is defective

Action: Ignition switch does not start the car

Condition/Action Analysis


We must now VERIFY each condition and action with EVIDENCE

Condition: Battery is dead
Evidence: voltmeter shows low

Effect: Car doesn’t start

Condition: Car is out of gas
Gage shows ¾ tank full

Condition: Starter is defective
New car with no prior starter issues

Action: Ignition switch does not start the car
Evidence: personal observation

Condition/Action Analysis


Next, we analyze the next “layer”
Effect: Car doesn’t start

Condition: Battery beyond warranty life Condition: Battery is dead
Evidence: voltmeter shows low Evidence: 5yr warranty v. purchase date

Action: Battery not replaced
Evidence: original batter observed

Condition: Car is out of gas
Gage shows ¾ tank full

Condition: Starter is defective
New car with no prior starter issues

Condition: No voltage to starter Action: Ignition switch does not start the Evidence: personal observation car
Evidence: observation of voltmeter

Action: Repeated trial of ignition switch
Evidence: personal observation

Condition/Action Analysis


Can we take these causes any further?
Effect: Car doesn’t start

Condition: Battery beyond warranty life Condition: Battery is dead
Evidence: voltmeter shows low Evidence: 5yr warranty v. purchase date

Action: Battery not replaced
Evidence: original batter observed

Condition: Car is out of gas
Gage shows ¾ tank full

Condition: Starter is defective
New car with no prior starter issues

Condition: No voltage to starter Action: Ignition switch does not start the Evidence: personal observation car
Evidence: observation of voltmeter

Action: Repeated trial of ignition switch
Evidence: personal observation

Condition/Action Analysis
Condition: Battery is dead Condition: Battery beyond warranty life Condition: Lowest cost objective Action: New battery purchase delayed

Effect: Car doesn’t start

Condition: Car is out of gas

Action: Battery not replaced


Condition: Starter is defective

These are the defect root causes
Condition: No voltage to starter



These are the systemic root causes

Action: Ignition switch does not start the car

Action: Repeated trial of ignition switch

Condition/Action Analysis


How do you know when to stop?  Answers are nonsense or repeated  Condition/Action Charting is an iterative process  Once a draft chart is finished, start at the beginning and refine  All Actions and Conditions should be verified with evidence  This may take some time

Solutions


 

The best solutions address CONDITIONS  If we can remove conditions, then it doesn’t matter what actions happen There may be multiple root causes with multiple conditions It may be too costly to address CONDITIONS, then ACTIONS should be addressed

Systemic Corrective Action on CONDITIONS will prevent recurrence

Apollo Root Cause Problem Solving


Condition/Action Charting and Analysis  Another tool in the tool box



Now you’ll try an example.


				
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