5 whys.docx
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5 whys.docx
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5whys
PRACTICALPROBLEMSOLVING
Introduction
IntheDelphiorganization,acommonproblemsolvingprocessisusedtoanalyzeandsolvequalityproblems.
Therearefourmajorpartsoftheprocess:
∙
GrasptheSituation
∙CauseInvestigation
∙ProblemCorrection
∙PreventionthroughErrorproofing
♦GrasptheSituation
Duringthefirstpartoftheprocess,you:
∙IdentifytheProblem
∙ClarifytheProblem
∙LocatethePointofCause(PoC)
♦CauseInvestigation
Inthesecondpartoftheprocess,you:
∙Conducta“5-Why”investigationtoidentifytherootcause
▪forthespecificproblem
▪forwhytheproblemwasnotdetected
▪forwhythe“system”allowedtheproblemtooccur
♦ProblemCorrection
Inthethirdpartoftheprocess,you:
∙Takespecificactiontocorrecttheproblem.Ataminimum,short-termtemporarymeasuresarerequiredtoprotectthecustomer.
♦PreventionThruErrorproofing
Inthefourthpartoftheprocess,you:
∙Takespecificactiontomakesuretheproblemcannotrecur,typicallythrougherrorproofing
∙CaptureLessonsLearned
PRACTICALPROBLEMSOLVINGMODEL
5WhyFunnel
BASICSTEPSOF
PRACTICALPROBLEMSOLVING
PartI–GrasptheSituation
♦Step1:
IdentifytheProblem
Inthefirststepoftheprocess,youbecomeawareofaproblemthatmaybelarge,vague,orcomplicated.Youhavesomeinformation,butdonothavedetailedfacts.Ask:
▪WhatdoIknow?
♦Step2:
ClarifytheProblem
Thenextstepintheprocessistoclarifytheproblem.Togainamoreclearunderstanding,ask:
▪Whatisactuallyhappening?
▪Whatshouldbehappening?
♦Step3:
BreakDowntheProblem
Atthispoint,breaktheproblemdownintosmaller,individualelements,ifnecessary.
▪WhatelsedoIknowabouttheproblem?
▪Arethereothersub-problems?
♦Step4:
LocatethePointofCause(PoC)
Now,thefocusisonlocatingtheactualpointofcauseoftheproblem.Youneedtotrackbacktoseethepointofcausefirst-hand.Ask:
▪WheredoIneedtogo?
▪WhatdoIneedtosee?
▪Whomighthaveinformationabouttheproblem?
♦Step5:
GrasptheTendencyoftheProblem
Tograspthetendencyoftheproblem,ask:
▪Who?
▪Which?
▪When?
▪Howoften?
▪Howmuch?
Itisimportanttoaskthesequestionsbeforeasking“Why?
”
PartII:
CauseInvestigation
♦Step6:
Identifyandconfirmthedirectcauseoftheabnormaloccurrence.
Ifthecauseisvisible,verifyit.Ifthecauseisnotvisible,considerpotentialcausesandcheckthemostlikelycauses.Confirmthedirectcausebasedonfact.Ask:
▪Whyistheproblemoccurring?
▪CanIseethedirectcauseoftheproblem?
▪Ifnot,whatdoIsuspectaspotentialcauses?
▪HowcanIcheckthemostlikelypotentialcauses?
▪HowcanIconfirmthedirectcause?
♦Step7:
Use5-Whyinvestigationtobuildachainofcause/effectrelationshipsthatleadtotherootcause.Ask:
▪Willaddressingthedirectcausepreventrecurrence?
▪Ifnot,canIseethenextlevelofcause?
▪Ifnot,whatdoIsuspectasthenextlevelofcause?
▪HowcanIcheckandconfirmthenextlevelofcause?
▪Willaddressingthislevelofcausepreventrecurrence?
Ifnot,continueasking“Why?
”untilyoufindtherootcause.
Stopatthecausethatmustbeaddressedtopreventrecurrence.Ask:
▪HaveIfoundtherootcauseoftheproblem?
▪CanIpreventrecurrencebyaddressingthiscause?
▪Isthiscauselinkedtotheproblembyachainofcause/effectrelationshipsthatarebasedonfact?
▪Doesthechainpassthe“therefore”test?
▪IfIask“Why?
”again,willIbeintoanotherproblem?
Besureyouhaveused5-WhyInvestigationtoanswerthesequestions:
▪Whydidwehavetheproblem?
▪Whydidtheproblemgettothecustomer?
▪Whydidour“system”allowittooccur?
5WHYCAUSEINVESTIGATION
AbnormalOccurrence
Why?
(cause/effectrelationship)
C
C
C
C
DirectCause
Why?
Why?
Why?
Why?
Therefore
Test
RootCause
Cause
Cause
Cause
(cause/effectrelationship)
(cause/effectrelationship)
(cause/effectrelationship)
C
C
C
C
C
C
C
C
C
C
C
C
C
Step8:
TakeSpecificActiontoAddresstheProblem
Usetemporarymeasurestoeliminatetheabnormaloccurrenceuntiltherootcausecanbeaddressed.Ask:
▪Doesitcontaintheproblemuntilapermanentsolutioncanbeimplemented?
Implementcorrectiveactionstoaddresstherootcausetopreventrecurrence.Ask:
▪Doesitpreventtheproblem?
Follow-upandcheckresults.Ask:
▪Isthesolutionworking?
▪HowdoIknow?
PRACTICALPROBLEMSOLVINGCHECKLIST
Tobesureyouhavefollowedtheproblemsolvingmodel,usethischecklistasyoucompletetheproblemsolvingprocess.
Graspthesituation
___Pick-uptheproblem.
___Clarifytheproblem.
___Breakdowntheproblem.
___LocatethePointofCause(PoC).
___Graspthetendencyoftheproblem.
CauseInvestigation
___Identify/confirmthedirectcause.
___Ask5Why'stoidentifytherootcause.
___Ask5Why'sfor“Whytheproblemwasnotdetectedandreachedthecustomer?
”
___Ask5Why'sfor“Whydidthesystemallowtheproblemtooccur?
”
ProblemCorrection
___Implementcorrectiveaction;ataminimum,implementtemporarymeasures
Prevention
___Errorprooftherootcause.
___CaptureLessonsLearned.
ACTIVITY:
FLEXINDUSTRIESCASESTUDY
Directions:
▪UsetheDelphiProblemSolvingProcesstoevaluatetheFlexIndustriesCaseStudybelowandonthefollowingpages.Reviewthe5-WhyInvestigationresultsonPage11.
▪UsetheworksheetsonPages13and14torecordyourwork.
▪Useonlytheinformationprovided.
▪Donottrytore-engineertherivetsorsolvethetechnicalproblemsinthecasestudy.ThepurposeofthisactivityistousetheProblemSolvingmodeltoorganizethegivendata.
FLEXINDUSTRIESCASESTUDY
Background
JakeRyanistheQualityManageratFlexIndustries.Flexisacomponentsupplierthatmanufacturesmetalstampingsandlightassemblyproducts.Thecompanyhasareputationforsupplyinghighqualitypartsonaconsistentbasis.Seldomhastherebeenacustomercomplaint.FlexhasQualityrepresentativescalledCustomerSupportEngineers(CSE’s)ateverycustomerassemblyplant.TheCSE’sreportanyproblemstoJakeforinvestigationandfollow-up.
At7:
00a.m.thismorning,JakereceivedacallfromJanet,CSEattheWindingRiverAssemblyPlant.Janetinformedhimthatthecustomerhadfoundfivedefectivestabilizingbracketsonsecondshiftlastnight.Shecheckedtheremaininginventoryandtherewerenodefectsintheremaining326pieces.Themanufacturingstickeronthebackofthebracketsindicatedthattheyweremadebythesecondshiftoperator.Normally,thestabilizingbracketisfastenedtotheregulatormotorwiththreerivets.Thefivedefectivebracketshadonlytworivetsinthem.Thelowersetofrivetsonallfivebracketswasmissingarivet.Thiswasthefirsttimethattheproblemoccurred.
GOODBAD
Jakeset-upcontainmentproceduresattheplantwarehousetosortfordiscrepantmaterials.Asofthismorning,twomoredefectivebracketshadbeenfoundintheremaining2019piecesofinventoryatFlex.
CauseInvestigation
Jakewentouttothefloortotalkwiththeteamleaderofthetworivetlines(EastandWest)andtheareaqualityassuranceauditor.HeinformedSam(theteamleader)ofthequalityproblemandaskedhimtoidentifythelinewhichrunsthestabilizingbracketassembly.SamdirectedJaketotheEastlinewhichrunsWindingRiverassemblybracketsonly.
AttheEastLine,hespokewithJudy(theQAAuditorforthearea)andaskedtoseethequalitylogsheets.JakeandJudyreviewedtheNov.11thlogsheetandcouldnotfindanythingoutoftheordinary.Heaskedhertoset-upin-housecontainmentprocedurestosortforanydiscrepantmaterialinthefinishedgoodsarea.
Next,Jaketriedtolocatethesecondshiftoperatorwhoseclocknumberwasonthedefectiveparts.Sincethatoperatorwasgone,Jakespokewiththecurrentmachineoperator(Ben).HeaskedBenaboutanyrecentdifficultieswiththerivetmachine.Bensaidthathehadn’tnoticedanythingoutoftheordinary.Benalsomentioned,however,thattherehadneverbeenanyqualitybulletinspostedinthetwoyearsthatthisparticularparthasbeenrunning.
Jakedecidedtostayintheareatowatchthemachinerunforawhile.Afterabout15minutes,hewatchedBendumprivetsintothefeederbowltoprepareforthenextrun.
Shortlyafterrestartingrivetoperations,Benwalkedovertoanotherriveterandcamebackwithasteelrod.Benpokedaroundtherivetchuteandthencontinuedworking.JakeapproachedBenandaskedhimaboutthesteelrod.Benrepliedthatfromtimetotimethechutegetsjammedandhehastoclearitout.Thishappenstwoorthreetimesduringashift.Hedidn’tmentionthisinhisearlierconversationwithJakebecausetheproblemhasexistedeversincehestartedworkingwiththismachine.Thepreviousoperatorshowedhimhowtoclearthechute.Alltherivetmachinesarelikethis.
JakecalledtheMachineRepairDepartmentandaskedthatsomeonelookattherivettrack.Aslightgapinthetrackwasfoundandremoved,andBencontinuedtowork.
Twohourslater,JakegotacallfromBensayingthatthetrackwasstilljamming.AsfarasJakecouldsee,onlyrivetswereinthebowl.Next,Jakelookedintotherivetsuppliercontainers.Therewassomeforeignmaterialinthebluecontainer,butnoneintheredcontainer.ThelabelonthebluecontainershowedthatitwasfromAjaxRivet,Inc.,andthelabelontheredcontainerindicatedthatitwasfromFrank’sFasteners.Obviously,theforeignmaterialwasenteringtherivetfeederbowlandjammingthetrack.
JakecalledMaintenanceandrequestedthatthebowlbecleaned.Healsoaddedthecleaningopera
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