Yet another tool in the CI box…

 The 8D approach to investigating and solving

problems is a widely-used, well-proven,
team-based methodology

 It is data-driven and prevention-minded

 It is based on the PDCA model (Dr. Deming)

 It is a structured problem solving process

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 D1 – Use a Team Approach

 D2 – Describe the Problem

 D3 – Interim Containment

 D4 – Define the Root Cause(s)

 D5 – Develop Solution(s)

 D6 – Implement Solution(s)

 D7 – Prevent Recurrence

 D8 – Congratulate the Team

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 Forming a team
◦ Team Make-up
◦ Team Size
◦ Selecting Team Members
◦ Team Roles
 Getting the team started
◦ Communicate
◦ Set ground rules

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 Overview

◦ Define the scope

◦ Explain how the problem is detected

◦ Provide known information

◦ Clarify Expectations

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 Determine if Interim Containment is needed
◦ If it’s a safety reason, Interim Containment is always
needed

 If Needed, Contact the customer to let them know

 The problem with Interim Containment is that it is a

Band-Aid approach
◦ This does not correct the problem, it only masks it
◦ It generally requires additional resources and adds internal
costs as well

◦ In many of our situations, we have no choice but to

implement Interim Containment measures

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 Interim Containment is a necessary evil
◦ It is “Necessary” to protect customers form the
effect of the problem
◦ It is “Evil” because it adds unnecessary costs that do
not add value to the process

 Typical Interim Containment techniques

◦ Sorting bad parts from good ones
◦ Adding Steps to the process
◦ Slowing the process down
◦ Adding more inspection

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 Do the Temporary Measures work?

◦ Verify and Validate Interim Containment Measures

 Verification ensures the temporary measures work as
indented

◦ Make sure temporary fixes don’t create new

problems
 Test for new problems, defects or conflicts

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 What is Root Cause?
◦ It represents the source of a problem, error or incident
◦ Often times, the apparent problem (what we see on the
surface) is only a symptom of the real problem.
◦ We need to drive down to the root and pull it out
 How to find the root cause
◦ Sorting through the symptoms
◦ Identify Cause and effect relationships
◦ Use data to pave the path to the real problem so the root
cause can be determined
 THE MOST IMPORTANT PART OF ROOT CAUSE
ANALYSIS
◦ We are NOT interested in assigning blame
◦ We are ONLY interested in getting results

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 What is the best approach to finding the root
cause?

 This step, although one of the most

important, is often one we rush through

◦ Imagine if Sherlock Holmes were to jump to

conclusions.
◦ If we go too quickly we will get poor results
◦ Poor results will lead us not fix the problem and
have to do it over again

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 Discipline 4: Define the Root Cause(s)

Total re-work by machine

collected during the week of 8/16/2010 in
45 minute intervals 1st & 2nd shift
400
Total number of Leakers

300
200
100
0

7 1 2 0 4 1&2 6 5 3
Machine # Let the data tell the story!
Machine Downtime
Remember: 80/ 20 Rule!
6

0
Week 1 Week 2 Week 3 Week 4

Machine 1 Machine 2
 Some Root Cause Identification tools
Affinity Diagram
Brainstorming

5 Why?
Cause & Effect diagram
1. Why?
Machines Methods Materials
2. Why?
Potential High-Level
3. Why?
Causes Problem 4. Why?
Statement 5. Why?

Manpower Mother Nature

Measures

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 5 Why Example (Production) – A robot is down
Why Answer Action
Why is the Robot down? The circuit has Replaced the fuse
overloaded, causing a
fuse to blow
Why is the Circuit There was insufficient Added Lubrication
overloaded? lubrication on the
bearings, so they locked
up
Why was there an The oil pump on the Investigate cause
insufficient lubrication robot is not circulating
on the bearings? sufficient oil
Why is the pump not The pump intake is Investigate cause
circulating sufficient oil? clogged with dirt and
grime
Why is the intake The Filter on the pump Replace filter
clogged with dirt and is worn and has a hole
grime? in it, allowing non
liquids to go through
Why is the filter worn There is no standard Add PM or job task to
work in place to change validate the integrity of 15
Why??????????????????????????

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 Train/Retrain associates
◦ This can be part of an action, but NOT THE action
 Wear and tear
◦ Unless it’s run to fail which should not be in most cases
 Talk to or disciplined associate
 Went to customers facility to sort (this is after the
fact)
 Didn’t have parts in stock, make sure they are in
stock
 Increase inspections (100% inspection does not
work)
◦ This is also part of Interim Containment D3, not a
corrective action
 Discipline 4: Define the Root Cause(s)

• Verification
• Once we believe the root cause has ben found, we need to verify it
• Some good questions to ask are:
• Is it “safe” to try to replicate the problem by “activating” the root
cause?
• When Activated, does the root cause trigger a failure?
• Are the failures triggered the expected failures?
• Are other failures found instead?
• Once we verify the root cause we can start working on the
prevention (next step)

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Discipline 5: Develop Solution(s)

 Now that the root cause is known, we can

address it with a solution!
◦ First review the problem statement to make sure the
team is focused on the Expectations that were originally
set

 In order be successful in completing Discipline 5,

we need to identify a solution that:
◦ Will prevent future incidents, or at a minimum, warn if a
problem may recur
◦ Is Practical, feasible and cost-effective
◦ Is Robust

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Discipline 5: Develop Solution(s)

 Reality Checks of Solutions

◦ Is it practical
 Is the solution realistic from a technological standpoint?
◦ Is it Feasible
 Do we have the capacity to implement the solution?
◦ Is it cost effective
 What is the ROI?
 Will it cost more to implement then the problem causes?

 What factors are intangible?

◦ Safety issues
◦ Regulatory considerations
◦ Customer commitments and requirements
◦ The “Cost of doing business”

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Discipline 5: Develop Solution(s)

 Robustness and Sustainability

◦ Robustness: Will the Solution work in tough conditions?

 Is it usable under normal conditions with out support?
 Will it work in an environment with high turnover?
 Have extreme conditions been considered?

◦ Sustainability: Will the solution stay viable over time?

 Will wear and tear cause difficulties?
 Is the life cycle of the solution adequate?
 Will changes in personnel affect the workflow?
 Does the solution depend on “tribal” knowledge?

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Discipline 5: Develop Solution(s)

 Run Confirmation trials

◦ Once a solution is selected, if it is possible, run a
confirmation trial to see if it works

◦ Example of trials might include:

 Prototypes
 Pilot Plant trials
 Controlled trial on the live process
 Models
 simulations

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Discipline 6: Implement Solution(s)

 Develop Action Plans

 Confirmation runs
◦ Check that the solution works
◦ Check that the solution does what it was intended
to do

 Document the Changes

◦ Communicate the changes
◦ Update related procedures and work instructions
◦ Provide Training

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Discipline 7: Prevent Recurrence

 Verify and Validate the solution

 Remove Interim containment measures

 Update related documentation

 Share lessons Learned

 Start audits to hold the gains

 Complete a Final Report

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Discipline 8: Congratulate the Team

 Share Lessons Learned

 Completing a project is a significant

milestone!

 The implemented solution will lead to

ongoing benefits

 The Team deserves a hearty, sincere

congratulations!

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Discipline 8: Congratulate the Team

 Congratulations via Recognition

◦ Recognize the accomplishment
 Make sure the team knows they have created something worthwhile
 Personalize recognition by linking it to their specific accomplishments
◦ Sincere recognition starts a cycle to more ideas and improvements
◦ Many aren’t comfortable recognizing others
 We need more practice doing this
 Most associates want to work hard and do the correct things each day
◦ Rewards?
 Working on a project team to solve problems should be part of the job
we are paid to do
 Usually financial rewards are not given for successful team projects
 However, Completing good projects and lead to better performance,
which leads to a better EVA, which IS a financial reward for good
performance

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Discipline 8: Congratulate the Team

 Be Timely and Sincere

◦ Don’t Wait!
 Recognition should be made really close to the
accomplishment
◦ Be Sincere
 No recognition at all may be better then manufactured
recognition
 If the message is genuine it will be much more
appreciated

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Discipline 8: Congratulate the Team

 Don’t forget ALL and NON “team member's”

◦ Team Champion
◦ Other Team Members
◦ SMEs
◦ Process Owners
◦ Managers and Supervisors
◦ Customers (if they helped)
◦ Suppliers (if they helped)
◦ Others

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