8 Disciplines (8D) Training

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

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

• 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

Round Robin Introductions
• Your Name
• Where you work -
position/responsibilities
• Personal objectives for this course

• 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

• 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

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

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.

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)

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.

• 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.

What is 8D?
1. Corporate Standard
2. Standardized Problem Solving
Process
• Language, Methodology
3. Reporting Format

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

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.

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.

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”?

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!

• 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

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.

– 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?

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)?
– When?

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?
– Where?

– 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?

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

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

• 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

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

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

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

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

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

Advantages/Disadvantages of Teams
WHY DO TEAMS FAIL?
WHAT ARE THE BENEFITS
OF A TEAM APPROACH?
What have been your experiences with teams??

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

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?”

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

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

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.

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

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

Fill Out Section 3 of the 8D
Summary Report

BREAK FOR 10 MINUTES

Where are We?
Place in the HBC 8D Process
• D-3 Choose, Implement and Verify Interim Containment
Action (I.C.A.)
DD--44 FIND ROOT CAUSEFIND ROOT CAUSE

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

• 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).

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

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?__________________

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

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

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.

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?__________________

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?__________________

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?__________________

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: ________________________________

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

Document Your Findings
Fill Out Section 4 of the 8D
Summary Report

8D – Step 5: Choose Corrective Action
Place in the HBC 8D Process:
• 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

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

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

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

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

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

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”

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

Fill Out Section 6 of the 8D Form
Summarize the Key Permanent
Corrective Actions

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

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

• 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

Mistake-Proofing – Levels of Prevention
Defect is the
evidence of an
error
More Proactive

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’”

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

Fill Out Section 7 of the 8D Form –
Prevention of Recurrence

8D - Step 8: Congratulate the Team
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

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

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

Fill Out Section 8 of the 8D Form
(and attach completed file to the
appropriate QN)

Comments, Suggestions??
Please fill out class/instructor
Evaluation Forms

Reference Material

QA Intranet Website

8 Disciplines (8D) Training

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