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A Structured Approach to Problem-Solving

The document is a comprehensive overview of a structured problem-solving process presented during a webinar by Chad Westbrook from AGCO. It includes various problem-solving tools such as 5G, 5W1H, 4M1D, and the 5 Whys technique, aimed at identifying and addressing manufacturing issues in a systematic way. The presentation emphasizes the importance of understanding the actual conditions and carefully analyzing the phenomena to develop effective countermeasures.

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A Structured Approach to Problem-Solving Host: Mark Graban KaiNexus Mark@KaiNexus.com Presenter: Chad Westbrook AGCO Chad.Westbrook@agcocorp.com
Webinar Logistics • Presentation (45 minutes) • Q&A (10 minutes) – Use the GoToWebinar Meeting Panel to submit a question at any time • Recording link & slides will be sent via email – Also – see the “Handouts” feature and Chat box
Our Presenter About Chad Westbrook Chad Westbrook is a manufacturing engineering manager and AGCO Production System manager at AGCO Corporation. Chad has a bachelor's degree in Mechanical Engineering Related Technologies from Kansas State University.
© 2012 AGCO Corporation All rights reserved. Combines 4 3 Brands 5 Models
© 2012 AGCO Corporation All rights reserved. Round Balers 5 2 Brands, 5 Models
© 2012 AGCO Corporation All rights reserved. Small Square Balers 6 2 Brands, 6 Models
© 2012 AGCO Corporation All rights reserved. Large Square Balers 7 3 Brands 7 Models
© 2012 AGCO Corporation All rights reserved.8 Self Propelled Windrowers 2 Brands 4 Models
© 2012 AGCO Corporation All rights reserved. Pull Type Mowers 9 2 Brands 7 Models
© 2012 AGCO Corporation All rights reserved. Headers 10 3 Brands 3 Models
• Overview the Structured Problem Solving Process • 5G • 5W1H - Phenomenon Description • 4M1D & Confirmation • 5 Whys • Levels of Countermeasures and Controls • Agco Example Agenda 11
Structured Problem Solving Process 12
13 Structured Problem Solving Process 1. 5G 2. 5W1H 3. 4M1D & Confirmation 4. 5 Whys INITIAL PHENOMENON ROOT CAUSE
5G 14
15 5G 1. Definition - 5G is a tool used to describe a loss phenomenon • Safety • Quality defect • Minor stoppage • Major breakdown • Long set-up • Parts shortage • Etc. 2. Purpose • To describe a situation in a complete and detailed way • To keep a proper relationship between theory and practice • To follow a logical flow during the process 3. When • Use 5G during the first phase of problem investigation
16 5G Process GEMBA GEMBUTSU GENJITSU GENRI GENSOKU Actual Place Actual Things Actual Facts Principles Standards & Parameters Go to the spot The workplace, the place where the event actually happens. Don’t be tempted to assume you know the problem, there may be things you will miss. Examine the objects The actual Materials, Processes, Machinery, People, and Objects that are actually involved in an event Check the facts Get the real facts and analyze the actual data (what actually happened, what you can actually observe with your own eyes, separate the facts from the assumptions) Refer to the theory Principles and process Follow the standards Standards & Parameters (physical values)
5W1H- Phenomenon Description 17
18 5W1H – Phenomenon Description 1. What is a Problem (Initial Phenomenon)? In Manufacturing: • A deviation or gap between the current condition (what is) and the desired condition (what should be) and the cause for the gap is unknown 2. What is the Revised Phenomenon? • The origin of the word (in Greek) means to make visible that which cannot be seen • It is an event or condition that results in a problem
19 5W1H – Phenomenon Description Initial Phenomenon Superficial Analysis with no 5G and 5W1H Many Possible Causes Vague Phenomenon Broad Scope
20 5W1H – Phenomenon Description Initial Phenomenon = Possible Causes = Root Cause Deep and detailed analysis using 5G during 5W1H Specific Revised Phenomenon Narrow Scope
21 5W1H – Phenomenon Description Line: QE: Machine: ME: Date: Supervisor/CC: Operator: Initial Phenomenon: Containment? What? When? Where? Who? Which? How? Revised Phenomenon: 5W1H - PHENOMENON DESCRIPTION What happened? What’s the phenomenon? Can we reproduce the phenomenon? What does the phenomenon look like? What machine, product, material? What size? Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved? How is it being done? What is the extent of the phenomenon? Is the process in control? How is the state of the equipment changed from the optimal? How many times does the phenomenon occur? Where did you see the phenomenon? Where did the phenomenon occur? Where on the equipment or material? Who is doing it? Who does it affect? Who can generate the phenomenon? Is it an individual or group? Is it skill related? Which trend or pattern does the phenomenon have? Which direction? Which factors influence the occurrence? Is it related to any process variable? When did the phenomenon start? When did the phenomenon occur (date, time, shift)? When in the process (startup, continuous, intermittent, shutdown, changeover)?
22 5W1H – Phenomenon Description Basic Information • Date and participants in team • What is the initial problem that was reported? Line: QE: Machine: ME: Date: Supervisor/CC: Operator: Containment? What? 5W1H - PHENOMENON DESCRIPTION Initial phenomenon: What does the phenomena look like? What product, machine, Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved?
23 5W1H – Phenomenon Description Containment • Are containment measures necessary? • Are damaged or failed parts accounted for? • Is delivery to any other customers prevented? • Are immediate measures documented and known to all parties involved?
24 5W1H – Phenomenon Description 1 - What? • What happened? • What’s the phenomenon? • Can we reproduce the phenomenon? • What does the phenomenon look like? • What machine, product, material? • What size? What? What happened? What’s the phenomenon? Can we reproduce the phenomenon? What does the phenomenon look like? What machine, product, material? What size?
25 5W1H – Phenomenon Description 2 - When? • When did the phenomenon start? • When did the phenomenon occur (date, time, shift)? • When in the process (startup, continuous, intermittent, shutdown, changeover)? When? When did the phenomenon start? When did the phenomenon occur (date, time, shift)? When in the process (startup, continuous, intermittent, shutdown, changeover)?
26 5W1H – Phenomenon Description 3 - Where? • Where did you see the phenomenon? • Where did the phenomenon occur? • Where on the equipment or material? Where? Where did you see the phenomenon? Where did the phenomenon occur? Where on the equipment or material?
27 5W1H – Phenomenon Description 4 - Who? • Who is doing it? • Who does it affect? • Who can generate the phenomenon? • Is it an individual or group? • Is it skill related? Who? Who is doing it? Who does it affect? Who can generate the phenomenon? Is it an individual or group? Is it skill related?
28 5W1H – Phenomenon Description 5 - Which? • Which trend or pattern does the phenomenon have? • Which direction? • Which factors influence the occurrence? • Is it related to any process variable? Which? Which trend or pattern does the phenomenon have? Which direction? Which factors influence the occurrence? Is it related to any process variable?
29 5W1H – Phenomenon Description 1 - How and How many? • How is it being done? • What is the extent of the phenomenon? • Is the process in control? • How is the state of the equipment changed from the optimal? • How many times does the phenomenon occur? How? How is it being done? What is the extent of the phenomenon? Is the process in control? How is the state of the equipment changed from the optimal? How many times does the phenomenon occur?
30 5W1H – Phenomenon Description Revised Phenomenon • What is the new abnormal condition creating the phenomenon? 5W1H process brings the same perception of the phenomenon to all Revised Phenomenon:
31 5W1H – Phenomenon Description Desired Observed Initial Phenomenon – Hole oversized in spacer plate Revised Phenomenon – Drill off angle
4M1D and Confirmation 32
33 4M1D – Fishbone Diagram (Ishikawa) P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H)
34 4M1D – Fishbone Diagram (Ishikawa) Step 1 • Transfer the “Revised Phenomenon” from the 5W1H into the circle P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H) Line: QE: Machine: ME: Date: Supervisor/CC: Operator: Containment? What? When? Where? Who? Which? How? How is the state of the equipment changed from the optimal? How many times does the problem occur? Do problems increase or decrease? Revised phenomenon: Where did you see the phenomena? Where on the equipment or material did you see the phenomena? Who does it effect? everyone? Is it a problem for some individuals or teams? If so, what info can they offer? Is it skill related? Which trend or pattern does the phenomena have? E.g. Is the phenomena more frequent on Monday mornings? After a change-over? Or is it random in nature? Which direction does the phenomena happen in? (Note: Not many phenomena are truly random!) When did the phenomena occur? When in the sequence of operation; startup, continuous running, intermittent problem, shutdown, changeover? 5W1H - PHENOMENON DESCRIPTION Initial phenomenon: What does the phenomena look like? What product, machine, material, was being used? What size? Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved?
35 4M1D – Fishbone Diagram (Ishikawa) Step 2 • Modify the major categories if Material, Method, Machine, Man, and Design don’t fit the problem P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H)
36 4M1D – Fishbone Diagram (Ishikawa) Step 3 • Brainstorm and document all contributing factors related to each main category P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H)
37 4M1D – Fishbone Diagram (Ishikawa) Step 4 • Eliminate the trivial, non-important causes and cross them off. • Discuss the remaining causes. Decide which are important and circle them. P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H) Important Trivial
P lant: S ugges tion # 4M Category Contributing Factors Cause Item Contributing Factors Cause Confirmation check OK Not OK Responsible 4M1D Confirmation Department: Machine/Area/S tation: P roject Number: 38 4M1D – Confirmation Step 5 • Transfer all important causes to the 4M1D confirmation
P lant: S ugges tion # 4M Category Contributing Factors Cause Item Contributing Factors Cause Confirmation check OK Not OK Responsible 4M1D Confirmation Department: Machine/Area/S tation: P roject Number: 39 4M1D – Confirmation Step 6 • Confirm each potential root cause as a contributing factor or not
5 Whys 40
41 5 Whys Simple problem solving tool that helps you identify a countermeasure 5 Whys Process: • Transfer non-confirmed “Not OK” effects from the 4M1D • Start by asking “why?” the problem is happening Ø Asking "why?" sounds simple, but answering it requires thought and intelligent application. Search for answers that are grounded in fact: they must be accounts of things that have actually happened – not guesses at what might have happened • The number “5” is not important. Continue asking “why?” until you have reached an effective countermeasure and you can go no further • The path should make sense when read in reverse using the statement “therefore” 1-Why 2-Why 3-Why 4-Why 5-Why 5 Whys Effect Potential causes Action
42 5 Whys – Machine Example Replace the sealSolution Coolant is leaking from machine WHY A seal was damaged WHY Metal shavings got into coolant Coolant pump guard allowed shavings to pass behind coolant screen. WHY You discover coolant on the floor WHY Counter Measure Design and install new guard over the screen Therefore Therefore Therefore
1-Why 2-Why 3-Why 4-Why 5-Why 5 Whys Effect Potential causes Action P lant: 4M Category Potential Root Cause Item Potential Root Cause Confirmtion check OK Not OK Responsible 4M1D Confirmation Department: S ugges tion # Machine/Area/S tation: P roject Number: P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H) Line: QE: Machine: ME: Date: Supervisor/CC: Operator: Containment? What? When? Where? Who? Which? How? How is the state of the equipment changed from the optimal? How many times does the problem occur? Do problems increase or decrease? Revised phenomenon: Where did you see the phenomena? Where on the equipment or material did you see the phenomena? Who does it effect? everyone? Is it a problem for some individuals or teams? If so, what info can they offer? Is it skill related? Which trend or pattern does the phenomena have? E.g. Is the phenomena more frequent on Monday mornings? After a change-over? Or is it random in nature? Which direction does the phenomena happen in? (Note: Not many phenomena are truly random!) When did the phenomena occur? When in the sequence of operation; startup, continuous running, intermittent problem, shutdown, changeover? 5W1H - PHENOMENON DESCRIPTION Initial phenomenon: What does the phenomena look like? What product, machine, material, was being used? What size? Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved? 43 Combine all details to create a few sentences. Root Causes Structured Problem Solving Process - Review A B C D A B C D Check A Check B Check C Check D B Why Why Why Why Why WhyWhy Why Why Actions C D E
Levels of Countermeasures and Controls 44
Defect Awareness • Use Visual Controls, Training, Documentation, and Communication to give operators information that may help prevent defects. Defect Detection • Test, Validate, or Inspect the product to catch defects before they are passed on Defect Prevention • Mistake Proof the product or process to minimize the chance of making a defect Defect Elimination • Error Proof the product or process to completely eliminate the opportunity of making a defect 45 Levels of Countermeasures
46 # Control Type Symb ol Description 0 Defect source or where defect enters the line 1 Error Proofing ˜ AIAG definition. Defect cannot be made. (e.g. electrical connector is different and will not fit) 2 Mistake Proofing in the Station » AIAG definition. 100% inspection by machine measurement. (Ex: Defect cannot leave the station) 3 Mistake Proofing in Plant ¢ 100% inspection by machine measurement. Defect cannot leave the plant. (Ex: Electrical Test knockdown) 4 Alarming in Station X Direct feedback to the operator is given to know when the job was done incorrectly. (e.g. buzzer when the operation is not completed) 5 Alert Aid Ì Direction is given to the operator to help make the right choice. (e.g. Color coding parts, flashing screen for low option) Note: A posted OPL is not an alert. 6 100% inspection by Measuring p Inspection with measurements made by 100% frequency. It can be manual or automated. If automatic, does not provide line stop in the event of not-compliance. 7 100% inspection by sensory check ¢ Inspection carried out by an operator to 100% of delivered components, the control is carried out through the use of sensory check (visual, touch, audible). 8 Sampling inspection by Measuring ® Product checks by frequency and size pre-defined by a control plan. The control is carried out through the use of proper measuring devices. 9 Sampling inspection by sensory check L Product checks by frequency and size pre-defined by a control plan. The control is carried out through the use of sensory check (e.g. for aesthetic characteristics, presence of all components, etc.) 10 Check inspection by Measuring U Product checks performed without defined frequency and size. The check inspection is generally fast. The control is carried out through the use of proper measuring devices. 11 Check inspection by sensory check T Product checks performed without defined frequency and size. The check inspection is generally fast. The control is carried out through the use of sensory check (e.g. for aesthetic characteristics, presence of all components, etc.) 12 Defect can no longer be inspected Levels of Controls
Real World Example Air Leaks after assembly on 9980 Windrower 47
48 Real World Example – 5G 1. Gemba – Go to the occurrence 2. Gembutsu – Examine the objects
49 Real World Example – 5G 3. Genjitsu - Facts
50 Line: QE: Machine: ME: Date: Supervisor/CC: Operator: Containment? What? When? Where? Who? Which? How? How is the state of the equipment changed from the optimal? How many times does the problem occur? Do problems increase or decrease? The cab should stay aired up after setting the cab onto windrower. The airbag assembly has leaked air on 7 units a week for 4 straight weeks. Revised phenomenon: Air leak on tractor cab suspension assembly 700206422 is occuring between the air hose (700732457 and 71420658) and air fittings (700737815, 700737816 and 700737818). Where did you see the phenomena? Where on the equipment or material did you see the phenomena? The phenomena is occuring between the fittings (700737815, 700737816 and 700737818) and air hose (700732457 and 71420658). Who does it effect? everyone? Is it a problem for some individuals or teams? If so, what info can they offer? Is it skill related? Assembly operator spends extra time and additional processes to reduce leaks. Customers have submitted warranty claims on this issue. Which trend or pattern does the phenomena have? E.g. Is the phenomena more frequent on Monday mornings? After a change-over? Or is it random in nature? Which direction does the phenomena happen in? (Note: Not many phenomena are truly random!) The phenomena has happened on and off for the past 3 years. With the new model year roll out, phenomena has happened on about every unit. Rework When did the phenomena occur? When in the sequence of operation; startup, continuous running, intermittent problem, shutdown, changeover? The phenomena occurs when assembling the airbag assembly. After installing the cab, the phenomena is very visible. Slow leaks may take 1-2 days to become visible. 5W1H - PHENOMENON DESCRIPTION Initial phenomenon: Air ride leaks after assembly on 9980 windrowers What does the phenomena look like? What product, machine, material, was being used? What size? The cab does not sit level due to air leaking out of the airbag assembly. Assembly number 700206422. Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved? Leaks are identified and rejected on finished goods units. Units are then reworked. Brock Wilkens Derrick Eldridge Bharath Gangichetty47200 9900 WR 12/17/2017
51 P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: Air leak on tractor cab suspension assembly 700206422is occuring between the air hose (700732457 and 71420658) and air fittings (700737815, 700737816 and 700737818). METHOD MAN MACHINEMATERIAL Air fittings 700737815, 700737816, 700737818 not to spec. Using current work instructions Correcttools being used. Air hose700732457 and 71420658 notto spec. Correctair hoses/fittings used. DESIGN Revised Problem Statement (from 5W1H)
52 P lant: Method Correct tools being used. Using pliers and lube when it should be able to install by hand Brock Wilkens Method Using current work instructions Current prints are in station Brock Wilkens Design Correct air hoses/fittings used. Incorrect hose being used with the fittings called out Brock Wilkens Material Air fittings 700737815, 700737816, 700737818 not to spec. Dimensions of fittings meet spec. Bharath Material Air hose 700732457 and 71420658 not to spec. Material and dimensions meet spec. Bharath 4M Category Potential Root Cause Item Potential Root Cause Confirmtion check OK Not OK Responsible 4M1D Confirmation Department: S ugges tion # Machine/Area/S tation: P roject Number:
53 1-Why 2-Why 3-Why 4-Why 5-Why Incorrect hose being used with the fitting s called out Desig n did not consider compatibility of the components Chang e to hose to meet fitting specs Using pliers and lube when it should be able to install by hand Incorrect hose being used with the fitting s called out Desig n did not consider compatibility of the components Chang e to hose to meet fitting specs 5 Whys Effect Potential causes Action Air leak on tractor cab suspension assembly 700206422 is occuring between the air hose (700732457 and 71420658) and air fittings (700737815, 700737816 and 700737818). Hose is not approved to use with push fittings.
54
• Overview the Structured Problem Solving Process • 5G • 5W1H - Phenomenon Description • 4M1D & Confirmation • 5 Whys • Levels of Countermeasures and Controls • Agco Example Summary 55
Announcements (Then Q&A)
Future Webinars • KaiNexus Office Hours – May 30, 2019 – KaiNexus customers only… • Chris Burnham – Continuous Improvement Program Manager at Wright Medical • June 5, 2019 • Open to all!
Other Resources www.KaiNexus.com
Book Giveaway Leanblog.org/kainexusgiveaway (Ends May 24)
Podcasts • www.KaiNexus.com/podcasts • Subscribe via: – Apple Podcasts – Google Play – Stitcher – Spotify (NEW!)
Q&A • Web: – www.kainexus.com – blog.kainexus.com • Webinars on Demand: – www.kainexus.com/webinars • Social Media: – www.twitter.com/kainexus – www.linkedin.com/company/kainexus – www.facebook.com/kainexus Mark Graban Senior Advisor, KaiNexus Mark@KaiNexus.com Presenter: Chad Westbrook AGCO Chad.Westbrook@agcocorp.com

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A Structured Approach to Problem-Solving

  • 1.
    A Structured Approach toProblem-Solving Host: Mark Graban KaiNexus Mark@KaiNexus.com Presenter: Chad Westbrook AGCO Chad.Westbrook@agcocorp.com
  • 2.
    Webinar Logistics • Presentation(45 minutes) • Q&A (10 minutes) – Use the GoToWebinar Meeting Panel to submit a question at any time • Recording link & slides will be sent via email – Also – see the “Handouts” feature and Chat box
  • 3.
    Our Presenter About ChadWestbrook Chad Westbrook is a manufacturing engineering manager and AGCO Production System manager at AGCO Corporation. Chad has a bachelor's degree in Mechanical Engineering Related Technologies from Kansas State University.
  • 4.
    © 2012 AGCOCorporation All rights reserved. Combines 4 3 Brands 5 Models
  • 5.
    © 2012 AGCOCorporation All rights reserved. Round Balers 5 2 Brands, 5 Models
  • 6.
    © 2012 AGCOCorporation All rights reserved. Small Square Balers 6 2 Brands, 6 Models
  • 7.
    © 2012 AGCOCorporation All rights reserved. Large Square Balers 7 3 Brands 7 Models
  • 8.
    © 2012 AGCOCorporation All rights reserved.8 Self Propelled Windrowers 2 Brands 4 Models
  • 9.
    © 2012 AGCOCorporation All rights reserved. Pull Type Mowers 9 2 Brands 7 Models
  • 10.
    © 2012 AGCOCorporation All rights reserved. Headers 10 3 Brands 3 Models
  • 11.
    • Overview theStructured Problem Solving Process • 5G • 5W1H - Phenomenon Description • 4M1D & Confirmation • 5 Whys • Levels of Countermeasures and Controls • Agco Example Agenda 11
  • 12.
  • 13.
    13 Structured Problem SolvingProcess 1. 5G 2. 5W1H 3. 4M1D & Confirmation 4. 5 Whys INITIAL PHENOMENON ROOT CAUSE
  • 14.
  • 15.
    15 5G 1. Definition -5G is a tool used to describe a loss phenomenon • Safety • Quality defect • Minor stoppage • Major breakdown • Long set-up • Parts shortage • Etc. 2. Purpose • To describe a situation in a complete and detailed way • To keep a proper relationship between theory and practice • To follow a logical flow during the process 3. When • Use 5G during the first phase of problem investigation
  • 16.
    16 5G Process GEMBA GEMBUTSU GENJITSU GENRI GENSOKU Actual Place ActualThings Actual Facts Principles Standards & Parameters Go to the spot The workplace, the place where the event actually happens. Don’t be tempted to assume you know the problem, there may be things you will miss. Examine the objects The actual Materials, Processes, Machinery, People, and Objects that are actually involved in an event Check the facts Get the real facts and analyze the actual data (what actually happened, what you can actually observe with your own eyes, separate the facts from the assumptions) Refer to the theory Principles and process Follow the standards Standards & Parameters (physical values)
  • 17.
  • 18.
    18 5W1H – PhenomenonDescription 1. What is a Problem (Initial Phenomenon)? In Manufacturing: • A deviation or gap between the current condition (what is) and the desired condition (what should be) and the cause for the gap is unknown 2. What is the Revised Phenomenon? • The origin of the word (in Greek) means to make visible that which cannot be seen • It is an event or condition that results in a problem
  • 19.
    19 5W1H – PhenomenonDescription Initial Phenomenon Superficial Analysis with no 5G and 5W1H Many Possible Causes Vague Phenomenon Broad Scope
  • 20.
    20 5W1H – PhenomenonDescription Initial Phenomenon = Possible Causes = Root Cause Deep and detailed analysis using 5G during 5W1H Specific Revised Phenomenon Narrow Scope
  • 21.
    21 5W1H – PhenomenonDescription Line: QE: Machine: ME: Date: Supervisor/CC: Operator: Initial Phenomenon: Containment? What? When? Where? Who? Which? How? Revised Phenomenon: 5W1H - PHENOMENON DESCRIPTION What happened? What’s the phenomenon? Can we reproduce the phenomenon? What does the phenomenon look like? What machine, product, material? What size? Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved? How is it being done? What is the extent of the phenomenon? Is the process in control? How is the state of the equipment changed from the optimal? How many times does the phenomenon occur? Where did you see the phenomenon? Where did the phenomenon occur? Where on the equipment or material? Who is doing it? Who does it affect? Who can generate the phenomenon? Is it an individual or group? Is it skill related? Which trend or pattern does the phenomenon have? Which direction? Which factors influence the occurrence? Is it related to any process variable? When did the phenomenon start? When did the phenomenon occur (date, time, shift)? When in the process (startup, continuous, intermittent, shutdown, changeover)?
  • 22.
    22 5W1H – PhenomenonDescription Basic Information • Date and participants in team • What is the initial problem that was reported? Line: QE: Machine: ME: Date: Supervisor/CC: Operator: Containment? What? 5W1H - PHENOMENON DESCRIPTION Initial phenomenon: What does the phenomena look like? What product, machine, Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved?
  • 23.
    23 5W1H – PhenomenonDescription Containment • Are containment measures necessary? • Are damaged or failed parts accounted for? • Is delivery to any other customers prevented? • Are immediate measures documented and known to all parties involved?
  • 24.
    24 5W1H – PhenomenonDescription 1 - What? • What happened? • What’s the phenomenon? • Can we reproduce the phenomenon? • What does the phenomenon look like? • What machine, product, material? • What size? What? What happened? What’s the phenomenon? Can we reproduce the phenomenon? What does the phenomenon look like? What machine, product, material? What size?
  • 25.
    25 5W1H – PhenomenonDescription 2 - When? • When did the phenomenon start? • When did the phenomenon occur (date, time, shift)? • When in the process (startup, continuous, intermittent, shutdown, changeover)? When? When did the phenomenon start? When did the phenomenon occur (date, time, shift)? When in the process (startup, continuous, intermittent, shutdown, changeover)?
  • 26.
    26 5W1H – PhenomenonDescription 3 - Where? • Where did you see the phenomenon? • Where did the phenomenon occur? • Where on the equipment or material? Where? Where did you see the phenomenon? Where did the phenomenon occur? Where on the equipment or material?
  • 27.
    27 5W1H – PhenomenonDescription 4 - Who? • Who is doing it? • Who does it affect? • Who can generate the phenomenon? • Is it an individual or group? • Is it skill related? Who? Who is doing it? Who does it affect? Who can generate the phenomenon? Is it an individual or group? Is it skill related?
  • 28.
    28 5W1H – PhenomenonDescription 5 - Which? • Which trend or pattern does the phenomenon have? • Which direction? • Which factors influence the occurrence? • Is it related to any process variable? Which? Which trend or pattern does the phenomenon have? Which direction? Which factors influence the occurrence? Is it related to any process variable?
  • 29.
    29 5W1H – PhenomenonDescription 1 - How and How many? • How is it being done? • What is the extent of the phenomenon? • Is the process in control? • How is the state of the equipment changed from the optimal? • How many times does the phenomenon occur? How? How is it being done? What is the extent of the phenomenon? Is the process in control? How is the state of the equipment changed from the optimal? How many times does the phenomenon occur?
  • 30.
    30 5W1H – PhenomenonDescription Revised Phenomenon • What is the new abnormal condition creating the phenomenon? 5W1H process brings the same perception of the phenomenon to all Revised Phenomenon:
  • 31.
    31 5W1H – PhenomenonDescription Desired Observed Initial Phenomenon – Hole oversized in spacer plate Revised Phenomenon – Drill off angle
  • 32.
  • 33.
    33 4M1D – FishboneDiagram (Ishikawa) P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H)
  • 34.
    34 4M1D – FishboneDiagram (Ishikawa) Step 1 • Transfer the “Revised Phenomenon” from the 5W1H into the circle P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H) Line: QE: Machine: ME: Date: Supervisor/CC: Operator: Containment? What? When? Where? Who? Which? How? How is the state of the equipment changed from the optimal? How many times does the problem occur? Do problems increase or decrease? Revised phenomenon: Where did you see the phenomena? Where on the equipment or material did you see the phenomena? Who does it effect? everyone? Is it a problem for some individuals or teams? If so, what info can they offer? Is it skill related? Which trend or pattern does the phenomena have? E.g. Is the phenomena more frequent on Monday mornings? After a change-over? Or is it random in nature? Which direction does the phenomena happen in? (Note: Not many phenomena are truly random!) When did the phenomena occur? When in the sequence of operation; startup, continuous running, intermittent problem, shutdown, changeover? 5W1H - PHENOMENON DESCRIPTION Initial phenomenon: What does the phenomena look like? What product, machine, material, was being used? What size? Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved?
  • 35.
    35 4M1D – FishboneDiagram (Ishikawa) Step 2 • Modify the major categories if Material, Method, Machine, Man, and Design don’t fit the problem P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H)
  • 36.
    36 4M1D – FishboneDiagram (Ishikawa) Step 3 • Brainstorm and document all contributing factors related to each main category P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H)
  • 37.
    37 4M1D – FishboneDiagram (Ishikawa) Step 4 • Eliminate the trivial, non-important causes and cross them off. • Discuss the remaining causes. Decide which are important and circle them. P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H) Important Trivial
  • 38.
    P lant: S uggestion # 4M Category Contributing Factors Cause Item Contributing Factors Cause Confirmation check OK Not OK Responsible 4M1D Confirmation Department: Machine/Area/S tation: P roject Number: 38 4M1D – Confirmation Step 5 • Transfer all important causes to the 4M1D confirmation
  • 39.
    P lant: S uggestion # 4M Category Contributing Factors Cause Item Contributing Factors Cause Confirmation check OK Not OK Responsible 4M1D Confirmation Department: Machine/Area/S tation: P roject Number: 39 4M1D – Confirmation Step 6 • Confirm each potential root cause as a contributing factor or not
  • 40.
  • 41.
    41 5 Whys Simple problemsolving tool that helps you identify a countermeasure 5 Whys Process: • Transfer non-confirmed “Not OK” effects from the 4M1D • Start by asking “why?” the problem is happening Ø Asking "why?" sounds simple, but answering it requires thought and intelligent application. Search for answers that are grounded in fact: they must be accounts of things that have actually happened – not guesses at what might have happened • The number “5” is not important. Continue asking “why?” until you have reached an effective countermeasure and you can go no further • The path should make sense when read in reverse using the statement “therefore” 1-Why 2-Why 3-Why 4-Why 5-Why 5 Whys Effect Potential causes Action
  • 42.
    42 5 Whys –Machine Example Replace the sealSolution Coolant is leaking from machine WHY A seal was damaged WHY Metal shavings got into coolant Coolant pump guard allowed shavings to pass behind coolant screen. WHY You discover coolant on the floor WHY Counter Measure Design and install new guard over the screen Therefore Therefore Therefore
  • 43.
    1-Why 2-Why 3-Why4-Why 5-Why 5 Whys Effect Potential causes Action P lant: 4M Category Potential Root Cause Item Potential Root Cause Confirmtion check OK Not OK Responsible 4M1D Confirmation Department: S ugges tion # Machine/Area/S tation: P roject Number: P lant: 4M1D Potential Phenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: METHOD MAN MACHINEMATERIAL DESIGN Revised Problem Statement (from 5W1H) Line: QE: Machine: ME: Date: Supervisor/CC: Operator: Containment? What? When? Where? Who? Which? How? How is the state of the equipment changed from the optimal? How many times does the problem occur? Do problems increase or decrease? Revised phenomenon: Where did you see the phenomena? Where on the equipment or material did you see the phenomena? Who does it effect? everyone? Is it a problem for some individuals or teams? If so, what info can they offer? Is it skill related? Which trend or pattern does the phenomena have? E.g. Is the phenomena more frequent on Monday mornings? After a change-over? Or is it random in nature? Which direction does the phenomena happen in? (Note: Not many phenomena are truly random!) When did the phenomena occur? When in the sequence of operation; startup, continuous running, intermittent problem, shutdown, changeover? 5W1H - PHENOMENON DESCRIPTION Initial phenomenon: What does the phenomena look like? What product, machine, material, was being used? What size? Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved? 43 Combine all details to create a few sentences. Root Causes Structured Problem Solving Process - Review A B C D A B C D Check A Check B Check C Check D B Why Why Why Why Why WhyWhy Why Why Actions C D E
  • 44.
  • 45.
    Defect Awareness • UseVisual Controls, Training, Documentation, and Communication to give operators information that may help prevent defects. Defect Detection • Test, Validate, or Inspect the product to catch defects before they are passed on Defect Prevention • Mistake Proof the product or process to minimize the chance of making a defect Defect Elimination • Error Proof the product or process to completely eliminate the opportunity of making a defect 45 Levels of Countermeasures
  • 46.
    46 # Control Type Symb ol Description 0Defect source or where defect enters the line 1 Error Proofing ˜ AIAG definition. Defect cannot be made. (e.g. electrical connector is different and will not fit) 2 Mistake Proofing in the Station » AIAG definition. 100% inspection by machine measurement. (Ex: Defect cannot leave the station) 3 Mistake Proofing in Plant ¢ 100% inspection by machine measurement. Defect cannot leave the plant. (Ex: Electrical Test knockdown) 4 Alarming in Station X Direct feedback to the operator is given to know when the job was done incorrectly. (e.g. buzzer when the operation is not completed) 5 Alert Aid Ì Direction is given to the operator to help make the right choice. (e.g. Color coding parts, flashing screen for low option) Note: A posted OPL is not an alert. 6 100% inspection by Measuring p Inspection with measurements made by 100% frequency. It can be manual or automated. If automatic, does not provide line stop in the event of not-compliance. 7 100% inspection by sensory check ¢ Inspection carried out by an operator to 100% of delivered components, the control is carried out through the use of sensory check (visual, touch, audible). 8 Sampling inspection by Measuring ® Product checks by frequency and size pre-defined by a control plan. The control is carried out through the use of proper measuring devices. 9 Sampling inspection by sensory check L Product checks by frequency and size pre-defined by a control plan. The control is carried out through the use of sensory check (e.g. for aesthetic characteristics, presence of all components, etc.) 10 Check inspection by Measuring U Product checks performed without defined frequency and size. The check inspection is generally fast. The control is carried out through the use of proper measuring devices. 11 Check inspection by sensory check T Product checks performed without defined frequency and size. The check inspection is generally fast. The control is carried out through the use of sensory check (e.g. for aesthetic characteristics, presence of all components, etc.) 12 Defect can no longer be inspected Levels of Controls
  • 47.
    Real World Example AirLeaks after assembly on 9980 Windrower 47
  • 48.
    48 Real World Example– 5G 1. Gemba – Go to the occurrence 2. Gembutsu – Examine the objects
  • 49.
    49 Real World Example– 5G 3. Genjitsu - Facts
  • 50.
    50 Line: QE: Machine: ME: Date:Supervisor/CC: Operator: Containment? What? When? Where? Who? Which? How? How is the state of the equipment changed from the optimal? How many times does the problem occur? Do problems increase or decrease? The cab should stay aired up after setting the cab onto windrower. The airbag assembly has leaked air on 7 units a week for 4 straight weeks. Revised phenomenon: Air leak on tractor cab suspension assembly 700206422 is occuring between the air hose (700732457 and 71420658) and air fittings (700737815, 700737816 and 700737818). Where did you see the phenomena? Where on the equipment or material did you see the phenomena? The phenomena is occuring between the fittings (700737815, 700737816 and 700737818) and air hose (700732457 and 71420658). Who does it effect? everyone? Is it a problem for some individuals or teams? If so, what info can they offer? Is it skill related? Assembly operator spends extra time and additional processes to reduce leaks. Customers have submitted warranty claims on this issue. Which trend or pattern does the phenomena have? E.g. Is the phenomena more frequent on Monday mornings? After a change-over? Or is it random in nature? Which direction does the phenomena happen in? (Note: Not many phenomena are truly random!) The phenomena has happened on and off for the past 3 years. With the new model year roll out, phenomena has happened on about every unit. Rework When did the phenomena occur? When in the sequence of operation; startup, continuous running, intermittent problem, shutdown, changeover? The phenomena occurs when assembling the airbag assembly. After installing the cab, the phenomena is very visible. Slow leaks may take 1-2 days to become visible. 5W1H - PHENOMENON DESCRIPTION Initial phenomenon: Air ride leaks after assembly on 9980 windrowers What does the phenomena look like? What product, machine, material, was being used? What size? The cab does not sit level due to air leaking out of the airbag assembly. Assembly number 700206422. Are containment measures necessary? Are damaged or failed parts accounted for? Is the delivery to any other customers prevented? Are immediate measures documented and known to all parties involved? Leaks are identified and rejected on finished goods units. Units are then reworked. Brock Wilkens Derrick Eldridge Bharath Gangichetty47200 9900 WR 12/17/2017
  • 51.
    51 P lant: 4M1D PotentialPhenomena Department: S ugges tion # Machine/Area/S tation: P roject Number: Air leak on tractor cab suspension assembly 700206422is occuring between the air hose (700732457 and 71420658) and air fittings (700737815, 700737816 and 700737818). METHOD MAN MACHINEMATERIAL Air fittings 700737815, 700737816, 700737818 not to spec. Using current work instructions Correcttools being used. Air hose700732457 and 71420658 notto spec. Correctair hoses/fittings used. DESIGN Revised Problem Statement (from 5W1H)
  • 52.
    52 P lant: Method Correcttools being used. Using pliers and lube when it should be able to install by hand Brock Wilkens Method Using current work instructions Current prints are in station Brock Wilkens Design Correct air hoses/fittings used. Incorrect hose being used with the fittings called out Brock Wilkens Material Air fittings 700737815, 700737816, 700737818 not to spec. Dimensions of fittings meet spec. Bharath Material Air hose 700732457 and 71420658 not to spec. Material and dimensions meet spec. Bharath 4M Category Potential Root Cause Item Potential Root Cause Confirmtion check OK Not OK Responsible 4M1D Confirmation Department: S ugges tion # Machine/Area/S tation: P roject Number:
  • 53.
    53 1-Why 2-Why 3-Why4-Why 5-Why Incorrect hose being used with the fitting s called out Desig n did not consider compatibility of the components Chang e to hose to meet fitting specs Using pliers and lube when it should be able to install by hand Incorrect hose being used with the fitting s called out Desig n did not consider compatibility of the components Chang e to hose to meet fitting specs 5 Whys Effect Potential causes Action Air leak on tractor cab suspension assembly 700206422 is occuring between the air hose (700732457 and 71420658) and air fittings (700737815, 700737816 and 700737818). Hose is not approved to use with push fittings.
  • 54.
  • 55.
    • Overview theStructured Problem Solving Process • 5G • 5W1H - Phenomenon Description • 4M1D & Confirmation • 5 Whys • Levels of Countermeasures and Controls • Agco Example Summary 55
  • 56.
  • 57.
    Future Webinars • KaiNexusOffice Hours – May 30, 2019 – KaiNexus customers only… • Chris Burnham – Continuous Improvement Program Manager at Wright Medical • June 5, 2019 • Open to all!
  • 58.
  • 59.
  • 60.
    Podcasts • www.KaiNexus.com/podcasts • Subscribevia: – Apple Podcasts – Google Play – Stitcher – Spotify (NEW!)
  • 61.
    Q&A • Web: – www.kainexus.com –blog.kainexus.com • Webinars on Demand: – www.kainexus.com/webinars • Social Media: – www.twitter.com/kainexus – www.linkedin.com/company/kainexus – www.facebook.com/kainexus Mark Graban Senior Advisor, KaiNexus Mark@KaiNexus.com Presenter: Chad Westbrook AGCO Chad.Westbrook@agcocorp.com