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A Project On
Root-cause analysis & Problem Solving using
Ishikawa Diagram & Why-why Technique
By Vedant Diwan
BE Mechanical Sandwich
Content
Project Objectives
About 8D methodology
Eight Disciplines of Problem Solving
Process followed
Sample PSRs
Aftermath
Conclusion
Project Objectives
To solve the defects occurring during assembly process of
Light commercial vehicles at H 3 Chassis line of Tata Motors.
It is part of efforts taken at Tata Motors H3 LCV Shop to
achieve World Class Quality Level 2.
8D Methodology
8D stands for the 8 disciplines or the 8 critical steps for
solving problems
Isolates and contains the most basic causes of any
undesirable condition
Identifies the factors that contribute to the problem
Eliminates systemic factors that cause the condition
Focuses on the origin of the problem by determining its
root cause and Prevents problem recurrence
Eight Disciplines of Problem Solving
D1: Form a Team
D2: Define and describe the Problem
D3: Develop Interim Containment
D4: Determine Root Cause(s)
D5: Permanent Corrections for Problem
D6: Implement and Validate Corrective Actions
D7: Take Preventive Measures
D8: Congratulate Your Team
D1: Team formation
The team leader must generate a list defining the team
structure in order to ensure that a team was actually
formed for the 8D project
The team leader must schedule meetings periodically to
review progress of the 8D project and discuss action
Team members must complete their actions and report
back to the team leader
So, a team of four members was formed
D2: Describe the Problem
Describing the problem starts with a well-thought-out problem
statement. The problem statement should
 Communicate the scope of the problem that the team is working on
and get the team focused.
 Provide information relevant to the problem: data and information
on what the problem is and what the problem isn’t.
 Determine root causes and implement or recommend a solution,
specify the deadline
D2: 5W 2H
Output of a process used to amplify the problem statement
in terms of 5W 2H
That is- Who, What, Why, Where, When, and How Big
(how much, how many, how often)
D3: Containment Actions
 A containment means Actions those are taken to prevent the effect
of the problem or to prevent the full effect from impacting
customers
 Quality alerts, purge and inspection, sorting bad parts from good
ones, adding short term operations, reviewing current procedures,
additional inspection and tests
 Why is interim containment necessary?
D3: Purging Sheet
D4: Develop Root Cause
Defining the root causes of a problem is the core of the 8D
problem-solving process
This is normally the toughest aspect of the problem-
solving process
Various tools are used for root cause analysis such as 5
Whys, Ishikawa diagram, etc.
D4: Ishikawa Diagram
Also known as Fishbone Diagram or Cause and Effect diagram
It classifies factors thought to be affecting characteristics
Associates these factors using arrows in a systematic and readily
understandable manner
This Provides an extremely good method for managing a large
number of factors in a single diagram
Determine probable causes from these
D4: To Prepare Cause and Effect Diagram
Various factors those affect the processes:
Man
Methods
Machines
Materials
Measurements
Environment
Cause and Effect diagram for Coolant leakage
D4: Why- Why Analysis
The Why-Why analysis is an iterative question-asking
technique
To explore the cause-and-effect relationships underlying a
particular problem
The primary goal: To determine the root cause of a defect
or problem
Also known as 5 Whys
D4: Why-Why analysis sample
D5: Develop Permanent Corrective Actions
 A systematic approach is needed to use the root cause analysis to develop a
solution
The solution should be:
 Practical - The 8D team should be able to implement the solution
practically.
 Feasible - The solution must be feasible.
 Cost effective - Implementing and using the solution must be cost effective.
 Robust - The solution shouldn’t fail when used in production.
D6: Implement Permanent Corrective Actions
 Once the solution and its implementation are approved, the next step
is to create an Action Plan.
 The Action Plan outlines what steps are needed to implement the
solution, who will do them, and when they will be completed.
D7: Prevent Re-occurrence
 Preventing recurrence is an important part of a problem’s solution
 To prevent recurrence of the problem, the team must verify that the
outcome of their Action Plan works and they must validate that the
outcome is on-target
 Various tools such as FMEA, Control plans, One-point lesson etc.
are used
D7: One Point Lesson
D8: Recognize the Team
 Once a team has completed implementing the solution and ensured
that the solution works, all team members deserve to be
congratulated.
 The organization (leadership group) shall recognize the team for
their efforts in a timely manner.
 The project team shall recognize those that have provided the team
with support and assistance.
A PSR for AC pipe foul to Long. Member
Problem defining:
A PSR for AC pipe foul to Long. Member
Finding possible causes:
A PSR for AC pipe foul to Long. Member
Finding Root cause:
A PSR for AC pipe foul to Long. Member
Corrective actions:
A PSR for Baby Filter Mounting Bkt bend
Defining a problem:
A PSR for Baby Filter Mounting Bkt bend
Containment and Possible causes:
A PSR for Baby Filter Mounting Bkt bend
finding root cause:
A PSR for Baby Filter Mounting Bkt bend
Corrective measures:
Aftermath of Project
 Problems were chosen based on their no. of occurrences & severity of problem.
 Purging was done for these problems’ containment i.e. to avoid occurrence before the
permanent actions are taken.
 Root cause is detected by following 8D methodology, using Why-Why analysis and
Ishikawa Diagram.
 This method was used for 10 different problems. Follow up of all these Problem solving
report was done by checking the status of all the defects.
Following table gives overview of all the defects, their root cause, and actions taken to solve:
Sr.
No.
Defect Root Cause Proposed Solution Vehicle
Problem Status
(On 15 Dec 2015)
1 AC Pipe foul to Long
Member
Improper clamping process
of AC Pipe fitment
Bracket hole on which pipe is
mounted is changed
810/38
LPT
Closed/ No
reoccurrence
2 Baby Filter Mounting
Bracket bent
Wrong mounting bracket in
used
Correct bracket is to be used
for mounting
Ultra
1012
Closed/ No
reoccurrence
3 Brake Chamber Stud
Washer Damaged
Incorrect procedure
followed
Operator be instructed to
remove plastic cap before
tightening
Y1 Bus Closed/ No
reoccurrence
4 Brake pipe and Rear
brake foul
Operator Unaware About
correct procedure
Operator was instructed to
follow correct procedure
Ultra
1012
Implemented,
No reoccurrence
5 AC pipe foul to Long
Member
Insufficient clamping of AC
Pipe
Clamping Bracket Changed Ultra
1012
Closed/ No
reoccurrence
Sr.
No. Defect Root Cause Proposed Solution Vehicle
Problem Status
(On 15 Dec 2015)
6 Propeller shaft offset
and Foul with centre
bearing
During inversion propeller
shaft Shifts and fouls
Centre bearing bracket be tilt
& adjusted so as to avoid
Offset and fouling
Ultra
1012
Implemented,
No reoccurrence
7 Gear lever cable
broken
Gear lever cable clamping
not done
‘P’ clamp is used on ‘L’ Bkt
To clamp gear lever
Y1 Bus Closed/No
reoccurrence
8 Silencer rubber
dislodged
Silencer mounting hook
fixture Faulty at supplier end
Silencer hook fixture to be
corrected at supplier’s end
909/27
LPK
Closed/No
reoccurrence
9 Cable connector not
parked
Operator unaware about
correct process
Checking started and operator
trained
407
LPT
Implemented,
No reoccurrence
10 Coolant Leakage
from Auxiliary tank
Fitment valve threading
mismatch
Ana-Bond should be started in
use for perfect tightening
Ultra
1012
Implemented,
No reoccurrence
Following table gives overview of all the defects, their root cause, and actions taken to solve (contd.):
Conclusion
 8D Methodology was designed to solve various problem solving using various quality
tools. These tools include 5W 2H, Why-Why analysis, Ishikawa diagram, Brainstorming,
etc.
 Vehicles should be checked for the effectiveness of solution for 20 days for the defects and
if no reoccurrence of these defects arise, then defect is closed.
 6 Such defects were closed and 4 Proposed & implemented solutions showed no
reoccurrence (till 15 Dec 2015). These defects solved will help Tata Motors achieve WCQ
level 2.
 So it can be established that 8D methodology using Why-Why analysis and Ishikawa
Diagram is an effective way to solve defects in a vehicle assembly process.

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Tata Project

  • 1. A Project On Root-cause analysis & Problem Solving using Ishikawa Diagram & Why-why Technique By Vedant Diwan BE Mechanical Sandwich
  • 2. Content Project Objectives About 8D methodology Eight Disciplines of Problem Solving Process followed Sample PSRs Aftermath Conclusion
  • 3. Project Objectives To solve the defects occurring during assembly process of Light commercial vehicles at H 3 Chassis line of Tata Motors. It is part of efforts taken at Tata Motors H3 LCV Shop to achieve World Class Quality Level 2.
  • 4. 8D Methodology 8D stands for the 8 disciplines or the 8 critical steps for solving problems Isolates and contains the most basic causes of any undesirable condition Identifies the factors that contribute to the problem Eliminates systemic factors that cause the condition Focuses on the origin of the problem by determining its root cause and Prevents problem recurrence
  • 5. Eight Disciplines of Problem Solving D1: Form a Team D2: Define and describe the Problem D3: Develop Interim Containment D4: Determine Root Cause(s) D5: Permanent Corrections for Problem D6: Implement and Validate Corrective Actions D7: Take Preventive Measures D8: Congratulate Your Team
  • 6. D1: Team formation The team leader must generate a list defining the team structure in order to ensure that a team was actually formed for the 8D project The team leader must schedule meetings periodically to review progress of the 8D project and discuss action Team members must complete their actions and report back to the team leader So, a team of four members was formed
  • 7. D2: Describe the Problem Describing the problem starts with a well-thought-out problem statement. The problem statement should  Communicate the scope of the problem that the team is working on and get the team focused.  Provide information relevant to the problem: data and information on what the problem is and what the problem isn’t.  Determine root causes and implement or recommend a solution, specify the deadline
  • 8. D2: 5W 2H Output of a process used to amplify the problem statement in terms of 5W 2H That is- Who, What, Why, Where, When, and How Big (how much, how many, how often)
  • 9. D3: Containment Actions  A containment means Actions those are taken to prevent the effect of the problem or to prevent the full effect from impacting customers  Quality alerts, purge and inspection, sorting bad parts from good ones, adding short term operations, reviewing current procedures, additional inspection and tests  Why is interim containment necessary?
  • 11. D4: Develop Root Cause Defining the root causes of a problem is the core of the 8D problem-solving process This is normally the toughest aspect of the problem- solving process Various tools are used for root cause analysis such as 5 Whys, Ishikawa diagram, etc.
  • 12. D4: Ishikawa Diagram Also known as Fishbone Diagram or Cause and Effect diagram It classifies factors thought to be affecting characteristics Associates these factors using arrows in a systematic and readily understandable manner This Provides an extremely good method for managing a large number of factors in a single diagram Determine probable causes from these
  • 13. D4: To Prepare Cause and Effect Diagram Various factors those affect the processes: Man Methods Machines Materials Measurements Environment
  • 14. Cause and Effect diagram for Coolant leakage
  • 15. D4: Why- Why Analysis The Why-Why analysis is an iterative question-asking technique To explore the cause-and-effect relationships underlying a particular problem The primary goal: To determine the root cause of a defect or problem Also known as 5 Whys
  • 17. D5: Develop Permanent Corrective Actions  A systematic approach is needed to use the root cause analysis to develop a solution The solution should be:  Practical - The 8D team should be able to implement the solution practically.  Feasible - The solution must be feasible.  Cost effective - Implementing and using the solution must be cost effective.  Robust - The solution shouldn’t fail when used in production.
  • 18. D6: Implement Permanent Corrective Actions  Once the solution and its implementation are approved, the next step is to create an Action Plan.  The Action Plan outlines what steps are needed to implement the solution, who will do them, and when they will be completed.
  • 19. D7: Prevent Re-occurrence  Preventing recurrence is an important part of a problem’s solution  To prevent recurrence of the problem, the team must verify that the outcome of their Action Plan works and they must validate that the outcome is on-target  Various tools such as FMEA, Control plans, One-point lesson etc. are used
  • 20. D7: One Point Lesson
  • 21. D8: Recognize the Team  Once a team has completed implementing the solution and ensured that the solution works, all team members deserve to be congratulated.  The organization (leadership group) shall recognize the team for their efforts in a timely manner.  The project team shall recognize those that have provided the team with support and assistance.
  • 22. A PSR for AC pipe foul to Long. Member Problem defining:
  • 23. A PSR for AC pipe foul to Long. Member Finding possible causes:
  • 24. A PSR for AC pipe foul to Long. Member Finding Root cause:
  • 25. A PSR for AC pipe foul to Long. Member Corrective actions:
  • 26. A PSR for Baby Filter Mounting Bkt bend Defining a problem:
  • 27. A PSR for Baby Filter Mounting Bkt bend Containment and Possible causes:
  • 28. A PSR for Baby Filter Mounting Bkt bend finding root cause:
  • 29. A PSR for Baby Filter Mounting Bkt bend Corrective measures:
  • 30. Aftermath of Project  Problems were chosen based on their no. of occurrences & severity of problem.  Purging was done for these problems’ containment i.e. to avoid occurrence before the permanent actions are taken.  Root cause is detected by following 8D methodology, using Why-Why analysis and Ishikawa Diagram.  This method was used for 10 different problems. Follow up of all these Problem solving report was done by checking the status of all the defects.
  • 31. Following table gives overview of all the defects, their root cause, and actions taken to solve: Sr. No. Defect Root Cause Proposed Solution Vehicle Problem Status (On 15 Dec 2015) 1 AC Pipe foul to Long Member Improper clamping process of AC Pipe fitment Bracket hole on which pipe is mounted is changed 810/38 LPT Closed/ No reoccurrence 2 Baby Filter Mounting Bracket bent Wrong mounting bracket in used Correct bracket is to be used for mounting Ultra 1012 Closed/ No reoccurrence 3 Brake Chamber Stud Washer Damaged Incorrect procedure followed Operator be instructed to remove plastic cap before tightening Y1 Bus Closed/ No reoccurrence 4 Brake pipe and Rear brake foul Operator Unaware About correct procedure Operator was instructed to follow correct procedure Ultra 1012 Implemented, No reoccurrence 5 AC pipe foul to Long Member Insufficient clamping of AC Pipe Clamping Bracket Changed Ultra 1012 Closed/ No reoccurrence
  • 32. Sr. No. Defect Root Cause Proposed Solution Vehicle Problem Status (On 15 Dec 2015) 6 Propeller shaft offset and Foul with centre bearing During inversion propeller shaft Shifts and fouls Centre bearing bracket be tilt & adjusted so as to avoid Offset and fouling Ultra 1012 Implemented, No reoccurrence 7 Gear lever cable broken Gear lever cable clamping not done ‘P’ clamp is used on ‘L’ Bkt To clamp gear lever Y1 Bus Closed/No reoccurrence 8 Silencer rubber dislodged Silencer mounting hook fixture Faulty at supplier end Silencer hook fixture to be corrected at supplier’s end 909/27 LPK Closed/No reoccurrence 9 Cable connector not parked Operator unaware about correct process Checking started and operator trained 407 LPT Implemented, No reoccurrence 10 Coolant Leakage from Auxiliary tank Fitment valve threading mismatch Ana-Bond should be started in use for perfect tightening Ultra 1012 Implemented, No reoccurrence Following table gives overview of all the defects, their root cause, and actions taken to solve (contd.):
  • 33. Conclusion  8D Methodology was designed to solve various problem solving using various quality tools. These tools include 5W 2H, Why-Why analysis, Ishikawa diagram, Brainstorming, etc.  Vehicles should be checked for the effectiveness of solution for 20 days for the defects and if no reoccurrence of these defects arise, then defect is closed.  6 Such defects were closed and 4 Proposed & implemented solutions showed no reoccurrence (till 15 Dec 2015). These defects solved will help Tata Motors achieve WCQ level 2.  So it can be established that 8D methodology using Why-Why analysis and Ishikawa Diagram is an effective way to solve defects in a vehicle assembly process.