3 Legged 5 Why Analysis

3 Legged 5 Why Effective Root Cause Analysis

A Focused Approach to Solving Chronic and/or Systemic Problems

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What is after Containment????

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Agenda
When

to Use 5 Why 3 Legged 5 Why Analysis 5 Why Examples Resources and References 5 Why and Customer Problem Solving Formats Where to Find the Blank Forms

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When to Use 5 Why

Customer

Issues Required for all Covisint Problem Cases May be requested for informal complaints May be requested for warranty issues Internal Issues (optional) Quality System Audit Non-conformances First Time Quality Internal Quality Issue

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When to Use 5 Why

5

Why Analysis can be used with various problem solving formats Internal Problem Solving GM Drill Deep Ford 8 D (Discipline) Chrysler 8 Step

5 Why, when combined with other problem solving methods, is a very effective tool
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3-Legged / 5-Why Form (Old Format)

Complaint Number: _______________ Issue Date: _____________
Define Problem Use this path for the specific nonconformance being investigated

Corrective Actions
A.

Date

Why?

c i f i ec p S
Why?

W hy d id w
Why?

Root Causes

Use this path to investigate why the problem was not detected

n o i t c e t De
Why?

W hy d

e ha ve t

he p r

Use this path to investigate the systemic root cause

idWhy? the p robl Why? em reac h

obl e m?

B.

A
C.

W er? h Why? y di d ic our m B e s Why? t y s tem ys allo SWhy? w it to o Why? ccur ?

Why? Why?

Why?

the c usto m

Lessons Learned

Look Across / Within Plant

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Problem Definition
c i f i ec p S

New Format of 5 Why

n o i t c e t De ic m e t s Sy

5 Why Analysis
General

Guidelines A cross-functional team should be used to problem solve Dont jump to conclusions or assume the answer is obvious Be absolutely objective

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5 Why Analysis
General

Guidelines

Ask Why until the root cause is uncovered

May be more than 5 Whys or less than 5 Whys

If you are using words like because or due to in any box, you will likely need to move to the next Why box Root cause can be turned on and off

Will addressing/correcting the cause prevent recurrence? If not what is the next level of cause?

If you dont ask enough Whys, you may end up with a symptom and not root cause. Corrective action for a symptom is not effective in eliminating the cause

Corrective action for a symptom is usually detective Corrective action for a root cause can be preventive

Path should make sense when read in reverse using therefore

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Problem Definition
c i f i ec p S

New Format of 5 Why

n o i t c e t De ic m e t s Sy

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Problem Definition
Define

the problem Problem statement clear and accurate Problem defined as the customer sees it Do not add causes into the problem statement

Examples:

GOOD: Customer received a part with a broken mounting pad NOT: Customer received a part that was broken due to improper machining GOOD: Customer received a part that was leaking NOT: Customer received a part that was leaking due to a missing seal
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Problem Definition
c i f i ec p S

New Format of 5 Why

n o i t c e t De ic m e t s Sy

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Specific Problem

Specific Problem Why did we have the specific non-conformance? How was the non-conformance created?

Root cause is typically related to design, operations, dimensional issues, etc.

Tooling wear/breaking Set-up incorrect Processing parameters incorrect Part design issue

Typically traceable to/or controllable by the people doing the work

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Specific Problem

Specific Problem Root Cause Examples

Parts damaged by shipping dropped or stacked incorrectly Operator error poorly trained or did not use proper tools Changeover occurred wrong parts used Operator error performed job in wrong sequence Processing parameters changed Excessive tool wear/breakage Machine fault machine stopped mid-cycle

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Specific Problem

What if root cause is?

Operator did not follow instructions

Do we stop here?

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Specific Problem
Operator did not follow instructions Do standard work instructions exist? Create a standard instruction

Or do we attempt to find the root cause?

Is the operator trained?

Train operator

Were work instructions correctly followed? Are work instructions effective?

Create a system to assure conformity to instructions

Modify instructions & check effectiveness

Do you have the right person for this job/task?

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Specific Problem
Specific Problem
Column would not lock in tilt position 2 and 4 Tilt shoe responsible for positions 2 and 4 would not engage pin Shifter assembly screw lodged below shoe preventing full travel Screw fell off gun while pallet was indexing Magnet on the screw bit was weak Exceeded the bits workable life

THEREFORE

WHY??

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Specific Problem
Specific Problem
Loss of torque at rack inner tie rod joint Undersized chamfer (thread length on rack) Part shifted axially during drill sequence Insufficient radial clamping load. Machining forces overcame clamp force Air supply not maintained Various leaks, high demand at full plant capacity, bleeder hole plugs caused pressure drop

THEREFORE

WHY??

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Problem Definition
c i f i ec p S

New Format of 5 Why

n o i t c e t De ic m e t s Sy

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Detection

Detection: Why did the problem reach the customer? Why did we not detect the problem? How did the controls fail?

Root Cause typically related to the inspection system

Error-proofing not effective No inspection/quality gate Measurement system issues

Typically traceable to/or controllable by the people doing the work

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Detection
Detection

Example Root Causes

No detection process in place cannot be detected in our plant Defect occurs during shipping Detection method failed sample size and frequency inadequate Error proofing not working or bypassed Gage not calibrated

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Detection
Detection
Column would not lock in tilt position 2 and 4 On-line test for tilt function is not designed to catch this type of defect

Test for tilt function is applied before shifter assembly

THEREFORE

WHY??

Process flow designed in this manner would not detect shifter assy screw lodged below tilt shoe

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Detection
Detection
Loss of torque at rack inner tie rod joint Undersized chamfer/thread length undetected

THEREFORE

WHY??

Inspection frequency is inadequate. Chamfer gage is not robust Process CPK results did not reflect special causes of variation affecting chamfer.

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Problem Definition
c i f i ec p S

New Format of 5 Why

n o i t c e t De ic m e t s Sy

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Systemic
Systemic

Why did our system allow it to occur? What was the breakdown or weakness? Why did the possibility exist for this to occur? Root Cause typically related to management system issues or quality system failures

Rework/repair not considered in process design Lack of effective Preventive Maintenance system Ineffective Advanced Product Quality Planning (FMEA, Control Plans)

Typically traceable to/controllable by Support People

Management Purchasing Engineering Policies/Procedures

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Systemic Issue
Systemic

Helpful hint: The root cause of the specific problem leg is typically a good place to start the systemic leg. Root Cause Examples

Failure mode not on PFMEA believed failure mode had zero potential for occurrence New process not properly evaluated Process changed creating a new failure cause PFMEAs generic- not specific to the process Severity of defect not understood by team Occurrence ranking based on external failures only, not actual defects

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Systemic
Column would not lock in tilt position 2 and 4

Systemic Root Cause

Detection for tilt function done prior to installation of shifter assembly PFMEA did not identify a dropped part interfering with tilt function

THEREFORE

WHY??

First time occurrence for this failure mode

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Systemic
Loss of torque at rack inner tie rod joint

Systemic Root Cause

Ineffective control plan related to process parameter control (chamfer)

THEREFORE

Low severity for chamfer control

WHY??

Dimension was not considered an important characteristic additional controls not required

Insufficient evaluation of machining process and related severity levels during APQP process

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Corrective Actions
Corrective

Actions Corrective action for each root cause Corrective actions must be feasible If Customer approval required for corrective action, this must be addressed in the 5 why timing Corrective actions address processes the supplier owns Corrective actions include documentation updates and training as appropriate

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Specific Problem
Corrective Action:
Loss of torque at rack inner tie rod joint Undersized chamfer (thread length on rack) Part shifted axially during drill sequence Insufficient radial clamping load. Machining forces overcame clamp force Air supply not maintained

WHY??

Reset alarm limits to sound if <90 PSI. Smith 10/12/10 Disable machine if <90 PSI. Jones 9/28/10 Dropped feed on drill cycle to .0058 from .008. Davis 10/10/10 Clean collets on Kennefec @ PM frequency Smith 10/12/10 Added dedicated accumulator (air) for system or compressor for each Kennefec Smith 10/12/10 Verify system pressure at machines at beginning , middle, and end of shift Smith 10/12/10

Various leaks, high demand at full plant capacity, bleeder hole plugs caused pressure drop

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Detection
Corrective Action:
Loss of torque at rack inner tie rod joint Undersized chamfer/thread length undetected Inspection frequency is inadequate. Chamfer gage is not robust Process CPK results did not reflect special causes of variation affecting chamfer.

Implement 100% sort for chamfer length and thread depth. Smith 9/26/10 Create & maintain inspection sheet log to validate Davis 8/22/10 Redesign chamfer gage to make more effective Jones 11/30/10 Increase inspection frequency at machine from 2X per shift to 2X per hour Johnson 10/14/10 Review audit sheets to record data from both ends on an hourly basis Davis 10/4/10 Conduct machine capability studies on thread depth Jones 9/22/10 Perform capability studies on chamfer diameters

WHY??
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10/14/10 Repair/replace auto thread checking unit to include thread length. 10/18/10
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Steering Solutions Services Corp.

Systemic
Loss of torque at rack inner tie rod joint Ineffective control plan related to process parameter control (chamfer) Low severity for chamfer control Dimension was not considered an important characteristic additional controls not required Insufficient evaluation of machining process and related severity levels during APQP process Corrective Action: Design record, FMEA, and Control Plan to be reviewed/upgraded by Quality, Manufacturing Engineering Update control plan to reflect 100% inspection of feature PM machine controls all utility/power/pressure Implement layered audit schedule by Management for robustness/compliance to standardized work Lessons Learned: PFMEA severity should focus on affect to subsequent internal process (immediate customer) as well as final customer Measurement system and gage design standard should be robust and supported by R & R studies Evaluate the affect of utility interruptions to all machine processed (air/electric/gas)

WHY??
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5-Why Critique Sheet

General Guidelines: Dont jump to conclusions..dont assume the answer is obvious Be absolutely objective A cross-functional team should complete the analysis Step 1: Problem Statement State the problem as the Customer sees itdo not add cause to the problem statement

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5-Why Critique Sheet

Step 2: Three Paths (Specific, Detection, Systemic)

There should be no leaps in logic Ask Why as many times as needed. This may be fewer than 5 or more than 5 Whys There should be a cause and effect path from beginning to end of each path. There should be data/evidence to prove the cause and effect relationship The path should make sense when read in reverse from cause to cause this is the therefore test (e.g. did this, therefore this happened) The specific problem path should tie back to issues such as design, operations, supplier issues, etc. The detection path should tieback to issues such as control plans, error-proofing, etc. The systemic path should tie back to management systems/issues such as change management, preventive maintenance, etc

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5-Why Critique Sheet

Step 3: Corrective Actions There should be a separate

corrective action for each root cause. If not, does it make sense that the corrective action applies to more than one root cause? The corrective action must be feasible If corrective actions require Customer approval, does timing include this? be communicated as Lessons

Step 4: Lessons Learned Document what should

Learned

Document completion of in-plant Look Across (communication of Lessons Learned) and global Look Across
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Within the plant Across plants At the supplier At the Customer

Steering Solutions Services Corp.

5 Why Analysis Examples

Group Exercise
Review

a 5 Why using the Critique Sheet and what you have learned
Note: These are actual responses as sent to our Customers! Has probable root cause been determined for:

Non-conformance leg Detection leg Systemic leg

Do corrective actions address root cause? Have Lessons Learned/Look Across been noted? If any above answers are no, what recommendations would you make to the team working on the 3 Leg 5 Why?
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Is this a good or bad Specific leg?

Missing o-ring on part number K10001J
WHY?

Parts missed the o-ring installation process

WHY?

Parts had to be reworked

WHY?

Why did they have to rework?

Operator did not return parts to the proper process step after rework
WHY?

No standard rework procedures exist This is still a systemic failure & needs to be addressed, but its not the root cause.

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Is this a good or bad Detection leg?

Missing threads on fastener part number LB123
WHY?

Did not detect threads were missing

WHY?

What caused the sensor to get damaged? Sensor to detect thread presence was not working
WHY?

Sensor was damaged

WHY?

This is still a systemic failure & needs to be addressed, but its not the root cause of the lack of detection.

No system to assure sensors are working properly

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Where to Find Forms..

Go to Nexteer Supplier Portal in Covisint

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Where to Find Forms.. (cont.)

Click Supplier Standards link under Frequently Used Documents

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Where to Find Forms.. (cont.)

Click APQP and Current Production Cycle Forms link to open the folder containing the 5-why form

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Summary of Key Points

When do you use it? Use a cross-functional team Never jump to conclusions Ask WHY until you can turn it off Use the therefore test for reverse path Strong problem definition as the customer sees it Specific Leg Typically applies to people doing work Detection Leg Typically applies to people doing work Systemic Leg - Typically applies to support people

Start with root cause of specific leg

Corrective

actions with date and owner Document lessons learned and look across
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