Corrective Action Problem Solving Carol Kurtz CJ Kurtz Associates LLC CJ Kurtz Associates LLC 1 Trainer Carol Kurtz American Society for Quality ASQ  by iuk55253

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									Corrective Action
Problem Solving
   Carol Kurtz
   CJ Kurtz & Associates LLC




               CJ Kurtz & Associates LLC   1
Trainer: Carol Kurtz

 American Society for Quality (ASQ)
  Certified Quality Engineer
  Certified Quality Auditor
  Certified Quality Manager
  Certified Mechanical Inspector

     20+ years of Quality & Manufacturing
     Experience


                   CJ Kurtz & Associates LLC   2
Course Objectives

  Understand 8D Corrective Action &
   Problem Process
  Identify and Use Tools for Each 8D
   Process Step
  Understand Vocabulary & Principles
  Compare to Other Fact Based Problem
   Solving Methods


               CJ Kurtz & Associates LLC   3
Corrective Action

  Action to eliminate the cause of a
   detected nonconformity.
  Action to protect the customer from
   receiving or using nonconforming
   product.
  Corrective action is taken to prevent
   recurrence.


                 CJ Kurtz & Associates LLC   4
Problem Solving

  Problem Solving: Typically involves a
   methodology of clarifying the description
   of the problem, analyzing causes,
   identifying alternatives, assessing each
   alternative, choosing one, implementing
   it, and evaluating whether the problem
   was solved or not.
  8D, PDCA, DMAIC (du-may-ic)


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Corrective Action Origins
    The origins of the 8-D
     system actually goes back
     many years.
    The US Government first
     „standardized‟ the system in
     Mil-Std-1520 “Corrective
     Action and Disposition
     System for Nonconforming
     Material”
    Mil-Std-1520 - First
     released: 1974
    Last Revision was C of 1986
    Cancelled in 1995

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What is 8D?

  8D means Eight Disciplines
  It is a methodology used for solving
   problems
  8D also refers to the form that is used to
   document the problem and resolution
      Also called 8-D Report
      Corrective Action Report

      EW8D Report – East-West-8D


                  CJ Kurtz & Associates LLC     7
Why 8D?
  8D is a structured approach to solving
   problems
  Fact Based
        Data Collection & Analysis
    Tests progress and results
        Verify & Validate
    Documented
        History – An information database
        Anticipate future problems
        Prevent recurrence

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8D Corrective Action
                       D4:
                                                               D5: Choose &
  D0: Recognize the                  Identify Potential
                                                              Verify Corrective
       Problem                            Causes
                                                                   Actions




                                                               D6: Implement &
   D1: Establish the                   Select Likely
                                                                    Validate
        Team                             Causes
                                                              Corrective Actions




   D2: Describe the                                              D7: Prevent
                             No        Root Cause?
       Problem                                                   Recurrence


                                            Yes

  D3: Determine and
      Implement                      Identify Possible        D8: Congratulate
    Containment                     Corrective Actions            the Team
       Actions



                                  CJ Kurtz & Associates LLC                        9
Six Sigma DMAIC
                D1: Team Approach
                D0: Recognize Problem
      Define    D2: Describe Problem
                D3: Containment


     Measure

      Analyze   D4: Define & Verify Root Causes




      Improve   D5: Select & Validate Corrective Actions
                D6: Implement Corrective Actions


      Control   D7: Prevent Recurrence

                D8: Congratulate Team

                   CJ Kurtz & Associates LLC               10
Plan Do Check Act - PDCA
                                  D1: Team Approach
   Plan:                          D0: Recognize Problem
      Identify the Problem        D2: Describe Problem
      Analyze The Problem         D3: Containment

   Do:
          Develop Solutions
         Implement Solutions
                                  D4: Define & Verify Root Causes
                                  D5: Select & Validate Corrective Actions
   Check:                         D6: Implement Corrective Actions
        Evaluate Results
    Achieve Desired Results?


   Act:
   Standardize Solution           D7: Prevent Recurrence

                                  D8: Congratulate Team

                               CJ Kurtz & Associates LLC                     11
Some Vocabulary

    Problem                          Effect
    Symptom                          Cause
    Concern                          Special Cause
    Root Problem                     Common Cause
    Failure Mode                     Root Cause




                    CJ Kurtz & Associates LLC          12
Verification & Validation
 Verification and Validation are often not
 well understood. Verification and
 Validation work together as a sort of
 „before‟ (Verification) and „after‟
 (Validation) proof.
  Verification  provides „insurance‟ at a point in
   time that the action will do what it is intended
   to do without causing another problem.
   Predictive.
  Validation provides measurable „evidence‟
   over time that the action worked properly.

                    CJ Kurtz & Associates LLC         13
Verification & Validation


 Step     Process                                  Purpose
                       That the containment action will stop the symptom from
  D3    Verification
                       reaching the customer.
                       That the containment action has satisfactorily stopped
        Validation     the symptom from reaching the customer according to
                       the same indicator that made it apparent.
  D4    Verification   That the real Root Cause is identified.
  D5    Verification   That the corrective action will eliminate the problem.
                       That the corrective action has eliminated the problem
  D6    Validation
                       according to the same indicator that made it apparent.



                               CJ Kurtz & Associates LLC                        14
Structure of a Problem

  Determining the structure of a problem
   assists in the selection of the correct
   tools to use.
  It may give clues to the nature of the root
   causes.




                  CJ Kurtz & Associates LLC   15
Structure of a Problem

 Gradual change, deteriorating performance over time:
    Established
    Performance
                                                        Time




 Sudden change, catastrophic change from standard:
    Established
    Performance
                                                        Time




                         CJ Kurtz & Associates LLC        16
Structure of a Problem                               (continued)



 Start-up, gap between expected and actual performance:
     Expected
    Performance
                                                                   Time


      Actual
    Performance



 Recurring change, comes and goes with unknown causes:
    Established
    Performance
                                                                   Time




                         CJ Kurtz & Associates LLC                   17
Structure of a Problem                         (continued)




Positive change:
   Established
   Performance
                                                             Time




 Sometimes we experience positive changes
 that need to be investigated so that processes
 and products may be improved.



                   CJ Kurtz & Associates LLC                    18
Classifying Problems

  Correctly categorizing and classifying a
   problem precedes any problem solving
   effort.
  Ensures proper methods and tools are
   selected.
  If not done, wasted time and effort may
   occur and wrong solutions may be
   implemented.

                 CJ Kurtz & Associates LLC    19
Classifying Problems – Type I

    Plant Floor Problems
        Rapid response is needed
        Usually have discernable root causes
        Usually require less data collection and analysis
        Usually can be solved by local experts
        Usually gradual or sudden problem structures
        Special causes
        Specific problem requiring Problem Analysis
        8D methodology applies


                         CJ Kurtz & Associates LLC           20
Classifying Problems – Type II

    Technical Problems
        Permanent corrective actions are needed
        Usually have difficult to discern root causes
        Usually require more data collection and analysis
        Usually require some technical expertise to solve
        May be any problem structure
        Special Causes
        Specific problem requiring Problem Analysis
        8D methodology applies


                         CJ Kurtz & Associates LLC           21
Classifying Problems – Type III
    Process Improvement
        Major systemic fixes needed
        Multiple causes and effects
        May require data collection and analysis
        May need “systems thinking” to solve
        Usually requires process owner‟s involvement
        Common cause problem
        Structures include startup and positive. Others may apply.
        Broad problems requiring a Situation Analysis
        Quality Improvement Projects, Continual Improvement
         Projects or other methodologies apply.




                            CJ Kurtz & Associates LLC                 22
Problem Solving Tools
  Trend Chart                     Situation Analysis
  Control Chart                   Flowchart
  Pareto Chart                    Failure Analysis
  Brainstorm                      Database
  Checksheet                      Decision Analysis
  Histogram                       Action Plan
  Nominal Group                   Root Cause Analysis
   Technique                       Cause & Effect Diagram
  Five Why‟s                      Scatter Diagram
  Computer Aided                  Design of Experiments
   Engineering                     Poka Yoke
  APQP
                                   Preventive Action Matrix


                    CJ Kurtz & Associates LLC                  23
Problem Solving Tools
             Tool                      Purpose                   8D Step
                           Indicator to track magnitude of D1 D2 D3 D4 D5 D6
     Trend Chart
                           symptoms                        D7 D8
                           Quantifier to prioritize and
     Pareto Chart                                          D2 D8
                           subdivide the problems
                           Indicator to monitor and
     Paynter Chart                                         D2 D3 D6 D8
                           validate the problems
                           Method to move from symptom
     Repeated Why                                      D2
                           to problem description
                          Process to find root cause
     Information Database using Is/Is Not, Differences,    D2 D4 D5 D6
                          Changes
                           Method to choose best action
     Decision Making                                    D3 D5
                           from among alternatives
                           Record of assignments,          D1 D2 D3 D4 D5 D6
     Action Plan
                           responsibilities and timing     D7 D8
                           Report of problem solving
                                                           D1 D2 D3 D4 D5 D6
     EW 8D                 process for management
                                                           D7 D8
                           review


                               CJ Kurtz & Associates LLC                       24
Problem Solving Tools Quiz

                               Trend Charts

          Pareto
          Analysis
                                                               RAC-
                                                             Root Cause
                                                              Analysis



      ?                          Problem
                                 Solving
                                  Tools
                                                                          ?
                                                       RAC-
              Pareto
                                                     Root Cause
              Analysis
                                                      Analysis



                                   ?
                         CJ Kurtz & Associates LLC                            25
D0: Recognize the Symptoms

    Detect the problem!
      Nonconforming Product
      Out of Control Conditions on Charts

      Rework

      Trend Charts

      What others?

     

     


                    CJ Kurtz & Associates LLC   26
D0: Recognize the Symptoms
   Here?        Supplier

                    In
                   Tran
 Or Here?           sit              Or Here?             Or Here?

            Company
                Receiving /                               Inventory /
                                     In-Process
                 Inventory                                 Shipping

                                                               In
                Or Here?                                      Tran
                                        Or Here?               sit      Or Here?


                                     Or Here?             Customer



                              CJ Kurtz & Associates LLC                      27
D0: Recognize the Symptoms
Trend Chart
 A line graph plotting data over time.
  Use to observe behavior over time
  Provides a baseline and visual examination of
   trends
  No statistical analysis
  Look for trends and patterns
  Ask “Why?”
  Good for operations/processes where data for
   control charts is not available


                   CJ Kurtz & Associates LLC       28
D0: Recognize the Symptoms
Trend Chart
           Average Hours Worked Per Employee (3rd shift)
   45
   44
   43
   42
   41
   40
   39
   38
   37
   36
   35
        Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
                Change shift starting times
                New entrance opened.
                Task group established.

                         CJ Kurtz & Associates LLC         29
D0: Recognize the Symptoms


    Nonconforming Product
    Out of Control Conditions on Charts

    Rework

    Trend Charts

    What others?

   

   



                  CJ Kurtz & Associates LLC   30
D0: Recognize the Symptoms
Control Chart
   A line graph of a quality characteristic
   that has been measured over time
    Based on sample averages or individual
     samples
    Includes statistically determined Control
     Limits.
    Requires certain assumptions and
     interpretation


                   CJ Kurtz & Associates LLC     31
Interpreting Control Charts
Control Charts provide information as to whether a process is being influenced by
Chance causes or Special causes. A process is said to be in Statistical Control
when all Special causes of variation have been removed and only Common
causes remain. This is evidenced on a Control Chart by the absence of points
beyond the Control Limits and by the absence of Non-Random Patterns or Trends
within the Control Limits. A process in Statistical Control indicates that production is
representative of the best the process can achieve with the materials, tools and
equipment provided. Further process improvement can only be made by reducing
variation due to Common causes, which generally means management taking action
to improve the system.

Upper Control Limit

          Average

Lower Control Limit


        A. Most points are near the center line.
        B. A few points are near the control limit.
        C. No points (or only a „rare‟ point) are beyond the Control Limits.


                                  CJ Kurtz & Associates LLC                                32
Interpreting Control Charts
When Special causes of variation are affecting a process and making it unstable
and unreliable, the process is said to be Out Of Control. Special causes of variation
can be identified and eliminated thus improving the capability of the process and
quality of the product. Generally, Special causes can be eliminated by action from
someone directly connected with the process.

The following are some of the more common Out of Control patterns:
                                                                Change To
                                                               Machine Made
                      Tool Broke
                                      Tool Wear?

Upper Control Limit

           Average

Lower Control Limit




                                   CJ Kurtz & Associates LLC                            33
Interpreting Control Charts
                          Points Outside of Limits

    Upper Control Limit


             Average

    Lower Control Limit



                                    Trends




         A run of 7 intervals up or down is a sign of an out of control trend.




                               CJ Kurtz & Associates LLC                         34
Interpreting Control Charts
                               Run of 7 ABOVE the Line




A Run of 7 successive points above or below the center line is an out of control condition.




                                       Run of 7 BELOW the line



                                   CJ Kurtz & Associates LLC                                  35
Interpreting Control Charts
                Systematic Variables




        Predictable, Repeatable Patterns
                        Cycles




                CJ Kurtz & Associates LLC   36
Interpreting Control Charts
                            Freaks




                  Sudden, Unpredictable

                           Instability




    Large Fluctuations, Erratic Up and Down Movements



                     CJ Kurtz & Associates LLC          37
Interpreting Control Charts
                                Mixtures




   Unusual Number of Points Near Control Limits (Different Machines?)




                                               Sudden Shift in Level




           Typically Indicates a Change in the System or Process



                           CJ Kurtz & Associates LLC                    38
Interpreting Control Charts


                           Stratification




    Constant, Small Fluctuations Near the Center of the Chart




                        CJ Kurtz & Associates LLC               39
Control Chart Analysis Reaction

There is a wide range of non-random patterns that require action. When
the presence of a special cause is suspected, the following actions should
be taken (subject to local instructions).

1. CHECK
Check that all calculations and plots have been accurately completed,
including those for control limits and means. When using variable charts,
check that the pair (x bar, and R bar) are consistent. When satisfied that
the data is accurate, act immediately.




                             CJ Kurtz & Associates LLC                       40
Control Chart Analysis Reaction
 2. INVESTIGATE
 Investigate the process operation to determine the cause.
 Use tools such as:
          Brainstorming
          Cause and Effect
          Pareto Analysis
 Your investigation should cover issues such as:
          The method and tools for measurement
          The staff involved (to identify any training needs
          Time series, such as staff changes on particular days of the week
          Changes in material
          Machine wear and maintenance
          Mixed samples from different people or machines
          Incorrect data, mistakenly or otherwise
          Changes in the environment (humidity etc.)



                              CJ Kurtz & Associates LLC                       41
Control Chart Analysis Reaction

3.ACT
Decide on appropriate action and implement it.
Identify on the control chart
          The cause of the problem
          The action taken
As far as possible,eliminate the possibility of the special cause happening
again.




                             CJ Kurtz & Associates LLC                        42
Control Chart Analysis Reaction
 4. CONTINUE MONITORING
 Plotting should continue against the existing limits
 The effects of the process intervention should become visible. If not, it should
 be investigated.
 Where control chart analysis highlights an improvement in performance, the
 effect should be researched in order that:
          Its operation can become integral to the process
          Its application can be applied to other processes where appropriate

 Control limits should be recalculated when out of control periods for which
 special causes have been found have been eliminated from the process.

 The control limits are recalculated excluding the data plotted for the out of
 control period. A suitable sample size is also necessary.

 On completion of the recalculation, you will need to check that all plots lie
 within the new limits

                               CJ Kurtz & Associates LLC                         43
D0: Recognize the Symptoms
Other Indicators
  Customer Concerns & Issues
  Warranty Data
  Quality Reports
  Product Quality Planning




               CJ Kurtz & Associates LLC   44
D1: Establish the Team

    Establish a small group of people with
     the knowledge, time, authority and skill
     to solve the problem and implement
     corrective actions. The group selects a
     team leader.




                    CJ Kurtz & Associates LLC   45
D1: Establish the Team
The 8D Team Members
  Cross Functional or Multi-Disciplinary
  Process Owner
  Technical Expert
  Others involved in the containment,
   analysis, correction and prevention of the
   problem



                 CJ Kurtz & Associates LLC   46
D1: Establish the Team
Team Roles
  Several roles need to be established for the team. These roles are:
  Leader, Champion, Record Keeper (Recorder), Participants and (if
  needed) Facilitator.
                                 Leader
  Group member who ensures the group performs its duties and
  responsibilities. Spokesperson, calls meetings, establishes meeting
  time/duration and sets/directs agenda. Day-to-day authority, responsible for
  overall coordination and assists the team in setting goals and objectives.

          Record Keeper                                     Participants
  Writes and publishes minutes.               Respect each others ideas.
                                              Keep an open mind.
              Champion                        Be receptive to consensus decision
  Guide, direct, motivate, train,             making.
  coach, advocate to upper                    Understand assignments and accept
  management.                                 them willingly.

                                CJ Kurtz & Associates LLC                          47
D1: Establish the Team
Problem Solver Characteristics
    Persistent
    Intuitive (supported by mechanical aptitude)
    Logic & discipline
    Common sense
    Ability to balance priorities
    Ownership
    Inquisitive and willing
    Creative and open minded
    Needs proof & facts

                     CJ Kurtz & Associates LLC      48
D1: Establish the Team
Effective Team Characteristics
  Leadership
  Clearly define goals
  Clearly defined responsibilities
  Trust & Respect
  Authority
  Positive Atmosphere
  Good two way communication
  Effective action plan with timing

                  CJ Kurtz & Associates LLC   49
D1: Establish the Team
Management Responsibility
  Provide time and resouces
  Provide mentoring
  Understand need for change
  Recognize accomplishments & team
   process




               CJ Kurtz & Associates LLC   50
D1: Establish the Team
Brainstorming
  Generate a great number of possible
   solutions to a problem
  Use to avoid conventional or in-the-box
   thinking
  Overcome mental blocks, inspire
   creativity
  Take advantage of team synergy
  Ideas from different perspectives

                 CJ Kurtz & Associates LLC   51
D1: Establish the Team
Team Check List
                            Team Check List                                      Yes   No
     Has a champion accepted responsibility for monitoring the measurables?

     Have measurables been developed to the extent possible?
     Have special gaps been identified? Has the common cause versus
     special cause relationship been identified?
     Has the team leader been identified?
     Does the team leader represent the necessary cross-functional
     expertise?
     Has team information been communicated internally and externally?
     Has the team agreed upon the goals, objectives, and process for this
     problem solving effort?

     Is a facilitator needed to help keep process on track and gain consensus?

     Does the team have regular meetings?
     Does the team keep minutes and assignments in an action plan?
     Does the team work well together in following the process and
     objectives?



                                      CJ Kurtz & Associates LLC                             52
D2: Problem Description

    Describe the problem in measurable
     terms. Specify the internal or external
     customer problem by describing it in
     specific terms.




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D2: Problem Description
Problem Statement
  Problem statement =
 Object + concern + quantification
  Example:
         20% of Tuesday‟s first shift production of
         end cap #3245A have a ¼” to ¾” crack at
         the lower left corner of the strain relief hole.
    Remember: A well defined problem is
     half solved!

                        CJ Kurtz & Associates LLC           54
D2: Problem Description
Five Why‟s
     A technique for stepping through successive layers of
     symptoms to find the root problem statement.
    Go to the point of occurrence of the problem (gemba)
    Begin asking “Why?”
    Using a flowchart, track back from symptom to
     symptom until you find:
        The root cause
        A level where permanent corrective action can be
         implemented
        A point where “Why?” can no longer be answered



                            CJ Kurtz & Associates LLC        55
D2: Problem Description
Flowchart
                                                   Start or input at the beginning of


   A picture of a
                                                               a process




   process using                                             Action Step
                                                                                         Document associated
                                                                                         with a step such as a
                                                                                            form or report


   symbols and arrows
   to represent                                              Action Step



   sequence of the
   steps.                                    Yes        Question or Decision?           No



                               Action Step                                                   Action Step




                                                         Completed process




                 CJ Kurtz & Associates LLC                                                                       56
D2: Problem Description
Situation Analysis
  Tool used to break broad problems into
   smaller prioritized pieces to attack one at
   a time.
  Many problem solving efforts start with
   large, messy, poorly defined, unforcused
   issues.
  This method is detailed in the book The
   New Rational Manager by Kepner &
   Tregoe

                  CJ Kurtz & Associates LLC   57
D2: Problem Description
Pareto Analysis
 A Pareto chart offers the following benefits:
  Focuses on the problems or causes of
   problems that have the greatest impact
  Displays the relative significance of
   problems or problem causes in a simple,
   quick-to-interpret, visual format
  Can be used repeatedly to produce
   continuous improvements

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D2: Problem Description
Pareto Analysis
 Ball Lifting                    Percent   Cum Percent
                     Frequency
       Cause                         (%)         (%)
 Bonder Set-up
                        19        38%         38%
      Issues

 Unetched Glass
       on Bond          11        22%         60%
       Pad

 Foreign Contam
       on Bond           9        18%         78%
       Pad

 Excessive Probe
                         3         6%         84%
       Damage
 Silicon Dust on
                         2         4%         88%
        Bond Pad

 Corrosion               1         2%         90%


 Bond Pad Peel-off       1         2%         92%


 Cratering               1         2%         94%


 Resin Bleed-out         1         2%         96%


 Others                  2         4%         100%


 Total                  50        100%          -




                                           CJ Kurtz & Associates LLC   59
D2: Problem Description
Paynter Chart
  This chart is combination of Trend and
   Pareto charts.
  Provides information on actions taken
   and shows effects.
  Can be modified for Returns, Scrap,
   Rework, etc.



                 CJ Kurtz & Associates LLC   60
D2: Problem Description
Paynter Chart
                                                                                   Number of 3rd shift workers affected
                                                            Problems:              July    Aug Sept    Oct    Nov     Dec   Total
                                                            Traffic jam on Hiway      90     84   4       3      0             90
                                                            Buses Late                30     30   9       8     30             30
% Late Employees      Third Shift        # Late Employees   Not Enough Parking        17     16  17       8      0             17
  100                                                  60   Bad Weather                9     10  20      21      9              9
                                                            Road Construction          4      0   0       0     21              4
   90                                                 54                            150     140  50      40     60            150


   80                                                 48                     = Containment Action: Change Shift Starting Time
                                                                             = Corrective Action: Open second gate,
   70                                                 42                      change shift starting times back to 'normal'.
                                                                             = Corrective Action: Task Group established.
   60                                                 36

   50                                                 30
                                                                      Average Hours Worked Per Employee (3rd shift)
   40                                                 24
                                                              45
                                                              44
   30                                                 18      43
                                                              42
   20                                                 12      41
                                                              40
   10                                                  6      39
                                                              38
    0                                                   0     37
             1                2                3              36
         Buses Late      Bad Weather   Not Enough Parking     35
                                                                   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
                                                                           Change shift starting times
                                                                           New entrance opened.
                                                                           Task group established.



                                              CJ Kurtz & Associates LLC                                                      61
D2: Problem Description
Information Database
  A tool for organizing all data about a
   problem into four categories: What,
   Where, When, Extent.
  Used for Problem Analysis
  Detailed in The New Rational Manager
   by Kepner/Tregoe



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D2: Problem Description
Information Database
                                         Is                                                         Is Not
     What: What is the object you are having a problem with?              What could be happening but is not?
            What is the problem concern?                                  What could be the problem concern, but is not?
            Where do you see the concern on the object? Be specific       Where on the object is the problem NOT seen? Does the
   Where:
            in terms of inside to outside, end to end, etc.               problem cover the entire object?
            Where (geographically) can you take me to show me the         Where else could you have observed the defective object,
            problem? Where did you first see it?                          but did not?
            When in time did you first notice the problem? Be as          When in time could it have first been observed, buy was
    When:
            specific as you can about the day and time.                   not?
            At what step in the process, life or operating cycle do you   Where else in the process, life or operating cycle might
            first see the problem?                                        you have observed the problem, but did not?

            Since you first saw it, what have you seen? Be specific
                                                                          What other times could you have observed it but did not?
            about minutes, hours, days, months. Can you plot trends?

  How Big: How much of each object has the defect?                        How many objects could be defective, but aren't?
            What is the trend? Has it leveled off? Has it gone away? Is What other trends could have been observed, but were
            it getting worse?                                           not?
            How many objects have the defect?                             How many objects could have had the defect, but didn't?
            How many defects do you see on each object?                   How many defects per object could be there, but are not?
            How big is the defect in terms of people, time, $ and/or
                                                                          How big could the defect be, but is not?
            other resources?
            What percent is the defect in relation to the problem?


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D2: Problem Description
Checksheet
  Checksheets are simple and effective
   method of gathering information
   on the job.
  Ensures consistency of data collected.
  Simplifies data collection and analysis.
  Highlights trends.
  Spots problems.


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D2: Problem Description
Checksheet
 Part Number 621532-B                 Part Defect Checksheet
 Date     12-16-04




 Defect                 1st Shift     2nd Shift             3rd Shift   Totals
 Nicks
                        22            14                    5           41
 Missing holes
                        1             0                     0           1
 Missing screws
                        8             4                     0           12

 Totals
                        31            18                    5           54

                                    CJ Kurtz & Associates LLC                    65
D2: Problem Description
Histogram
  Chart using bars of varying height to
   show frequency distribution of some
   characteristic.
  Use for problem recognition, problem
   definition, data analysis, and validation of
   corrective actions.
  Visually evaluate spread, centering,
   capability.

                  CJ Kurtz & Associates LLC   66
D2: Problem Description
Histogram
                          23mm OD Histogram
                        P/N 543612 on Machine 6
                  6
                  5
      Frequency




                  4
                  3
                                                            Frequency
                  2
                  1
                  0
                  19


                       21


                             23


                                     25


                                              27


                                                        e
                                                      or
                                                    M

                            Outside Diameter


                               CJ Kurtz & Associates LLC                67
D3: Containment

  Define and implement those intermediate
   actions that will protect the customer
   from the problem until permanent
   corrective action is implemented.
  Verify with data the effectiveness of
   these actions.




                CJ Kurtz & Associates LLC   68
D3: Containment
Contain Symptom Flow
   Immediate Containment             Choose
         with Current
       Information and               Verify Before
     Problem Description             Implement

     Stop Defect at Each              Certify parts and Confirm
     Point in the Process             Customer Dissatisfaction
     Back to the Source               No Longer Exists

         Determine
        Escape Point
                                      Should an existing ‘check’ (control)
                                      have caught the defect?

      Validate that Action
    Taken is Fully Effective
                                      Validate After Implementation




                               CJ Kurtz & Associates LLC                     69
D3: Containment
Objectives
    The objective of this step is to isolate the effects of the problem
     by implementing containment actions.
    Once a problem has been described, immediate actions are to be
     taken to isolate the problem from the customer. In many cases
     the customer must be notified of the problem.
    These actions are typically „Band-aid‟ fixes.
    Common containment actions include:
             100% sorting of components
             Items inspected before shipment
             Parts purchased from a supplier rather than manufactured in-
              house
             Tooling changed more frequently
             Single source


                               CJ Kurtz & Associates LLC                     70
D3: Containment
Containment Action Checksheet
                       Containment Action Checksheet                                          Yes   No
  Has immediate containment action been taken to protect the customer?

  Has the concern been stopped at each point in the process back to the source?

  Have you verified that the action taken is FULLY effective?

  Have you certified that parts no longer have the symptom?

  Have you specially identified the 'certified' parts?

  Have you validated the containment action?

  Is data being collected in a form that will validate the effectiveness of the containment
  action?

  Has baseline data been collected for comparison?

  Are responsibilities clear for all actions?

  Have you ensured that implementation of the containment action will not create other
  problems?

  Have you coordinated the action plan with the customer?



                                                CJ Kurtz & Associates LLC                                71
D4: Determine Root Causes

  Identify potential causes which could
   explain why the problem occurred.
  Test each potential cause against the
   problem description and data.
  Identify alternative corrective actions to
   eliminate root cause.



                  CJ Kurtz & Associates LLC     72
D4: Determine Root Causes

  Root Cause of Event (Occur or Occurrence)
  What system allowed for the event to occur?




  Root Cause of Escape
  What system allowed for the event to escape
   without detection?



                  CJ Kurtz & Associates LLC      73
D4: Determine Root Causes
Root Cause Analysis – 5 Why‟s
  The 5 why's refers to the practice of
   asking, five times, why a failure has
   occurred in order to get to the root
   cause/causes of the problem.
  There can be more than one cause to a
   problem as well.
  This root cause analysis is often done by
   a team with knowledge the problem
   process or item.

                 CJ Kurtz & Associates LLC     74
D4: Determine Root Causes
Root Cause Analysis
    Process of analyzing “is” & “is not” pairs
     of information for differences and
     changes that lead to root cause




                    CJ Kurtz & Associates LLC     75
D4: Determine Root Causes
Root Cause Analysis
                                                         Is                Is Not
  What:
  Object                                Heavy traffic
  Defect                                Late Employees
  Where:
  Seen on object                        I-70 Expressway
  Seen geographically                   East bound I-70 near Main Street
  When:
  First seen                            July 7, 1996
  When else seen                        Ever since
  When seen in process (life cycle)     Afternoon
  How Big:
  How many objects have the defect?     Third shift (4:00PM)
  How many defects per object?          Once per day
  What is the trend?                    Increasing --> SPECIAL CAUSE!
  Enhanced Problem Description -->


                                      CJ Kurtz & Associates LLC                     76
D4: Determine Root Causes
Cause & Effect Diagram
    Shows the relationship of causes and sub-causes to
     an identified effect or problem. Clearly identify the
     problem or effect to be diagrammed in the box at the
     right
    Draw the fishbone structure
    Identify the major categories, factors, the causes
     related to the effect.
    Brainstorm, or note the causes of the problem that fall
     within each of the major categories.
    Each branch may have sub-branches, or sub-sub-
     branches
    As ideas are generated determine which branch of the
     "bone" they should be placed

                        CJ Kurtz & Associates LLC              77
D4: Determine Root Causes
Cause & Effect Diagram

       Man            Machine         Measurement




                                                    Effect




             Method              Materials




                        CJ Kurtz & Associates LLC            78
D4: Determine Root Causes
Scatter Diagram
    Scatter diagrams are used to study possible
     relationships between two variables. Although these
     diagrams cannot prove that one variable causes the
     other, they do indicate the existence of a relationship,
     as well as the strength of that relationship.
    A scatter diagram is composed of a horizontal axis
     containing the measured values of one variable and a
     vertical axis representing the measurements of the
     other variable.
    The purpose of the scatter diagram is to display what
     happens to one variables when another variable is
     changed. The diagram is used to test a theory that the
     two variables are related. The type of relationship that
     exits is indicated by the slope of the diagram.

                         CJ Kurtz & Associates LLC              79
D4: Determine Root Causes
Scatter Diagram




            Strongly correlated


               CJ Kurtz & Associates LLC   80
D4: Determine Root Causes
Scatter Diagram




           Moderately correlated

                CJ Kurtz & Associates LLC   81
D4: Determine Root Causes
Scatter Diagram




            No Correlation

              CJ Kurtz & Associates LLC   82
D4: Determine Root Causes
Design of Experiments - DOE
  Shanin‟s Red X Component Search
  Taguchi‟s Methods
  Classical Design of Experiments




               CJ Kurtz & Associates LLC   83
D5: Select & Verify CA

  After root causes and possible corrective
   actions have been identified, select the
   corrective actions that will permanently
   correct the problem.
  Decision analysis may be needed if the
   choice is not obvious.
  Verify that the selected corrective actions
   will resolve the problem.

                  CJ Kurtz & Associates LLC   84
D5: Select & Verify CA
Poka Yoke
          Poka Yoke Devices
 Are Built within the Process
 In General Have Low Cost
 Have the Capacity for 100%
  Inspection
   Remember SQC is performed outside the
   process which adds cost and allows defects
   to escape the system.
                   CJ Kurtz & Associates LLC    85
D5: Select & Verify CA
Poka Yoke
   Interference Fit
      Poka Yoke




    Orientation
    Poka Yoke




                      CJ Kurtz & Associates LLC   86
D5: Select & Verify CA
Poka Yoke
 Floppy disks                                                                     Spring loaded
 have many           1                              1                             shutter
 poka-yokes built
                     6            4             6                  4        6     mechanism - Do
                                                                                  you remember
 in. One example
 is you cannot                                                                    the old 5.25 inch
 insert the disk                                                                  floppies from the
 into the drive                                                                   early to mid-
 completely if the                                                                1980‟s? Failsafe
 disk is upside                                                                   disk surface
 down. This is         3                   5        2                   5         protection [#4].
 because of the
 corner notch                                                                     Slide Tab to
 [#1].                                                                            protect against
                                                                                  erasure.
 720k disks have                                                                  Mechanism
 no hole [#2]                                                                     senses [#5].
 while HD disks
 have hole       „Precision‟ alignment. Disk alignment holes and notches [#6] ensure the disk is
 (mechanism      properly aligned and also provides a „focus‟ area for manufacturing.
 senses)[#3].



                                       CJ Kurtz & Associates LLC                                      87
D5: Select & Verify CA
Poka Yoke
                               Computer Files              Computer Floppy
                                                               Drives
                             Microsoft: File type
                             identified by file         Microsoft: Disk must
                             name suffix. If one        be inserted and ejected
                             does not add the
                                                        by hand. It is possible to   Warning lights alert the
                             correct suffix, the
                                                        eject a disk while it is     driver of potential
                             program the file is
                             from will not              being written to.            problems. These
 New lawn mowers are         recognize it.                                           devices employ a
 required to have a                                     Macintosh Poka Yoke          warning method
 safety bar on the           Macintosh Poka             (1984): Disk drive grabs     instead of a control
 handle that must be         Yoke (1984): File          disk as it is being          method.
 pulled back in order to     type and creator           inserted and draws it in
 start the engine. If you    application are            and seats it. Disk
 let go of the safety bar,   identified and             cannot be manually
 the mower blade stops       embedded in the first      ejected. You must drag
 in 3 seconds or less.       part of every file. File   the „desktop‟ icon for
 This is an adaptation of    name plays NO part
 the "dead man switch"                                  the disk to the „Trash‟.
                             in recognition by the
 from railroad                                          The drive then ejects
                             originating program.
 locomotives.                                           the disk as long as
                                                        there are no disk
                                                        operations taking place.

                                             CJ Kurtz & Associates LLC                                          88
D5: Select & Verify CA
Corrective Action Check List

           Corrective Action & Verify Check List                             Yes   No
 Has corrective action been established?

 Does it meet the required givens?
 Have different alternatives been examined as possible corrective actions?
 Have Poke-Yoke techniques been considered?
 Has each alternative been screened?
 Have the risks involved with the corrective action been considered?
 Was the corrective action verified?
 Was the corrective action proven to eliminate the root cause?




                                       CJ Kurtz & Associates LLC                        89
D6: Implement & Validate CA

  Implementation can proceed when best
   corrective action has been selected &
   verified.
  An effective implementation plan
   reduces problems.
  Validation is obtained by tracking
   performance over time after
   implementation to ensure the corrections
   are permanent.

                 CJ Kurtz & Associates LLC    90
D6: Implement & Validate CA
Implementation Check List
            Implement CA & Validate Over Time                                       Yes   No
Has the implementation plan been constructed to reflect Product
Development Process events and engineering change process?
Do the corrective actions make sense in relation to the cycle plan for the
products?
Have both Design and Process FMEAs been reviewed and revised as
required?
Have significant / safety / critical characteristics been reviewed and identified
for variable data analysis?
Do control plans include a reaction plan?
Is simultaneous engineering used to develop process sheets and
implement manufacturing change?
Is the Paynter Chart in place for validating data?




                                        CJ Kurtz & Associates LLC                              91
D7: Prevent System Recurrence

  Implement the corrective actions in other
   potentially affected areas.
  Ensure the systems that allowed the
   problem to occur and escape have been
   corrected.
  The problem is now Type III requiring a
   larger scale continual improvement
   project of some type.

                 CJ Kurtz & Associates LLC     92
D7: Prevent System Recurrence
Prevent System Problems Check List
           Prevent System Problems Check List                                    Yes   No
  Have the system prevention practices, procedures & specification standards
  that allowed the problem to occur and escape been identified?
  Has a champion for system prevention practices been identified?

  Does the team have the cross-functional expertise to implement the solution?

  Has a person been identified who is responsible for implementing the system
  preventive action?
  Does the system preventive action address a large scale process in a
  business, manufacturing or engineering system?
  Does the system preventive action match root cause (occur & escape) of the
  system failure?
  Does the team utilize error proofing and successive checks on a proactive
  on-going basis to eliminate the occurrence and escape of all defects?
  Has a pieces over time (Paynter Chart) been used to indicate that the system
  preventive actions are working?
  Has the System Preventive Action been linked to the Product Development
  phase?



                                        CJ Kurtz & Associates LLC                           93
D8: Congratulate the Team

    Recognize the collective efforts of your
     team. Publicize your achievement. Share
     your knowledge and learning.




                   CJ Kurtz & Associates LLC   94
D8: Congratulate the Team
Congratulate The Team Checksheet

           Congratulate The Team Checksheet                           Yes   No
 Have documented actions and lessons learned been linked to Product
 Development Process for future generations of products?
 Has appropriate recognition for the team been determined?
 Has application for patents & awards been considered?
 Has team been reassessed?
 Has the team analyzed data for next largest opportunity?




                                      CJ Kurtz & Associates LLC                  95
References
    http://elsmar.com/
    http://www.isixsigma.com/spotlight/default.asp
    http://www.isixsigma.com/dictionary/glossary.asp
    http://www.asq.org/learn-about-quality/
    Prince Corp, Corrective Action Manual
    The New Rational Manager, Kepner & Tregoe
    http://deming.eng.clemson.edu/pub/tutorials/
    http://www.qualityspctools.com/menu.html
    Ford Team Oriented Problem Solving
    http://www.cjkurtz.com/qualitytools.htm




                           CJ Kurtz & Associates LLC    96

								
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