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Training Materials – For Reference Only Slide 1
Finding and eliminating (forever) the root
cause of a problem.
HBC 8D Proc...
Training Materials – For Reference Only Slide 2
Course Objectives
At Completion YOU should:
• Understand HBC’s 8D process
...
Training Materials – For Reference Only Slide 3
• Origin of HBC’s 8D process
• Fit with:
– Hawker Beechcraft Performance S...
Training Materials – For Reference Only Slide 4
Round Robin Introductions
• Your Name
• Where you work -
position/responsi...
Training Materials – For Reference Only Slide 5
• Root Cause: The very basic reason why, how, & when the condition
occurre...
Training Materials – For Reference Only Slide 6
• A systematic approach to effectively identify the
cause chain of a nonco...
Training Materials – For Reference Only Slide 7
Origin of HBC’s 8D Process
• 8D (8 Disciplines) first standardized by the ...
Training Materials – For Reference Only Slide 8
HBPS Initiative Positioning
• Goal – solve the problem
– Smooth land (drai...
Training Materials – For Reference Only Slide 9
Time
Planning
0
40
0
Lessons Learned
Sporadic Spike
(Special Cause: HBC 8D...
Training Materials – For Reference Only Slide 10
8D “Process” Fit
• Policy & Procedures – 12 0008 Corrective Action
System...
Training Materials – For Reference Only Slide 11
• Changes being made to:
– WI 04-09-009 – Creating and Updating
Correctiv...
Training Materials – For Reference Only Slide 12
What is 8D?
1. Corporate Standard
2. Standardized Problem Solving
Process...
Training Materials – For Reference Only Slide 13
8 Disciplines (8D’s)
D-0 Decide to use the 8D Process – existing processe...
Training Materials – For Reference Only Slide 14
What can “trigger” an 8D analysis?
“When do we
use the
8D Process?”
• Pro...
Training Materials – For Reference Only Slide 15
Who can initiate an 8D analysis?
• Request for an 8D analysis can be made...
Training Materials – For Reference Only Slide 16
Place in 8D Process
D-0 Decide to use the 8D Process
D-1 DESCRIBE THE PRO...
Training Materials – For Reference Only Slide 17
8D Step 1 – Describe the Problem
What is the problem?
This should be a sh...
Training Materials – For Reference Only Slide 18
• What is the problem?
• Where was it detected?
• How serious is the prob...
Training Materials – For Reference Only Slide 19
Problem Definition/Analysis Prompts
– Who?
Who notified you of the proble...
Training Materials – For Reference Only Slide 20
Problem Definition/Analysis Prompts
– What?
What is the part name/number/...
Training Materials – For Reference Only Slide 21
When in the build process/production schedule/work shift did the problem
...
Training Materials – For Reference Only Slide 22
Where is the part being contained?
Where is the part being used?
Where is...
Training Materials – For Reference Only Slide 23
Problem Definition/Analysis Prompts
– Impact?
How many times and in what ...
Training Materials – For Reference Only Slide 24
Importance of Problem Description
– Focuses team on same objective
– Dire...
Training Materials – For Reference Only Slide 25
Tool: “Is”/”Is Not” for Problem Definition
• Reasons to use “IS” - “IS NO...
Training Materials – For Reference Only Slide 26
• Development of “IS”:
Identity - What is the problem?
Space - Where is t...
Training Materials – For Reference Only Slide 27
IS IS NOT
(What, Where, When, How Big) would you EXPECTEXPECT to..
SEE, H...
Training Materials – For Reference Only Slide 28
Reasons to use “IS” - “IS NOT”
– Establishes points of comparison
– Leads...
Training Materials – For Reference Only Slide 29
Document Your Work
1) Open a QN in SAP
2) Fill Out Section 1 of the 8D Su...
Training Materials – For Reference Only Slide 30
Step 2 in the HBC 8D Process
D-0 Decide to use the 8D Process
D-1 Define ...
Training Materials – For Reference Only Slide 31
8D - Step 2: Form a Team
• A “Team” may be:
• formal (scheduled meetings,...
Training Materials – For Reference Only Slide 32
Advantages/Disadvantages of Teams
WHY DO TEAMS FAIL?
WHAT ARE THE BENEFIT...
Training Materials – For Reference Only Slide 33
Major Problems with Team Problem
Solving
•• Problem incorrectly described...
Training Materials – For Reference Only Slide 34
Typical Team Organization
Champion/Sponsor
Leader
Recorder – rotate this ...
Training Materials – For Reference Only Slide 35
Step 3 in the HBC 8D Process
• D-0 Decide to use 8D Process
• D-1 Define ...
Training Materials – For Reference Only Slide 36
8D Step 3: Implement Interim
Containment Action
• Decide whether you need...
Training Materials – For Reference Only Slide 37
Purpose of Interim Containment
• Used to “buy time” to find root cause wh...
Training Materials – For Reference Only Slide 38
Int. Cont. Action vs. Typical BAND AID
__X__ Attacks Symptoms __X__
__X__...
Training Materials – For Reference Only Slide 40
Key Points of Step 3: Interim Containment
• Act quickly (and carefully)
•...
Training Materials – For Reference Only Slide 41
Fill Out Section 3 of the 8D
Summary Report
Training Materials – For Reference Only Slide 42
BREAK FOR 10 MINUTES
Training Materials – For Reference Only Slide 43
Where are We?
Place in the HBC 8D Process
• D-0 Decide to use 8D Process
...
Training Materials – For Reference Only Slide 44
Root Cause Analysis Common Tools
• Your Brain
– Especially the ‘Collectiv...
Training Materials – For Reference Only Slide 45
• Don’t try to do solutions before the analysis is
complete.
• It is futi...
Training Materials – For Reference Only Slide 46
Types of data to collect:
1. Location: where problem was detected
2. Pers...
Training Materials – For Reference Only Slide 47
Once the problem is defined, natural tendency is to rush forward
RESIST T...
Training Materials – For Reference Only Slide 48
What is the current
bit brand
and quality used?
Is the perceived
bit qual...
Training Materials – For Reference Only Slide 49
Tools: Process Mapping/Value
Stream Mapping
• Graphical Depiction of “How...
Training Materials – For Reference Only Slide 50
Tools: 5 (OK, maybe just 3) Senses
• Talk to, Listen to, Observe:
– Peopl...
Training Materials – For Reference Only Slide 51
Tools: Brainstorming
When the best solution isn’t obvious, one technique ...
Training Materials – For Reference Only Slide 52
1. Why? – There was oil on the floor.
2. Why? – The machine in that cell ...
Training Materials – For Reference Only Slide 53
Tools: Cause and Effect Diagram
A Cause-and-Effect (fishbone or Ishikawa)...
Training Materials – For Reference Only Slide 54
Tools: Graphical Analysis
• Histogram –
• Used to show patterns/distribut...
Training Materials – For Reference Only Slide 55
Use Common Sense:
1. The more significant or involved
the problem, the mo...
Training Materials – For Reference Only Slide 56
Document Your Findings
Fill Out Section 4 of the 8D
Summary Report
Training Materials – For Reference Only Slide 57
8D – Step 5: Choose Corrective Action
Place in the HBC 8D Process:
• D-0 ...
Training Materials – For Reference Only Slide 58
Decision Making Steps
(note: can also be used in Step 3)
1. Define end re...
Training Materials – For Reference Only Slide 59
Use the Corrective Action Plan Worksheet
in the 8D File and Summarize in ...
Training Materials – For Reference Only Slide 60
Place in the HBC 8D Process:
D-0 Decide to use D8 Process
D-1 Choose team...
Training Materials – For Reference Only Slide 61
Goals of Permanent Corrective Action
• Permanent Corrective Action MUSTMU...
Training Materials – For Reference Only Slide 62
Keys to Successful Corrective Action
– Persistence
• Natural Tendency to ...
Training Materials – For Reference Only Slide 63
Why should we do planning and NEW
problem prevention when considering
imp...
Training Materials – For Reference Only Slide 64
Why Planning and Problem Prevention?
• Many of our current problems are t...
Training Materials – For Reference Only Slide 65
Fill Out Section 6 of the 8D Form
Summarize the Key Permanent
Corrective ...
Training Materials – For Reference Only Slide 66
D-0 Decide to use D8 Process
D-1 Choose team members
D-2 Define problem
D...
Training Materials – For Reference Only Slide 67
Steps to Preventing Recurrence
– Identify what systems, practices, or
pro...
Training Materials – For Reference Only Slide 68
• Poka-yoke is the Japanese term that means “fail-safing” or
"mistake-pro...
Training Materials – For Reference Only Slide 69
Mistake-Proofing – Levels of Prevention
Defect is the
evidence of an
erro...
Training Materials – For Reference Only Slide 70
HUMAN ERRORS – do not make a root cause
How does HBC approach human error...
Training Materials – For Reference Only Slide 71
How Can We Standardize Lessons Learned & System
Improvements?
• Communica...
Training Materials – For Reference Only Slide 72
Fill Out Section 7 of the 8D Form –
Prevention of Recurrence
Training Materials – For Reference Only Slide 73
8D - Step 8: Congratulate the Team
D-0 Decide to use D8 Process
D-1 Choos...
Training Materials – For Reference Only Slide 74
How to Congratulate the Team
• Review significance of contribution
• Prov...
Training Materials – For Reference Only Slide 75
How Would You Congratulate Your
Team?
What are some things that have work...
Training Materials – For Reference Only Slide 76
Fill Out Section 8 of the 8D Form
(and attach completed file to the
appro...
Training Materials – For Reference Only Slide 77
Comments, Suggestions??
Please fill out class/instructor
Evaluation Forms
Training Materials – For Reference Only Slide 78
Reference Material
Training Materials – For Reference Only Slide 79
QA Intranet Website
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8 Disciplines (8D) Training

8 Disciplines ( 8D) Trainning - Problem Solving Tool -
Formación en las 8 Disciplinas (8D) - Herrammienta de Resolución de Problemas

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8 Disciplines (8D) Training

  1. 1. Training Materials – For Reference Only Slide 1 Finding and eliminating (forever) the root cause of a problem. HBC 8D Process for Problem Solving Course Duration: 4.0 hours
  2. 2. Training Materials – For Reference Only Slide 2 Course Objectives At Completion YOU should: • Understand HBC’s 8D process • Know when to use the 8D Process • Be able to write an 8D Summary Report • Be comfortable using typical problem solving tools • Know how to get additional help/training I hear...I forget I see...and I remember I do...and I understand Ancient Chinese Proverb
  3. 3. Training Materials – For Reference Only Slide 3 • Origin of HBC’s 8D process • Fit with: – Hawker Beechcraft Performance System (HBPS) Initiatives – Existing processes • Overview of the 8 Steps 0 - Decide to use the HBC 8D Process 1 - Describe the Problem 2 - Assemble a Team 3 - Implement Interim Containment 4 - Find Root Cause 5 - Develop Corrective Action 6 - Implement Permanent Fix 7 - Prevent Recurrence 8 - Recognize the Team • Additional Information – contacts, reference material Agenda
  4. 4. Training Materials – For Reference Only Slide 4 Round Robin Introductions • Your Name • Where you work - position/responsibilities • Personal objectives for this course
  5. 5. Training Materials – For Reference Only Slide 5 • Root Cause: The very basic reason why, how, & when the condition occurred. A Root Cause Mentality: An insatiable desire to understand why things go wrong, why people do what they do, and how things got into their present state. (C. Robert Nelms) • This takes persistence • Interim Containment Action: This is the action taken which should address and correct the actual nonconforming condition. • Permanent Corrective Action: This should address the root cause of a nonconformance and prevent future occurrences of the problem which caused the nonconformance. • Contributing Cause: This factor contributed to the problem, but it is not the root cause. Keep going to get to Root Cause. • Verification: Making sure that something is going to work prior to implementation. • Validation: Checking to make sure that the change is working (after implementation) Definitions
  6. 6. Training Materials – For Reference Only Slide 6 • A systematic approach to effectively identify the cause chain of a nonconformance and to permanently eliminate the source(s) of problems. • Directed at reducing, and if possible eliminating, quality system escapes and the costs associated with “poor quality”. Root Cause / Corrective Action (RCCA) is: More on Root Cause
  7. 7. Training Materials – For Reference Only Slide 7 Origin of HBC’s 8D Process • 8D (8 Disciplines) first standardized by the U.S. government during World War 2 – Military Standard 1520: “Corrective action and disposition system for nonconforming material” • Popularized by Ford Motor Company in the 1960’s and 1970’s (called Global 8D or G8D) • 8D now a standard in the Auto Industry • 8D fills a void we currently have at HBC – We reference root cause (internally, with our suppliers and customers) • BUT, we don’t provide a standard process to get to root cause HBC 8D – a Structured Process (and Tool Set) for Root Cause Corrective Action
  8. 8. Training Materials – For Reference Only Slide 8 HBPS Initiative Positioning • Goal – solve the problem – Smooth land (drain the lake, remove boulders) – No leaks in the boats (rental income while lake is here) • Pick the “best fit” methodology – Drain the lake (remove “waste”) – use LEAN Six Sigma – Remove boulders (variation reduction) – use Lean SIX SIGMA – Leaks (immediate problems that must be fixed) – use HBC 8D • Use the right tools for the job – Common tools will be used by all methodologies • This Analogy: Bucket – can be used to empty the lake, remove rubble, and bail out the boat In general, Lean Six Sigma projects take longer; 8D is for everyday, immediate problems.
  9. 9. Training Materials – For Reference Only Slide 9 Time Planning 0 40 0 Lessons Learned Sporadic Spike (Special Cause: HBC 8D) Control (During Production) Significant Shift AND/OR Variation Reduction (Lean SIX SIGMA)Common cause (random) variation/waste (LEAN Six Sigma) Special cause (assignable) variation HBPS Initiative Positioning (alt. view)
  10. 10. Training Materials – For Reference Only Slide 10 8D “Process” Fit • Policy & Procedures – 12 0008 Corrective Action System • Quality Assurance Instruction (QAI) -- QAI 03-01-015 – Corrective Action Response and Review Requirements • Corrective Action requests resulting from: – Nonconforming material – Out of control processes – Internal audits – Supplier issues – Customer complaints – Operator self-verification process – Other nonconformances in product or process • Via: – PCAS - Production Corrective Action System – FCAS - Field Corrective Action System – IQAG - Internal Quality Audit Group – OSV - Operator Self Verification – + Management Directive 8D adds structure (defined steps, language) to what we already have.
  11. 11. Training Materials – For Reference Only Slide 11 • Changes being made to: – WI 04-09-009 – Creating and Updating Corrective Action Records in SAP – WI 04-09-014 – Responding to the Corrective Action in SAP – WI 04-14-005 issuing Corrective Action Requests for Major Noncompliances • Documents Created in SAP: – Q1 – Customer Complaint – Q2 – Vendor Product Non-Conformance – Q3 – HBC Product Non-Conformance – Q4 – Vendor Product CA – Q5 – HBC Product CA – Q6 – Vendor Audit CA/PA – Q7 – HBC Audit CA/PA • HBC 8D form will be attached to the appropriate Q1-Q7 record in SAP – Reference Hard Copy of HBC 8D Form handouts 8D “Process” Fit (cont.) Work Instructions are being modified now to incorporate 8D.
  12. 12. Training Materials – For Reference Only Slide 12 What is 8D? 1. Corporate Standard 2. Standardized Problem Solving Process • Language, Methodology 3. Reporting Format
  13. 13. Training Materials – For Reference Only Slide 13 8 Disciplines (8D’s) D-0 Decide to use the 8D Process – existing processes D-1 Describe Problem D-2 Establish Team D-3 Implement Interim Containment D-4 Find Root Cause D-5 Choose Corrective Action D-6 Implement Permanent Corrective Action D-7 Prevent Recurrence D-8 Congratulate Team
  14. 14. Training Materials – For Reference Only Slide 14 What can “trigger” an 8D analysis? “When do we use the 8D Process?” • Problem with Cause Unknown • Need to Cure - Not Mask Problem • Justifies a Structured/Team Approach – Factors – Severity, Cost, Time, etc. • Examples: Whenever you open a QN, ask yourself if Root Cause/8D should be done.
  15. 15. Training Materials – For Reference Only Slide 15 Who can initiate an 8D analysis? • Request for an 8D analysis can be made by: – Customer • Current Sales/Support Interface – HBC Employee • Initially, by contacting QA rep’s • Eventually, anyone – Working out details defining when it makes sense – Not all problems need an 8D level of analysis – HBC Supply Chain • Supplier will perform the 8D – Management Anyone can use the process. Using SAP makes sure we capture/share knowledge.
  16. 16. Training Materials – For Reference Only Slide 16 Place in 8D Process D-0 Decide to use the 8D Process D-1 DESCRIBE THE PROBLEMDESCRIBE THE PROBLEM Why is it important for a Problem Solving team to start with “Describe the Problem”?
  17. 17. Training Materials – For Reference Only Slide 17 8D Step 1 – Describe the Problem What is the problem? This should be a short, simple and concise definition. “IF YOU CANNOT SAY IT SIMPLY, YOU DO NOT UNDERSTAND THE PROBLEM” REMEMBER: A problem well stated is a problem half solved!
  18. 18. Training Materials – For Reference Only Slide 18 • What is the problem? • Where was it detected? • How serious is the problem? • How many occurrences? • Who is affected? • When did it surface? Remember: on the problem. Information about the problem
  19. 19. Training Materials – For Reference Only Slide 19 Problem Definition/Analysis Prompts – Who? Who notified you of the problem? - Manufacturing, Engineering, SAP QN Review, QA Audit, etc. Who are the people involved with the problem? (for step 2 – team formation) - Supplier, customer, material handlers, assemblers, supervisors, engineers, QA personnel, etc. High Level information belongs in the Problem Description, Investigate all others in Step 3 & 4.
  20. 20. Training Materials – For Reference Only Slide 20 Problem Definition/Analysis Prompts – What? What is the part name/number/other identification? What type of product or process? - Detail, assembly, vendor part - Part manufacturing process, assembly process? What is the type of nonconformance? - Scratch, Dent, Oversize hole, Fit? - Lack of communication, waiting too long for info/parts? What characteristic of the part/process is having the failure - hole radius, linear dimension? - manufacture of the part, movement, inspection? What method of measurement was used to identify the failure? What are special circumstances surrounding the problem? - new personnel, equipment move, new tool, etc.? What environmental conditions existed? - extremely cold/hot, rainy, humidity, lighting, etc.? What is the design/nonconformance criteria in question? - Drawing, Spec, Task Planning, Policy, Process? What training has been done or is available? What hardware or software is associated with the issue? Have there been recent administrative, program or equipment changes?
  21. 21. Training Materials – For Reference Only Slide 21 When in the build process/production schedule/work shift did the problem occur? - note: occurrence point and detection point may (and usually aren’t) at the same time When in the task did the problem occur? (what step?) When in the functional test did the problem occur (what step?) When in the day, week, month did it/has it occurred (patterns)? Problem Definition/Analysis Prompts – When?
  22. 22. Training Materials – For Reference Only Slide 22 Where is the part being contained? Where is the part being used? Where is the geographical location of the failure? What plant/line/station cell? Is the problem in-house or external (supplier) or external (in the field)? Where are similar nonconformance records located? Problem Definition/Analysis Prompts – Where?
  23. 23. Training Materials – For Reference Only Slide 23 Problem Definition/Analysis Prompts – Impact? How many times and in what period? Cost of nonconformance in dollars? Safety impact? Cost of delay? Warranty cost? Impact to worker morale/productivity? Has this issue been “fixed” before? Impact on Business processes? - production - delivery - product use - field reliability Impact on Customer Satisfaction?
  24. 24. Training Materials – For Reference Only Slide 24 Importance of Problem Description – Focuses team on same objective – Direction set here is used throughout the HBC 8D process (foundation) – Forces all to agree on the scope and goal – Note: Operational Definitions MUST accompany the Problem Description • What does “failure” mean? • What is “bad”? • What does “success” look like? Ice-scraping video
  25. 25. Training Materials – For Reference Only Slide 25 Tool: “Is”/”Is Not” for Problem Definition • Reasons to use “IS” - “IS NOT” – Establishes points of comparison – Leads to a more complete problem description – Provides a Test base for Root Cause – Gives you a fingerprint of the problem – Draws better boundaries around the problem • SCOPE – what’s in, what’s out
  26. 26. Training Materials – For Reference Only Slide 26 • Development of “IS”: Identity - What is the problem? Space - Where is the problem? Time - When is the problem happening? (also When did it start?) Mass - How Big is the problem? Tool: “Is”/”Is Not” for Problem Definition
  27. 27. Training Materials – For Reference Only Slide 27 IS IS NOT (What, Where, When, How Big) would you EXPECTEXPECT to.. SEE, HEAR, FEEL, SMELL, OBSERVE . . . .....but DO NOT?DO NOT? ((close cousinsclose cousins)) <<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>>>>>>>>>>>><<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>>>>>>>>>>>> Development of “IS NOT” (What, Where, When, How Big) “IS” it? (What, Where, When, How Big) could it be but it “IS NOT”? Once you have the Problem Defined, get feedback from others (coworkers, manager, others) who have done 8D/RCCA
  28. 28. Training Materials – For Reference Only Slide 28 Reasons to use “IS” - “IS NOT” – Establishes points of comparison – Leads to a more complete problem description – Provides a Test base for Root Cause – Gives you a fingerprint of the problem – Draws better boundaries around the problem • SCOPE – what’s in, what’s out
  29. 29. Training Materials – For Reference Only Slide 29 Document Your Work 1) Open a QN in SAP 2) Fill Out Section 1 of the 8D Summary Report - go to the Quality Forms link on the QA home page 3) Attach the 8D Summary Report file to the QN
  30. 30. Training Materials – For Reference Only Slide 30 Step 2 in the HBC 8D Process D-0 Decide to use the 8D Process D-1 Define the Problem DD--2 Form the Team2 Form the Team
  31. 31. Training Materials – For Reference Only Slide 31 8D - Step 2: Form a Team • A “Team” may be: • formal (scheduled meetings, for ex.) or • informal (consulted as needed) • Agree on work group guidelines Customer Complaint
  32. 32. Training Materials – For Reference Only Slide 32 Advantages/Disadvantages of Teams WHY DO TEAMS FAIL? WHAT ARE THE BENEFITS OF A TEAM APPROACH? What have been your experiences with teams??
  33. 33. Training Materials – For Reference Only Slide 33 Major Problems with Team Problem Solving •• Problem incorrectly describedProblem incorrectly described ! ! !! ! ! (biggest inhibitor)(biggest inhibitor) – Make sure Problem Description is accurate and team members agree • Problem solving process rushed • Poor team participation • No logical (group) process • Lack of technical skills • Management impatience • Permanent Corrective Action Not Implemented
  34. 34. Training Materials – For Reference Only Slide 34 Typical Team Organization Champion/Sponsor Leader Recorder – rotate this role Team Members (SME’s - Subject Matter Experts) Facilitator (optional) Customer/Supplier Are we having fun yet? Recommend: 4-7 members (10 max.) <4, consider leader driving results by consulting with SME’s >10, consider subteams Ask the initial team: “Who else needs to be involved, but isn’t here?”
  35. 35. Training Materials – For Reference Only Slide 35 Step 3 in the HBC 8D Process • D-0 Decide to use 8D Process • D-1 Define the Problem • D-2 Establish a Team DD--33 CHOOSE, IMPLEMENT AND VERIFYCHOOSE, IMPLEMENT AND VERIFY INTERIM CONTAINMENT ACTIONINTERIM CONTAINMENT ACTION -- basically youbasically you’’rere DispositioningDispositioning thethe QNQN
  36. 36. Training Materials – For Reference Only Slide 36 8D Step 3: Implement Interim Containment Action • Decide whether you need to use one • Choose the best (benefits vs. risks) – Tools • Brainstorming to generate ideas • Pro’s/Cons lists; Effort (or cost or time) vs. Benefit (or risk) graphic…. • Action Plan • Test feasibility of the containment action (Verify it will work) • Commit to it • Implement • Validate containment action effectiveness Action Plan ALWAYS +’s and –’s to every decision. BALANCE (and action) are the Keys! L H L H Ideal Effort Benefit
  37. 37. Training Materials – For Reference Only Slide 37 Purpose of Interim Containment • Used to “buy time” to find root cause while protecting your customer (external or downstream operation) from the problem • Authorized “first aid”, but. . . . . – can be costly – attacks “symptoms” (not the cause) – has a masking effect • Purpose of this step: – Enforce SCOPE and EFFECTIVENESS of customer protection needed It’s OK to not have containment, it’s NOT OK to not THINK about it.
  38. 38. Training Materials – For Reference Only Slide 38 Int. Cont. Action vs. Typical BAND AID __X__ Attacks Symptoms __X__ __X__ Added Costs __X__ __X__ Monitored while being used _____ __X__ Documented &Data Collected _____ __X__ Verified for effectiveness _____ __X__ Replaced by Perm. Correction _____ Interim Containment Action BANDAID
  39. 39. Training Materials – For Reference Only Slide 40 Key Points of Step 3: Interim Containment • Act quickly (and carefully) • Use the team to come up with the list of potential actions – Minimizes risk, results in better ideas • Pick the best overall Containment Action(s) • Consider actions that may be needed to address other areas: – Product in the field – WIP – Work In Process – Product in transit/at the Supplier – Spares • Use Action Plan to make sure nothing falls through the cracks – Examples: • VERIFICATION and VALIDATION • Airworthiness Directives • Service Bulletins • Kits for field • DON’T STOP HERE!!! XX Action Plan
  40. 40. Training Materials – For Reference Only Slide 41 Fill Out Section 3 of the 8D Summary Report
  41. 41. Training Materials – For Reference Only Slide 42 BREAK FOR 10 MINUTES
  42. 42. Training Materials – For Reference Only Slide 43 Where are We? Place in the HBC 8D Process • D-0 Decide to use 8D Process • D-1 Define the Problem • D-2 Establish a Team • D-3 Choose, Implement and Verify Interim Containment Action (I.C.A.) DD--44 FIND ROOT CAUSEFIND ROOT CAUSE
  43. 43. Training Materials – For Reference Only Slide 44 Root Cause Analysis Common Tools • Your Brain – Especially the ‘Collective Brain’ of your team • Data • Thought Map • Process Map • Brainstorming • 5 Why’s • Cause and Effect (Fishbone) Diagram • Graphical Analysis (misc. graphs) • +…… What tool to use? Problem ->Questions->Data/Tools ->More Questions…ROOT CAUSE Thought Map
  44. 44. Training Materials – For Reference Only Slide 45 • Don’t try to do solutions before the analysis is complete. • It is futile to continue doing things the same way while expecting different results. • Don’t fall into the trap of jumping to conclusions. General Information about Step 4 “OUR DESIRE TO ACT, OVERPOWERS OUR NEED TO UNDERSTAND” (Brad Baker, CONOCO) • This can’t be a part time job. Assign a Point Of Contact (POC) to focus on closure. • The RCCA response ECD must be based on a planned list of things to do (Action Item Lists).
  45. 45. Training Materials – For Reference Only Slide 46 Types of data to collect: 1. Location: where problem was detected 2. Personnel: who found problem 3. Specifications: what are the requirements 4. Environment: noise, lighting, temperature, etc… 5. Sequence of events 6. Equipment 7. Training 8. Other occurrences 9. Recent changes: personnel, process, weather Data Collection Insufficient data can result in solving only the specific instance. Challenge the basis for why it’s been determined to be an isolated event and why it couldn’t potentially be a systemic problem
  46. 46. Training Materials – For Reference Only Slide 47 Once the problem is defined, natural tendency is to rush forward RESIST THE URGE!! Take a few minutes to plan your “journey” to root cause 1) Write your Problem Statement at the top of the page 2) Capture questions that you have • Assumptions, potential causes, sources of the problem that don’t belong in the problem statement SHOULD be captured as questions 3) Answer each question with data 4) Questions (and data) will lead to more questions 5) Capture dead-ends as well as ‘fruitful’ paths 1) Why? NOTE: Review the Problem Definition (Step 1) often! Tools: Thought Map Used: When? ________________________ Why?__________________
  47. 47. Training Materials – For Reference Only Slide 48 What is the current bit brand and quality used? Is the perceived bit quality difference real or just perception? What specific features of the bit performance are perceived as the problem? Is it possible to attribute QNs and other sheet metal defects to bit quality? Is there a statistically significant difference in the number of holes drilled before dull? What other factors contribute to manual, hand drilling performance? How much is the difference? What are the bit performance indicators? 1 - Penetration – Sharpness 2 - Straightness 3 - Centering What is considered the ‘premium’ bit? 1 – Number of holes drilled 2 - Straightness 3 – Centering 4 – Penetration 5 – QNs Resulting Precision Twist Brand Bruckner provides a standard, such as Michigan Twist LEGEND: Dashed Lines Indicate Links What is the difference in cost for the bits? Thought Map example: Drill Bit Quality
  48. 48. Training Materials – For Reference Only Slide 49 Tools: Process Mapping/Value Stream Mapping • Graphical Depiction of “How It’s Done” – Terminator (start/stop) – Process Step – Decision Point – Connector (off-page) • General Rules: – Left to Right – Yes’s/No’s consistent ? ?? ? How would you map out the process for 8D so far? Used: When? ________________________ Why?__________________ Assembly Transport Inspection Outputs Inputs Transport Storage Machine Transport
  49. 49. Training Materials – For Reference Only Slide 50 Tools: 5 (OK, maybe just 3) Senses • Talk to, Listen to, Observe: – People performing the job – “Suppliers” (internal/external) – “Customers” (internal/external) You are a root cause “detective”. Use all the tools you can.
  50. 50. Training Materials – For Reference Only Slide 51 Tools: Brainstorming When the best solution isn’t obvious, one technique for generating ideas (possible root causes, potential interim corrective or permanent actions…) is brainstorming. 1. Generates a large number of ideas 2. Encourage free-thinking 3. Don’t criticize 4. Encourage everyone to participate 5. Record all ideas. There is no bad idea. 6. Let ideas incubate – give it a little time A minimum group of at least three people to make this work Used: When? ________________________ Why?__________________
  51. 51. Training Materials – For Reference Only Slide 52 1. Why? – There was oil on the floor. 2. Why? – The machine in that cell was leaking oil. 3. Why? – A pressure fitting on the machine failed. 4. Why? – Inspection of hoses and fittings is not part of the preventive maintenance (PM) schedule. 5. Why? – The PM system does not consider Equipment Manufacturer’s recommendations to develop PM schedules. 6. Why?- There’s check to make sure this is done. Don’t stop with “Because we don’t have enough people, money, time… – it’s a fact of life. Solve the problem with the people, money, time you DO HAVE. Tools: 5 Why’s An employee in the plant slipped and fell while performing their regular duties. “Peel the onion”- challenge the basis for root cause. Most people can only support 1-2 layers of questions with their basis for root cause or corrective action. Used: When? ________________________ Why?__________________
  52. 52. Training Materials – For Reference Only Slide 53 Tools: Cause and Effect Diagram A Cause-and-Effect (fishbone or Ishikawa) diagram – an easily applied tool used to analyze possible causes to a problem. Non-conforming coating Manpower - inexperienced Methods - incorrect prep of metal surface Machinery - microscope Materials - poor quality of standards - microscope setting not optimized to detect the smearing -not following the “frozen” coating parameters - inadequate training -inadequate technique MUST BE TESTED AND VERIFIED! 5 M’s and an E - add Measures and Environment for 6 “Bones” Used: When? ________________________ Why?__________________
  53. 53. Training Materials – For Reference Only Slide 54 Tools: Graphical Analysis • Histogram – • Used to show patterns/distribution in ordered data • Categories on the x-axis, # of occurrences on the y axis. • Pareto Chart (80/20 rule) – • Used when many problems or causes and you want to focus on the most significant • Causes on x-axis, Results on the left (primary) y- axis, Cumulative % on the right (secondary) y- axis. • Scatter Diagram – • Used to illustrate relationships between 2 variables. 1 variable on each axis. • "Correlation does not imply causality." • Ex. Shark Bites and Ice Cream Purpose of Graphical Analysis: ________________________________
  54. 54. Training Materials – For Reference Only Slide 55 Use Common Sense: 1. The more significant or involved the problem, the more detail may be needed to identify the Root Cause 1. Also more advanced tools 2. Avoid data that leads to other problems. 1. Don’t get sidetracked 1. Review Step 1 – Problem Description. 2. Use the Thought Map Word of Caution: Stay on Track! Start Goal Side Issue Side Issue Side Issue Complex problems usually require at least a fishbone diagram of the potential root causes sorted from the brainstorm list • Define the actions to validate or dismiss each one • Technical problems usually require a structured FMEA
  55. 55. Training Materials – For Reference Only Slide 56 Document Your Findings Fill Out Section 4 of the 8D Summary Report
  56. 56. Training Materials – For Reference Only Slide 57 8D – Step 5: Choose Corrective Action Place in the HBC 8D Process: • D-0 Decide to use 8D Process • D-1 Define the Problem • D-2 Establish a Team • D-3 Choose, Implement and Verify Interim Containment Action (I.C.A.) • D-4 Find Root Cause DD--5 DETERMINE PERMANENT CORRECTIVE5 DETERMINE PERMANENT CORRECTIVE ACTIONACTION
  57. 57. Training Materials – For Reference Only Slide 58 Decision Making Steps (note: can also be used in Step 3) 1. Define end result (action verb & object) • Eliminating/Preventing/Reducing (verbs) • Errors/Safety Incidents/QN/s (objects) 2. List decision criteria –– GIVENSGIVENS - Mandatory –– WANTSWANTS - Desirable 3. Decide relative importance of wantswants 1-10 4. Identify the possible choices 5. Compare possible choices against the decision criteria 6. Analyze risk IF/THEN terms: If we choose to___________, Then _________ will happen. 7. Make the final BALANCED choice and VERIFY NOTE: Use the Action Item Tracking Sheet to Capture and Track Actions ALWAYS +’s and –’s to every decision. BALANCE (and action) are the Keys! Action Plan
  58. 58. Training Materials – For Reference Only Slide 59 Use the Corrective Action Plan Worksheet in the 8D File and Summarize in Section 5 of the 8D Summary Report Track Action Items to Completion and Summarize Results
  59. 59. Training Materials – For Reference Only Slide 60 Place in the HBC 8D Process: D-0 Decide to use D8 Process D-1 Choose team members D-2 Define problem D-3 Choose Interim Corrective Action(s) & verify D-4 Find Root Cause D-5 Choose & verify Permanent Corrective Action DD--66 IMPLEMENT PERMANENTIMPLEMENT PERMANENT CORRECTIVE ACTIONCORRECTIVE ACTION 8D - Step 6: Implement the Fix
  60. 60. Training Materials – For Reference Only Slide 61 Goals of Permanent Corrective Action • Permanent Corrective Action MUSTMUST: – Address the systemic problem (in addition to this specific instance) – Eliminate the Root Cause – Prevent recurrence – Be implemented in a timely manner – Include a detailed plan (especially if it will take considerable time and people) – Be comparable to the risk involved • Risk to the customer, employee, organization, public, etc. – Be verified Objectively • Three knowledgeable people must agree
  61. 61. Training Materials – For Reference Only Slide 62 Keys to Successful Corrective Action – Persistence • Natural Tendency to slack off once the Fix is determined and partially implemented • Follow the Action Plan to Completion – Involve “Do-It-Level” people • Key to preventing recurrence – Review Interim Containment Action(s) • Remove/discontinue any not needed – adds cost, time, etc. – VERIFY IT!!! – VALIDATE IT!!! Action Plan
  62. 62. Training Materials – For Reference Only Slide 63 Why should we do planning and NEW problem prevention when considering implementing a permanent corrective action for THIS problem? – see next slide…. More than “Just Do It”
  63. 63. Training Materials – For Reference Only Slide 64 Why Planning and Problem Prevention? • Many of our current problems are the result of not following through with previous plans • Must allocate limited resources effectively – Optimize implementation • Don’t waste Time/$$ • Prevent other problems from occurring – With change comes risk of creating NEW problems – Control Mr. Murphy
  64. 64. Training Materials – For Reference Only Slide 65 Fill Out Section 6 of the 8D Form Summarize the Key Permanent Corrective Actions
  65. 65. Training Materials – For Reference Only Slide 66 D-0 Decide to use D8 Process D-1 Choose team members D-2 Define problem D-3 Choose Interim Containment Action(s) & verify D-4 Find Root Cause D-5 Choose & verify permanent corrective action D-6 Implement Permanent Corrective Action(s) DD--77 PREVENT RECURRENCEPREVENT RECURRENCE 8D - Step 7: Prevent Recurrence
  66. 66. Training Materials – For Reference Only Slide 67 Steps to Preventing Recurrence – Identify what systems, practices, or procedures allowed the problem to occur • The “why’s” – Identify and implement improvements – VALIDATE the results
  67. 67. Training Materials – For Reference Only Slide 68 • Poka-yoke is the Japanese term that means “fail-safing” or "mistake-proofing" • Examples: – Can’t start car until in park, Child-proof caps, laser beam shut- offs for machinery – Others?? • One of the best ways to prevent problems from occurring/recurring • Use mistake-proofing techniques when there are: – Process steps where human intervention is required – Decision points in the process – Repetitive tasks where physical manipulation of objects is required – Steps where errors are known to occur – Opportunities for predictable errors to occur Tool: Mistake-Proofing
  68. 68. Training Materials – For Reference Only Slide 69 Mistake-Proofing – Levels of Prevention Defect is the evidence of an error More Proactive
  69. 69. Training Materials – For Reference Only Slide 70 HUMAN ERRORS – do not make a root cause How does HBC approach human error? • Positive – Defects can be eliminated – Create a mistake-proof environment – Ask “Why?” • Focus on the Process/Product NOT the Person – Apply Mistake-Proofing device for 100% inspection • Negative – Defects are inevitable – People make mistakes – Place blame – Detect at final inspection – Sampling inspection – Some are bound to reach the customer Beware of “Root cause was ‘Human Error’”
  70. 70. Training Materials – For Reference Only Slide 71 How Can We Standardize Lessons Learned & System Improvements? • Communication • Same/similar problem other plants • Same/similar problem different systems • Content Quality • Appropriate Quantity Once Root Cause is Determined, Broaden your Thinking Effect Root Cause Potential Causes Current/Future Problems in other areas
  71. 71. Training Materials – For Reference Only Slide 72 Fill Out Section 7 of the 8D Form – Prevention of Recurrence
  72. 72. Training Materials – For Reference Only Slide 73 8D - Step 8: Congratulate the Team D-0 Decide to use D8 Process D-1 Choose team members D-2 Define problem D-3 Choose I.C.A., verify D-4 Find Root Cause D-5 Choose & verify P.C.A. D-6 Implement P.C.A.(s) D-7 Prevent recurrence DD--88 CONGRATULATE THE TEAMCONGRATULATE THE TEAM
  73. 73. Training Materials – For Reference Only Slide 74 How to Congratulate the Team • Review significance of contribution • Provide appropriate recognition for all members • Document the efforts & results • Celebrate successful completion • Celebrations don’t have to be elaborate/expensive • Be creative
  74. 74. Training Materials – For Reference Only Slide 75 How Would You Congratulate Your Team? What are some things that have worked well in the past? What are some things that didn’t? 5 minutes
  75. 75. Training Materials – For Reference Only Slide 76 Fill Out Section 8 of the 8D Form (and attach completed file to the appropriate QN)
  76. 76. Training Materials – For Reference Only Slide 77 Comments, Suggestions?? Please fill out class/instructor Evaluation Forms
  77. 77. Training Materials – For Reference Only Slide 78 Reference Material
  78. 78. Training Materials – For Reference Only Slide 79 QA Intranet Website

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