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Problem solving
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- 2. What is aProblem? A problem is a discrepancy between an existing standard or expectation and the present or actual condition.
- 3. What is problemsolving? A systematic approach to improve a deviation to a standard or expectation. It can be done individually, however a team approach is recommended. The problem solving goal for any organization: to have all people participating in problem solving in all aspects of their work.
- 4. Why Support andEncourage Problem Solving? = Problem Solving Improvement
- 5. Traditional Reactions toProblems CAN YOU BLAME ANYBODY ELSE DOES THE DARN THING WORK WILL YOU CATCH HECK DOES ANYBODY KNOW DID YOU MESS WITH IT DON’T MESS WITH IT FOUL-UPS HAPPEN YOU’RE IN TROUBLE DUMP IT HIDE IT NO PROBLEM Yes Yes No No Yes No No Yes No Yes
- 6. When Can anOrganization Say It Has Effective Problem Solving Throughout It’s Ranks When It Has Total Participation in Problem Solving ! When People Have a Feeling of Control Over Their Problem ! When 100% of the People Have Been Trained in Problem Solving ! When Problem Solving Is a Habit ! When an Organization Has a Culture of Empowerment ! When an Organization Utilizes Problem Solving and Other Lean Tools to Be Best in Quality, Lowest in Cost and Best in Productivity !
- 7. Creativity Exercise Instructions: You mustdraw three lines. A to A B to B C to C Rules: The lines can not touch. Can not go through the blocks. Can not go outside the main box.
- 8. Creativity Exercise C C A B A B Instructions: You mustdraw three lines. A to A B to B C to C Rules: The lines can not touch. Can not go through the blocks. Can not go outside the main box. 5 Minutes
- 9. Typical Problem SolvingFunnel (Solution Unknown) Large Vague Problem Observation 5Why 3 legged / 8D Fishbone Point of Cause Standardize Evaluate Implement 5 Why’s 1) Problem Identification 2) Find Point Of Cause 3) Find the Root Cause (5 Why RCA) 4) Implement Corrective Actions 5) Evaluate Corrective Actions 6) Standardize 6 Steps of Problem Solving
- 10. • Stop &Notify – Understanding if we have a problem • Highlight problems (Visual Management) • Pareto Analysis of Issues • Do we need to Protect the Customer? – Never send defective product to your customer – Fix & eliminate the problem quickly to meet your customers needs • Is the Solution / Point of Cause Known? – Yes: • Rapid Problem Solving…fix it now! – No: • 5 Why Root Cause Analysis Problem Identification Find Point Of Cause Find the Root Cause Implement Corrective Actions Evaluate Corrective Actions Standardize Problem Identification Problem Identification
- 11. Understanding we havea Problem: • Problems Identified through the basics: – Good 5S – Daily Management – Visual Management – Problem Analysis…Pareto Charts, Control Charts, etc… Unplanned Maint. DT: 4.0 hrs THROUGH PUT GOAL: 100,000spd A MR GOAL: 4.0 hrs B MR GOAL: 1.9 hrs C MR GOAL: 1.5 hrs PRODUCTIVITY Record of # good sheets/total production hours Record total hours for MR Record total hours for Unplanned Maint. DT 1 2 3 6 7 9 10 12 15 17 25 5 8 11 20 22 13 16 21 4 18 23 14 19 24 31 30 29 28 27 26 1 2 3 4 5 6 7 10 8 9 11 12 MONTH What caused this? Productivity Pareto 0 10 20 30 40 50 60 Unplanned D/T MR Time Scrap Jams Planned D/T Large Vague Problem
- 12. Identify large vagueproblem collect data based on fact determine biggest problem Grasp the Facts! VS. 0 5 10 15 20 Dust Drip Black Skin Scratch/ Hit 0 5 10 15 20 Scratch/ Hit Dust Black Skin Drip GO & SEE
- 13. Find Point ofCause Problem Identification Find Point Of Cause Find the Root Cause Implement Corrective Actions Evaluate Corrective Actions Standardize • Grasp the facts – “Go and See” (see with your own eyes) – Understand and be able to describe what happened – Observe the Process and ask questions – Use all of your senses • Understand the process where the problem occurred – Sketch out the problem area…understand the flow • Use Flip Charts in the area of the problem • 2 Suggested Methods to find point of cause – Cause and Effect Analysis—6M’s (Fishbone – good for 5 Why RCA) – 5 W’s and 1 H (good for rapid problem solving) • Who, What, When, Where, Why and How
- 14. 5W’s and 1H Who Whosaw it happen? Who was involved/affected with the issue? What What happened/What type of problem? What occurred? What has the problem? When When did it occur? When in the sequence of the process? Where Where did it occur? Is it only happening in 1 area/product? Why Why did it happen? Why is it a problem? How How did it occur? How many? How often? 5W1H What is it? Method of asking questions in the “Grasp the facts” phase of understanding the problem that occurred. Why is it useful? 5W1H are the typical questions that need to be answered to better understand the problem. When is it used? It useful at the beginning of the problem solving process in the initial data gathering process. How is it done? By asking the questions: Who, What, When, Where, Why and How.
- 15. 6M Analysis (Fish Bone) • Use 6M analysis to better understand the problem: – Man – human variation: person to person, shift to shift – Machine – machine warm-up, shutdown, settings – Material – age of material, dimensions – Method – standard work, work instructions – Mother Nature – environmental factors, humidity, etc. – Measurement System – are we measuring it correctly? Material Man Machine Mother Nature Method Measurement System
- 16. 6M Analysis • Whatis it? – The 6M Analysis (also known as Fishbone, Ishikawa or Cause & Effect Diagram) is a technique to graphically identify and organize many possible causes of a problem (effect). • Why is it useful? – 6M Analysis helps identify the most likely Root CauseS of a problem. They can also help teach a team to reach a common understanding of the problem. This tool can help focus problem solving and reduce subjective decision making. • When is it used? – When the need exists to display and explore many possible causes of a specific problem or condition. This diagram allows the team to systematically analyze cause & effect relationships. This tool is typically used with the 5 Why Root Cause Analysis, as it will highlight many potential points of cause which can then be driven to root cause with the 5 Why RCA tool. • How is it done? – Assemble your brainstorming team and using the 6M analysis form, document the problem (effect) on the right side of the diagram. Brainstorm all possible causes of the problem and categorize them under the appropriate heading. Once complete, review all the possible causes and select the most likely causes of the problem and then utilize 5 Why Root Cause Analysis to solve for root cause.
- 17. Rapid Problem SolvingFishbone Diagram/Template Problem Statement Measurement Material Method Mother Nature Machine Man Variation Variation Availability Quality In Spec. Capability Speed Availability Condition Set-Up / Program Troubleshooting Training Std. Work Procedure / Visuals Skills Training Attitude / Fatigue Sense of Urgency Attendance Accuracy Frequency What to Measure Standards Set-Up / Calibration Environment Utilities Humidity Temp. Tooling Mistake Proofing Process Changed?
- 18. Find the RootCause • 5 Why Root Cause Analysis – Not always a single path to the true root cause – Possibility of multiple root causes • For part/product quality defects, it is critical to find the root cause of 2 issues: – Why made? – Why missed? • When to use the Root Cause Analysis report – Delivery Miss, Part Shortages, Engineering Issue, Quality Problem, Productivity (Downtime), Supplier Defects, Scrap, Safety, etc… – Performance Metrics not being met (Inventory, Workmanship Errors, etc…) – Process problems, Countermeasure Sheets, etc… – Order to Cash cycle interruptions Problem Identification Find Point Of Cause Find the Root Cause Implement Corrective Actions Evaluate Corrective Actions Standardize These 2 Root Causes are NEVER the same
- 19. 5 Why’s: TheProcess • Driving to root cause using the 5 Why technique. – Perhaps the simplest of problem solving and creativity tools, the 5 Whys can easily be taught and used by everyone in the organization. – Simply start the process from the “Point of Cause” determined through the other problem solving tools (Go & See, 5H1W, Fishbone, etc…). – Then ask why it is so, for up to 5 successive iterations, until the true root cause has been identified. – If performed correctly and the correct point of cause found then you will have found the true Root Cause.
- 20. Root Cause Root Cause:The fundamental breakdown or failure of a process When you fix Root Cause, the problem goes away & doesn’t come back!
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- 22. The National ParkService asked the 5 Why’s to attack a crumbling stone problem on and within the Jefferson Memorial. Point of Cause Crumbling caused by excessive washing. 5 WHY’s Why does the stone need regular washing? Because a large amount of bird droppings on the stone. WHY? Because of the large number of birds inside the memorial. WHY? Because there is a large food supply (spiders) inside the memorial. WHY? Because a large number of midges are inside and around the memorial. WHY? ROOT CAUSE The lights that illuminate the memorial attract mating midges at dusk. COUNTERMEASURE The memorial lights were not needed at dusk – there was still enough light to see the memorial, so they were delayed to illuminate 1 hour after dusk. RESULTS The result was a 90% reduction in midges, fewer spiders, fewer birds, and far fewer washings. The Jefferson Memorial – 5 Why Example
- 23. A short lessonin technology • Why #1: Why are space shuttle booster rockets the size they are? – Answer - Because they are limited by tunnel widths when being transported by rail during assembly. • Why #2: Why are tunnel widths as wide apart as they are? – Answer - Because that was the typical width of rail road tracks. • Why #3: Why are railroad track as wide apart as they are? – Answer - Because that was the typical width of wagon wheels. • Why #4: Why are wagon wheels as wide apart as they are? – Answer - So they could fit in Roman chariot wheel ruts left in ancient roads across Europe. • Why #5: Why are Roman chariot wheels as wide as apart as they are? – Answer - Because that was the typical width of two horses' hind ends. 5 Why’s: Extra Example Lesson to be Learned • Even the most complex technology is ultimately driven by a pair of horses' rear ends.
- 24. 5 Why Exercise •Let’s work together to solve the following problem for root cause… – “My car would not start this morning”
- 25. Typical Problem SolvingFunnel (Solution Unknown) Large Vague Problem: “Car won’t start” 2) Observation: - Check battery cables for corrosion - Check fluid in battery cells - Check alternator belt - Check battery voltage 3) 5W1H: (Grasp the facts) -Who: I saw it & was impacted by it. - What: Car wouldn’t start, no sign of elec. - When: When I turned the key. - Where: At home - Why: I can’t get to work - How: 1st time for occurring 4) Fishbone: “See next Slide” Point of Cause: -“Dead Battery”…Findings: - Battery won’t hold charge - Low fluid in cells Standardize Evaluate Implement 5 Why’s 5) 5 Why’s: - Why 1: Why was the fluid low in the battery? - Owner didn’t add fluid to battery - Why 2: Why was fluid not added? - Owner not aware of need to add fluid -Solutions: - Create/Implement P.M. Schedule for battery - Purchase “No Maintenance” Battery - Why 3: Why was the owner unaware of maintenance? - Didn’t read manual on battery - Why 4: Why didn’t owner read manual? - Didn’t have time… - Why 5: etc…
- 26. Car won’t start Measurement Material Method MotherNature Machine Man Training on how to start a car Error: Leaving lights on Poor Assembly Maintenance of car Voltage of battery Alternator output Continuity of wiring Bad Alternator Bad Switch Bad Cables Dead Battery How to turn on car How to shut down car How to maintain car Corrosion Too cold to start car Car is old Car draws too much current Short in wiring Fishbone Exercise
- 27. Root Cause Analysis Commonmistakes in root cause analysis 1. Confusing the symptoms with the root causes Symptoms are defined as the observable effects of a problem (example: car won’t start) Root Causes are defined as the reason for the existence of the symptoms (example: dead battery) 2. Assuming that the true root cause of the problem is known without adequately testing or verifying the theory. 3. Assuming there was only one root cause. For example: Why did the Titanic sink? The rudder was too small to turn in time The night watchman did not have binoculars The rivets used to assemble to boat were bad quality
- 28. Root Cause Analysis Commonmistakes in root cause analysis 4. Focusing on filling out a problem solving form rather than on solving a problem 5. Jumping to conclusions without data, without “Go & See” 6. Not digging deep enough to find point of cause 7. Documenting 5 Why’s, just because it’s called 5 Why Analysis 8. Brainstorming to get 5 un-related answers to “Why”
- 29. Implement and EvaluateCorrective Actions • Don’t be a “Fire Fighter” • Fix all possible root causes (if more than 1) • Evaluate the corrective actions – Confirm that the problem has been eliminated – Audit system (Leadership Standardized Work) Problem Identification Find Point Of Cause Find the Root Cause Implement Corrective Actions Evaluate Corrective Actions Standardize
- 30. Standardize Prevent Re-Occurrence Change processdocumentation to new, improved process: Standardized work Work instructions Etc. Share the improved process as a best practice (Knowledge Sharing) Problem Identification Find Point Of Cause Find the Root Cause Implement Corrective Actions Evaluate Corrective Actions Standardize
- 31. Problem Solving Summary Followthe process. Go see! Observe the process. Find the “point of cause” – where is the defect occurring, when is it occurring, etc. After point of cause is found, do root cause analysis. Think deeply. You are not done just because you filled out a form answering “why?” 5 times. Did you go deep enough? Did you go broad enough? Correct the problem, standardize the solution to prevent future similar problems from occurring.
- 32. Knowledge Check 1. Whatis a problem? 2. What should your first action be when dealing with a problem? 3. What are the 5Ws and 1H? When are they used? 4. What are the 6Ms? What is another name for this form? 5. When do you use the 5 Whys Process? If performed correctly, what will the 5 Why Process lead you to? Knowledge Check 1. What is a problem? 2. What should your first action be when dealing with a problem? 3. What are the 5Ws and 1H? When are they used? 4. What are the 6Ms? What is another name for this form? 5. When do you use the 5 Whys Process? If performed correctly, what will the 5 Why Process lead you to?
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