MODULE 4 Solution Corrective Action: A set of planned actions implemented for the purpose of resolving the problem. Corrective action is the goal of the process. Corrective action can be simple or complex, but rarely is it made of just one action Module 4 PW page 1

There are two types of corrective action taken during the process. Specific corrective action (changing the direct cause and effect). Preventive corrective action (eliminating contributing and root causes). The two categories of actions are quite different in how they are applied and what they do. Not understanding this leads to serious mistakes in fixing problems. People routinely stop at specific corrective action and never make it to the more important preventative actions. Let us look at how they work. Module 4 PW page 2

Specific corrective action does not SPECIFIC CORRECTIVE ACTION: Actions taken to correct the direct cause and the effect. *Event* Effect Direct Cause Specific CA Specific corrective actions are only used to correct the direct cause and change the effect. It’s really a form of damage control and clean up. The purpose is to limit or stop the effects from getting any worse and repairing whatever was affected. Often a specific corrective action occurs at the scene in response to the event. When this happens there may not be anything for the team to do but report what was done. Occasionally there is no specific corrective action! A special case. Stopping a process until preventive corrective actions can be applied is also a form of specific corrective action! It temporarily stops the direct cause from operating, but it does not provide an acceptable long-term fix. Specific corrective action does not prevent recurrence ! Module 4 PW page 3

Specific corrective action at work Event: The gun the daughter dropped discharged and broke the window. Direct Cause: The gun discharged. Effect: Broken window. Specific Corrective Action: Took the gun away from daughter. (direct cause) Repair window. (effect) In this example there were two parts to the specific corrective action. One limited the direct cause (kept the daughter from discharging the gun). The other fixes the effect (broken window). They do nothing to prevent the daughter from getting the gun again. Controlling the direct cause can range from putting the fire out, shutting down the process, changing the instructions, etc. Changing the effect can range from repairing damage, fixing defective parts, recalling material, getting medical treatment, etc. These actions may occur any time after the event. Even though the team may not have taken these actions themselves, they are still corrective actions for that event. The team must document the actions even if they occurred before the team was formed. Module 4 PW page 4

Identify specific corrective actions for each direct cause and any effect. (Was there an effect?) Event 1. Oak floor in bedroom was damaged. Direct Cause: Water seeping onto floor and warping the floor boards. Specific c/a: Event 2. Parents find large hole in ceiling. Direct Cause: Kids were walking in attic and slipped off one of the rafters. Event 3. Couldn’t get automatic car door locks to operate. Direct Cause: Battery was dead. Event 4. Kid comes home with an “A” on a test. Direct Cause: Kid knew the material. Module 4 PW page 5

PREVENTIVE CORRECTIVE ACTION: Actions taken to prevent recurrence of the event. Preventive corrective actions focus on the root and contributing causes. Preventive actions are focused on breaking the cause chain. Normally, you do not have a 100% effective fix at just one point (the root cause); often, two or more contributing causes must be addressed to ensure the chain is broken. Determining the number of corrective actions to take and how effective they will be in breaking the cause chain requires careful analysis by the team. Contributing causes not directly leading to the root cause should be evaluated for corrections to other possible problems. Interim (Temporary) Corrective Action This is a special type of preventive corrective action used to prevent an event from recurring until the final corrective actions can be put in place. Interim C/A is used when it is important to get a process back on line as soon as possible. Interim C/A is temporary. It can take the form of barriers that block off a cause or corrective actions that would not be cost effective in the long run. If you must use an interim C/A then report is as such and give a deadline for the final preventive C/A to be in place. Contrib. Cause Preventive C/A Contrib. Cause Root Cause Module 4 PW page 6

Correcting the Root Cause So how do you fix the problem? Yes, but…. If you define the root cause as being the “fundamental reason for the event,” you would expect to get the best fix by applying corrective action there. It’s a good place to start. However, there are times when the root cause is not easily fixed. There are even times where the root cause doesn’t appear to be under your control to fix, even though you have ownership. Operator error For example, a true case of “operator error” is very difficult to correct. As a fix, using work verification or inspection to detect errors is only 50% to 70% effective. A much better approach would be to look for ways to change the process so that the error can’t be made. That requires applying corrective action against a contributing cause, not the root cause. Can’t fix it? What about a root cause you can’t fix? Even though you can’t fix it you must identify it! That’s for your own protection. Establishing barriers around a root cause (fixable or not) is an often used method to protect people and equipment (re: Barrier Analysis). If you don’t identify the root cause, no one will know why the barriers were put in place! So how do you fix the problem? Module 4 PW page 7

Corrective Action Effectiveness An Example Deciding where to apply the corrective action effort may take some study. Let’s look at a problem with a single source vendor making a limited number of special parts for us. Events: Parts have a high failure rate in the field. Direct cause: Parts are not built to meet life expectancy per specifications. Contributing cause: Type of material originally chosen is difficult to process. Contributing cause: Only a small amount of parts being built makes processing harder. Root cause: Process being used was designed for a different material, but it is the only process available. Fixing the root cause would require an expensive upgrade of the process. Our management can’t justify the cost. The vendor can, however, add additional processing for a moderate cost that would increase the quality by 50%. Fixing the contributing cause of small amounts being built can be met by buying ahead (making larger, but less frequent orders). This would net only a 10% increase in quality. Looking at the type of material being processed led to discovering a newer and better material that the vendor had a good process for. This would net a 95% increase in quality with only a small increase in cost. Solving this problem the best way requires fixing a contributing cause, not the root cause. As you can see, all corrective actions are not born equal. Some, by the nature of what they are acting on, are much more effective than others. Rarely is a single corrective action 100% effective. Choose the ones that will give you the best chance of permanently breaking the chain. Defective Parts Not built to spec. Small quantities Change Material Material type Increase Orders C/A 95% effective Add Processing C/A 10% effective Marginal process C/A 50% effective Module 4 PW page 8

How far should you take corrective actions? Not all problems warrant the same level of attention. A typographical error that caused no harm will not receive as much effort to correct as will a fire or the loss of thousands of dollars of product. The team must take a close look at the severity and the frequency of the problem. It helps to answer the following questions: What is the cost of the event in terms of: Personal & environmental safety? Lost money? Lost time? Product loss? Customer dissatisfaction? Schedules? How likely is the event to recur if not fixed? Can you accept the consequences of a recurrence? If there is any doubt about how to evaluate the costs or you need help in getting the corrective action approved, bring in a management representative as a qualified team member. Module 4 PW page 9

The team must deal with: Global Issues: Significant issues with a high probability of occurring in areas outside of the team’s control. ISO defines fixing global issues as a large part of taking “preventive corrective action.” We have to have a system of stopping problems before they happen to someone else. How does the team handle issues out of their area of control? Bring in the right team members! Most global issues can be handled by the team by bringing in just one or two more members that have the authority to apply the corrective actions over a larger area. If you don’t know who to turn to, get help from your Single Point of Contact. Your SPOC is a management appointed specialist and can help you contact the associates you need. Module 4 PW page 10

Want to use some common sense? Preventive Action Test Here it is! The natural team should test all corrective actions before implementation. Preventive Action Test 1. Do the preventive corrective actions lower the risk of the event reoccurring to an acceptable level? 2. Are there adverse effects caused by implementing the corrective actions that make them undesirable? For interim actions the last question is changed to read: 3. Do the interim corrective actions adequately lower the risk of the event recurring to an acceptable level until final preventive corrective actions can be completed? Module 4 PW page 11

What is the corrective action? Who is responsible for getting it done? CORRECTIVE ACTION IMPLEMENTATION Proposed solutions do not become preventive corrective actions until they are implemented. To implement, you have to know: What, Who, When What is the corrective action? Who is responsible for getting it done? When is the deadline? Every corrective action listed on an RCAR should have the “what, who, when” to be complete. The team needs to: 1. Prioritize actions based on importance. 2. Schedule with dates & milestones. 3. Specify who’s responsible. 4. Track all commitments for timeliness. ** REMINDER ** Effective preventive corrective action is what this workshop is all about. Nothing else we’ve learned in this process is of value if preventive corrective action is not achieved. Module 4 PW page 12

Identify preventive corrective actions for the root and contributing causes. List the WHAT, WHO, WHEN. Event 1. Oak floor in bedroom was damaged. Causes: C Water bed mattress and liner were leaking. R Short in bed heater burned through the mattress and liner. Preventive c/a: Event 2. Parents find large hole in ceiling. Causes: C Heavy smoke irritated eyes and made it difficult to see. R Kids hid in attic to smoke cigarettes. Event 3. Couldn’t get automatic car door locks to operate. Causes: C Car battery was six years old. R Kids were playing in the car and left the radio on. Event 4. Kid comes home with an “A” on a test. Causes: C Kid studied real hard. R New girlfriend refused long date unless kid passed test. Module 4 PW page 13

DO WHAT YOU SAY! WARNING!! Don’t hang yourself with your own report! Corrective actions must be done as stated. It’s important to take things literally. Did you do everything just like you reported? Were they done on time? Don’t sign up for actions you can’t deliver on. Be careful of using words like everyone or all. If you say “all” or “everyone,” then you had better mean it and be ready to prove you did it. If you said people would be trained, then their training records must show it. If you change a corrective action after signing off a RCAR, either ask the requester or your data base coordinator to reopen the RCAR or generate a related RCAR containing the new action. Our auditors, our customers, and the ISO auditors review the RCARs in the system to see if corrective actions were done as stated. Not doing them as stated damages our relationship with our customers and could cost us our ISO certification. Don’t hang yourself with your own report! Write your corrective actions clearly. Module 4 PW page 14

Using form 4 cause chains: INSTRUCTIONS FOR MILL FIRE EXERCISE Using form 4 cause chains: Determine the corrective actions needed to fix the causes identified. (The What) Perform tests. Develop implementation plan. (The Who and When) PREVENTIVE ACTION TEST: 1. Do the preventive corrective actions lower the risk of the event recurring to an acceptable level? 2. Are there adverse effects caused by implementing the corrective actions that make them undesirable? 3. Do the interim corrective actions adequately lower the risk of the event recurring to an acceptable level until final preventive corrective actions can be completed? Module 4 PW page 15