Relentless Root Cause Analysis Definition: The rapid and persistent pursuit of the fundamental breakdown or failure of the process that, when resolved, prevents a recurrence of the problem. The root cause is the fundamental breakdown of the process. The root cause must be controllable and not an act of nature. 8/02/04

Relentless Root Cause Analysis What is a process? The combination of people, material, machines,tools, environment, preventative maintenance, measuring and test equipment, and work instructions needed to produce a product or service. In other words – a series of inputs are combined with a series of actions that result in a finished part. Actions Inputs Outputs 8/02/04

Relentless Root Cause Analysis What are the fundamental elements of root cause analysis? Each problem is a golden nugget or treasure. Each problem tells a story about why and how it occurred. (There are no isolated incidents.) Solving problems requires a mindset that is alert, open-minded, patient, tenacious, and persistent. It is critical that everyone take a personal and active role in improving quality. The “true” problem must be understood from the data before action is taken. Each problem must be pursued and resolved rapidly. 8/02/04

Relentless Root Cause Analysis Why is relentless root cause analysis important? Defect found at: The first process The next process The last process Final Inspection Customer production line Cost to TSCO $1 $10 $100 $1000 $10000 Impact to TSCO Very Minor Minor Delay Minor scrap/ rework Rework Partial work orders High Scrap Significant rework Work order 0 qty. Delay in delivery Additional inspection Excessive Scrap Off-line charges Expedited freight Reputation Loss of customer 8/02/04

Symptom Root Cause Relentless Root Cause Analysis The danger in root cause analysis – treating the symptom. Symptom Root Cause Assumes at any given time a worker makes a choice to work error-free or not. Assumes errors are the result of worker carelessness. The method is to motivate workers to be more careful (write-ups and termination are common motivational techniques used) Assumes that errors are the result of defects in the process. People are only part of the process. Assumes there are multiple causes of errors. The method of improvement involves identifying appropriate ways to improve the process (action plans involving multiple responsibilities are used). 8/02/04

D I V E Relentless Root Cause Analysis The Problem Solving Process. Investigate Problem Verify Root Cause Ensure a Mistake Proof Solution Problem Found Form Team Analyze data Customer Feedback Implement Corrective Action Define Problem Conduct failure analysis Verify Corrective Action Update Documents Contain problem Lesson’s Learned 8/02/04

D I V E Relentless Root Cause Analysis The DIVE Approach to problem solving D - Define the problem I - Investigate the problem V - Verify the root cause E - Ensure a mistake-proof solution is achieved and implemented 8/02/04

Relentless Root Cause Analysis The DIVE Approach to problem solving LESSON’S LEARNED: After the problem is resolved, you must: Update the FLOW, PFMEA, CONTROL PLAN, and WORK INSTRUCTIONS Review SIMILAR PRODUCTS and IMPLEMENT the same or similar Mistake-Proof solution. Share the LESSON with other departments and Plant locations 8/02/04

D I V E Relentless Root Cause Analysis The Problem Solving Process. Problem Found Form Team Define Problem Contain problem 8/02/04

Relentless Root Cause Analysis Step 1: Define the Problem Write a good Problem Statement: Problem: The turbo pipe is bad. What is bad? It is a value statement that does not communicate the problem Better: The turbo pipe is too small. What information does this give? What information is missing? The problem description is a little more clear, but it is missing something. Best: The turbo pipe 04-60121-008 inlet ID measures 4.5” and the spec calls for 5.0”. This statement tells what product, what location on the part, and what dimension is not meeting the customer requirement. 8/02/04

Relentless Root Cause Analysis Step 1: Define the Problem Contain the problem: Protection of the customer is crucial. Gather all suspect materials and establish how you will prevent the problem from escaping. Identify suspect material with “HOLD for DISPOSITION” tag. Inspect all Suspect Material for problem. Clearly identify any material that has been checked and found good. Disposition ALL materials in a manner that protects the customer and TSCO 8/02/04

Relentless Root Cause Analysis Root Cause Toolbox. Generating Ideas: Brainstorming Force Field Analysis 5 WHY’s IS / IS NOT Finding Patterns: Cause and Effect Diagram Scatter Diagram PFMEA Control Charts Run Charts Check Sheets Examining Results: Root cause test Solution Selection Worksheet DOE (design of experiments) Prioritizing Data: Histogram Pareto charts Nominal Grouping 8/02/04

D I V E Relentless Root Cause Analysis The Problem Solving Process. Investigate Problem Problem Found Form Team Analyze data Define Problem Conduct failure analysis Contain problem 8/02/04

Relentless Root Cause Analysis Step 2: Investigate the Root Cause using the right tools. Generating Ideas: Brainstorming Force Field Analysis 5 WHY’s IS / IS NOT Prioritizing Data: Histogram Pareto charts Nominal Grouping 8/02/04

Relentless Root Cause Analysis Step 2: Investigate the Root Cause using the right tools. Method of “throwing out” any possible idea that anyone on the team thinks could be the cause. Brainstorming Guidelines: Record all ideas No Judgment (there are no “bad” ideas. Combine like ideas Rank in order of likelihood Note: Say the first thing you think of. Rules: One thought at a time Don’t interrupt Don’t criticize Don’t discuss / analyze Build on ideas Record the ideas Collect as many ideas as you can 8/02/04

Relentless Root Cause Analysis Step 2: Investigate the Root Cause using the right tools. 5 WHY’s Problem: Flat tire in garage Why? Nails on garage floor Why? Box on shelf split Why? Box got wet Why? Roof leaks Why? Shingles blown off in hurricane. 8/02/04

Relentless Root Cause Analysis Step 2: Investigate the Root Cause using the right tools. 5 WHY’s – there can be multiple root causes. Problem: Parts are dirty Why? Wash did not clean parts. Why? No Soap was added on schedule. Why? Operation being ran by operators from another area Why? No operator for the process Why? Wash did not clean parts. Why? Pressure too low. Should be 45 psi is 14 psi Why? Pump is not working Why? Pump gets clogged with rags, tags, and paper. Why? Operators not removing from baskets. Why? Wash did not clean parts. Why? Parts not stacked where water can penetrate Why? No documented instructions for part placement. Why? Tribal knowledge Why? 8/02/04

5 Why Worksheet 8/02/04 Problem Statement: Why: Answer: Why: Answer:

Relentless Root Cause Analysis Step 2: Analyze the data using the right tools. Prioritizing Data: Histogram Sometimes called a correlation chart, a perfect 450 angle returns a value of 1. It means that as the one event occurs, the other event will always occur in direct relationship with the amount of change. X Independent Variable X X X X X X X X Dependant Variable 8/02/04

Revolutions per minute (RPM) Relentless Root Cause Analysis Step 2: Analyze the data using the right tools. Prioritizing Data: Histogram Example: If pressing the gas pedal of my car is the Independent variable, and rpm is the dependant variable, then as I press the gas pedal my rpm will increase in direct proportion to the amount of pressure I exert on the pedal. X Press pedal X X X X X X X X Would this work for braking? Why or why not? Revolutions per minute (RPM) 8/02/04

Relentless Root Cause Analysis Step 2: Analyze the data using the right tools. Prioritizing Data: Pareto charts Method of “Ranking” issues / problems. It allows you to see which items contribute most to our problem. 8/02/04

Relentless Root Cause Analysis Step 2: Analyze the data using the right tools. Focus on the top 2 or 3: called the principle of the many over the few. 8/02/04

Relentless Root Cause Analysis Step 2: Analyze the data using the right tools. METHOD MANPOWER Finding Patterns: Cause and Effect Diagram Effect MACHINES / equipment MATERIAL ENVIRONMENT 8/02/04

Settings APQP Pump PM’s Work Instructions Stacking Turn-over Water Problem Statement (cause):Customer received CAC tubes that are dirty and have lubricant, metal shavings, and other debris METHOD: CP-000173 Machine/tools: Mart Wash PFMEA Control Plan Settings Temperature ? No clearWI APQP Pump Pressure at 14 psi s/b 45 PM’s Order of Operations Frequency of Operations Disorganized? Water jets Work Instructions Stacking Effect Soap requirements Turn-over Water SOAP Staffing No dedicated resource De-foam Training Manpower: MATERIAL ENVIRONMENT: 8/02/04 WORKSHEET: Cause and Effect

8/02/04 Problem Statement (cause): METHOD: Machine/tools: Effect Manpower: MATERIAL ENVIRONMENT: 8/02/04 WORKSHEET: Cause and Effect

Relentless Root Cause Analysis Step 2: Analyze the data using the right tools. METHOD Inspection MANPOWER Skills Work Instructions Staffing BP Reading Set-up Experience Control Plan Training Set-up sheets TUBE IS 15 mm Undersized Frequency Hardness Temperature Camber 5S PM Wear In / out Physical properties Storage MACHINES / equipment Work Area MATERIAL ENVIRONMENT Tools 8/02/04

Relentless Root Cause Analysis Step 2: Analyze the data using the right tools. Finding Patterns: Scatter diagrams 8/02/04

Relentless Root Cause Analysis Step 3: Verify the Root Cause using the right tools. Examining Results: Root cause test Answers to these questions will tell you if you have identified the root cause. Does the root cause statement identify an element of a process? YES Is the root cause controllable? YES Can you ask “why” one more time and get another controllable cause? NO Is our identified root cause the fundamental breakdown or failure of the process? Yes If we correct/improve the root cause we have identified, will that ensure that the identified problem will not recur? YES Have we identified the real root cause of the problem? YES Have you checked to see if our identified root cause is applicable to more than one part/process? YES 8/02/04

Relentless Root Cause Analysis Step 3: Verify the Root Cause using the right tools. Examining Results: Solution Selection work sheet 8/02/04