Module 3 Analysis Running, like solving problems is a natural process that everyone just “ learns as they go.” Becoming a good runner however, takes training and practice that does not come naturally. Doing a good job of analyzing problems also takes training and practice.

The process requires complete honesty and no predetermined assumptions. Eliminating preconceived notions is critical. Preconcceived notions cause the team to side track the process. It leads the team to ignore the data that points to the real problems.

Follow The Data!! This process is a tool used to get a permanent fix. You won’t get it if you try to force the analysis into supporting a preconceived corrective action. Remember: Don’t get personal. It’s not a witch hunt. What we really want to know is: Why did it happen? Not who did it. Predetermined Assumption Don’t get caught in the Predetermined assumption trap!!!!

“Operator Error” Used too often. Used as easy way out. The problem lies with the process, not the operator! Be careful when your analysis leads you to this cause. We’re all operators! We all have tasks to do. Blaming the operator is used to much too often and usually means you stopped searching too early. Ask yourself; If the operator was replaced with someone else, could the event still happen? If yes, then it wasn’t just operator error!

Why do people not perform? Improper Instructions Improper Tools Improper Training Lost Expectations Instructions - were they complete, clear, accurate, and understood by the user? Tools - were the right and nessesary tools there? Training - was the training proper and complete for the job? Expectations - Have they been clearly stated, and are they built into the working environment? Does the operator feel that they will/can be taken seriously?

What role did management systems play? Dont Limit The Search! What role did management systems play? Don’t be affraid to look at management systems and procedures as causes. A missing , incomplete, or improper system of doing business is found to be a major cause about 85% of the time! Don’t be affraid to look beyond the areas you work in. Problems that come from the other departments can and must bee addressed. Rember the 80/20 Rule 80% of the problems can be attributed to 20% of the causes. Be attentive to causes that show up frequently. Are you looking beyond your own back yard?

Why Why Why???? (Cause and effect) Even the most serious or complex problems can be handled by using the why-why method coupled with cause chain diagrams. The why-why analysis method is used by everyone, everyday. It’s a natural, logical progression for thinking through a problem. You learned it as a child. Given a structure to apply it in makes it a powerful tool. CHAINS ARE THE SECRET Using cause chain diagrams allows you to handle large or complex problems that are impossible for the human brain to see as a whole. They also keep you honest!

Just Keep Asking “Why?” EQ: Why were you late? Car wouldn’t start. Event: Didn’t get to work on time. EQ: Why were you late? Car wouldn’t start. Why didn’t it start? Battery was dead. Why was the battery dead? Dome light stayed on all night. Why was the light on? Kids played in car , left the door ajar Ask the class: What was the fourth word you learned to use? Answer: First word mom, then dad, then no, and then why? Once you learned the why question you made your parents life miserable for the next several years. Using the why-why with cause chains works on all problems.

Take small steps! Work from an effect back to a cause Restate the cause as a problem(Why….?) Find the next cause Repeat until you run into success Take the smallest step possible when asking why. Don’t skip over important causes.

The Best Question is ... ...one that starts with “WHY?” If you want to get the most out of your Data: Make Questions Simple Don’t ask complex or poorly focused questions, they will lead you off the correct path and waste time.

So what does why-why do for you? It creates your cause chain which will contain 3 types of causes: Direct Cause Contributing Cause Root Cause Let’s look at definitions for these…..

The first cause(s) after the event. Direct Cause: The first cause(s) after the event. This is the answer to the first question.(your problem statement)

The causes after the Direct Cause(s). Contributing Cause: The causes after the Direct Cause(s). Note: For a simple problem, there may not be any contributing causes, for a complex problem there could be dozens.

Root Cause: The last cause(s) in the chain. ( The fundamental reason for the event) Use the root cause definition to sort out contributing causes at the end of the chain. As will be shown, the root cause is not always the most significant cause in the chain and sometimes it can’t be corrected easily or well. Focus instead on the fact that it is just the last cause in the chain.

Let’s put labels on the chain! Direct Cause Event: Didn’t get to work on time. Why were you late? Car wouldn’t start. Why didn’t it start? Battery was dead. Why was the battery dead? Dome light stayed on all night. Why was the light on? Kids played in car , left the door ajar Contributing Contributing Root Cause

Picking Up the Pieces Event Direct Cause Contributing Cause This is how it happens. A chain of causes link up to form a path to an event. We don’t see it until it’s to late. After the event has happened, we have to analize it. We work from the event to the direct cause. From there we seek out the contributing cause(s) and continue the search down the chain to the root cause. Note that you often find the contributing causes that do not lead directly to the root cause. Even though they may have plyed a minor role in the event, These branching causes often point out other problems that may need to be fixed to prevent other events from occurring. Contributing Cause Contributing Cause Root Cause

How many Root Causes can you have? Event Problem One Problem Two One, two, or more, depending on how many problem statements you have. Each problem will have it’s own cause chain ending in a root cause. Direct Cause Direct Cause Root Cause Root Cause

How many Root Causes can you have? (cont.) Event Direct Cause Contributing Cause Two, or more, if your cause chain breaks off into multiple contributing causes where a side contributing cause becomes a major issue. That contributing cause points out a major problem that needs its own solution and forces you to work that branch of the chain down to the root cause. These two chains are somewhat interchangeable depending on how the team chooses to look at it. The second problem could be worked as a major contributing cause. Or a significant contributing cause could be broken out as its own problem, Use a second PCAR. Only one problem per PCAR. Contributing Cause Contributing Cause Root Cause Root Cause

How many Root Causes can you have? (cont.) Event Direct Cause Contributing Cause Contributing Cause None, if the trail is lost! There are occasions when the chain stops because there is no more data. People retire, records are missing, the problem is very old, etc. In some cases the organization you may be responding to will request that you call the last available cause in the chain the root cause. None if the trail is lost!!

How many Contributing Causes can you have? Event Direct Cause Contributing Cause Root Cause For small problems your direct cause could lead straight to the root cause. For bigger problems you may have to ask “why” many times before reaching the root cause. Each time you ask “why” after the direct cause gets you another contributing cause. Many to none, depending on the size of the problem

Big Clue!! When a cause has two or more items inside of it, it may be time for a new branch!

How to keep things straight: Write down each possible cause. Use the why-why process to sort. Start with the event question. Take small steps. Solutions come later! Test the chain!

Let’s put labels on the chain! Direct Cause Event: Didn’t get to work on time. Why were you late? Car wouldn’t start. Why didn’t it start? Battery was dead. Why was the battery dead? Dome light stayed on all night. Why was the light on? Kids played in car , left the door ajar Contributing Contributing Root Cause

Find Direct, Contributing, and Root causes Find Direct, Contributing, and Root causes. Exercises 1-9 PW Pages 12, 13, and 14 Use only what you’ve been given for causes! Remember: - Think about possible branching. - Problems may not have Contributing Causes, Direct could lead straight to Root Causes. - Contributing Causes may not have Root Causes

Event 1 Kid comes home with an “A” on a test Causes: ___ Kid Knew Material ___ New girlfriend would not go out on date unless kid passed test. ___ Kid studied real hard. Answers: Direct cause ContributingCause Root Cause Kid knew material Kid studied real hard New girlfriend would not go out on late date unless kid passed test

Cause and Effect Received ticket for safety violation. Car exhaust to loud. Muffler knocked loose from tailpipe. Daughter hit pothole. Potholes in road. Winters damage roads. Congress won’t allow money needed for repair. Congress doesn’t have extra money. Congress spent money on pork barrels. Too many lawyers in congress. Like answering questions from a four year old child, asking why can be taken to far.

Y-Y Curve Unworkable Workable Ignorance Silly Times “Why” asked Normal progression of any analysis is to move from a point of not knowing enough about why the event occurred(first x on left) to a point where a problem becomes well understood and workable (bottom of curve). Past that point the problem picks up a “silliness factor” and quickly becomes unworkable. Knowing where to stop takes practice, experience, and some help in defining the limits of a root cause. Times “Why” asked

Did you go to far? Root Cause: Do we own it? You may identify the root cause even though you may not have the resources in your team to solve it. Do not use these tests as an excuse to take the easy way out and not follow the process to the root cause. Just because you feel a problem is beyond your personal ownership or the ownership of the natural team, does not mean it’s beyond the company’s ownership. There are rare occasions when the root cause has been properly identified, but has no solutions. It’s still the root cause and needs to be documented as such. (Module 4 will discuss what to do when the root cause has no solution). If the root cause lies within our facility, inside the company, or even inside a vendor, we have ownership.

Instructions for Mill Fire Exercise Blue Sheets under tab 10 Using forms 2a and 2b: Using the Data to build cause chains for the fire and the burns. Use the why-why method and start with your event questions.

The Causes are your Keystones Direct Corrective Action Contributing Root

Bridge Between The Event and The Solution Building a bridge between an event and a solution requires finding the correct causes.If you don’t know what caused the problem, how are you going to fix it?

Review How do you begin your analysis? Where does the event question lead you? What follows the direct cause? What’s the last cause in the chain called?

Module 4 Solutions Transition root cause analysis to corrective action - Moving from problem solving to Decision making mode. Using the flow chart - point out to participants the items in module 4 Root cause analysis is all about implementing effective corrective actions.

Corrective Action Definition Corrective Action: A set of planned actions implemented for the purpose of resolving the problem. What is corrective action?

True or False If you correct only the root cause, every problem will be fixed forever. Slaying another sacred cow. Ask: Here is the commonly accepted definition of root cause. Does everyone believe that if you correct only thr root cause, every problem will be fixed forever. contributing causes need to be addressed also.

Two Types of Corrective Action Specific Corrective Action ( changing the direct cause and effect) Preventive Corrective Action (eliminating contributing and root causes) Two Categories: PW-2 Specific corrective action (addresses only the direct causeand effect). Preventive corrective action ( addresses contributing and root causes). To class: This is a new way of looking at the definitions! We have found one big reason why corrective actions have not worked. People just don’t understand the difference between these two actions. To fix the problem requires understanding the difference.

Specific Corrective Action: Actions taken to correct the direct cause and effect. *Event* Effect Direct Cause Specific C.A. Very important page! Have class read text carefully. When people get specific C/A confused with preventive action they will stop and not go any further. Make sure the students fully understand just what specific c/a is and how limited it is ( i.e. does very little to prevent recurrence). C/A’s that stop at specific are a major problem seen in audit responses. History repeatedly shows that people do not understand the difference between specific and preventative. Stopping a process until preventive corrective actions can be applied is a form of specific corrective action. Specific Corrective Action does not prevent recurrence! Occasionaly there is no specific corrective action! PW-3

Exercise Module 4 page 5 Using the four examples given on page 5 of your workbook, Identify the specific corrective actions to change the direct cause and to change the effect. Event one: Specific C/A stop leak and /or drain water. (keeps damage from getting worse). Does this action change the effect? NO Action taken to change effect: repair floor. Event two: Specific C/A: Remove kids from attic if still there, otherwiseNONE. Does this action change the effect? NO Action taken to change effect: Repair Hole Event Three: Specific C/A recharge battery Does this action change the effect? yes. Event Four: Specific C/A: NONE. Can’t change the test or take away his knowledge. Note: In event 1 the specific C/A worked on the direct cause. In event 3 it did both. Wrap up by handing out event sheet.

Preventive Corrective Action: Actions taken to prevent reccurrence of the event Contrib. Cause Preventive C/A Contrib. Cause Root Cause Note that contributing as well as root causes have been addressed. Preventive corrective actions focus on the root and contributing causes.

WHACK-A-MOLE Problems always popping up!!! We play Whack a Mole with defects and events in the plant. We often take Specific corrective actions and move on without doing the preventative C/A. The Mole gos back down the hole only to appear later in a different place. (global applications). Good preventive C/A’s attack the contributing and root causes.

Corrective Action Effectiveness Defective Parts Not built to spec Small Quantities Change Material Increase Orders Material Type Notice that the different causes when remedied have a percentage effect on preventing reccurrance. Root causes are not simple to correct. Lets look at operator error. In the cause chain you can always go beyond operator error becausethere are always reasons why people make mistakes. However, those reasons areoften beyond company control, e.g. illness, personal problems, family tragedy, not paying attention etc. Note that relying on inspection or work verification ia a poor substitute for an error free process. Even if you can’t correct the root cause, you must identify it so that barriers can be put in place. 95% Effective 10% Effective Add Processing Marginal Process 50% Effective PW-8

The more you run over a dead cat, Corrective Action the flatter it gets!! Make your corrective actions count! Don’t waste time doing the wrong thing.

Cost Of Non-Conformance Time Money Product Loss Customer Dissatisfaction Personal & Environmental Safety 1. Compare the cost of nonconformance of a repeat event to the cost of fixing the problem. 2. To determine the cost, ask the questions on pw page 9. there is also a risk decision matrix in tab 9 to help determine costs/risks factor. 3. Remember to get someone with the authority to get corrective action implemented if they extend beyond the teams power. PW-9

Global Issues Definition: Significant issues with a high probability of occuring in areas outside of the teams control. Global Issues Definition: PCAR system designed to deal with global issues. Management Rep and ISO Team facilitate bridging global issues to affected areas. What is a Global Issue to you? PW-10

Preventive Corrective Action Test “Common sense test” Do the preventive corrective actions lowers the risk of the event recurring to an acceptable level? Are the adverse effects caused by implementing the corrective actions that make them undesirable? For the interim actions the last question is changed to read: 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. Question 1. If the set of corrective actions prevent the event from recurring, then you’re done. However, if the C/A’s are not 100% effective then you need to determine if the risk of recurrence is acceptable. Question 2. If there are adverse effects caused by implementing the corrective actions that make them undesirable, alternate actions need to be identified. Be sure to consider demands on resources on the affected organizations. Question 3. If you are into a temporary fix, are the interim C/A’s effective enough? How long can they stay in place? i.e. sorting Always test preventive actions before your team decides an implementation plan. Testing actions will save more time and money than any part of the process. If you implement actions not acceptable to the causes you’ll spend more time and money fixing the same problem again or a totally new set of problems. PW-11

Proper - W - Etiquette Why What Who When Is for Cause Chains It’s corrective action! Now ask the “other 3” W’s (What, Who, When) Always list them on the PCAR.!!! Are for Corrective Actions PW-12

Corrective Action Implementation Prioritize actions by importance Schedule dates and milestones Track all commitments for timeliness Specify who is responsible Implementation of C/A’s is ……. “Just Do It” The team decides the priorities and selects the best person responsible for implementation. Make sure other parties buy into your proposed corrective actions. This could be where you add new team members. PCAR system tracks corrective actions.

Exercise for problems on page 13…. Instructions Identify preventive corrective actions for the root and contributing causes. List the What, Who, When. Apply test from page 11 Event 1. Preventive c/a: Repair mattress and liner. Replace bed heater. Event 2. Preventive c/a: Lock attic. Instruct kids not to smoke; Training Event 3. Preventive c/a: Routine maintenance, keep car locked, have kids push car around block 4 times. Event 4. Preventive c/a: Pay kids for datewith girlfriend. Beg girlfriend to keep pressure on. Have kid marry girlfriend.(Solves event for parents, not for girlfriend!) Test: 1. Risk of recurrence 2. Adverse effects 3. Interim actions effective? -Sustainable

Warning Do What You Say! PW-14 Get the class to repeat the ISO creed: “Say What You Do - Do What You Say” Make sure the corrective actions are done as stated. Be carful in the words you choose. Do you follow them to the letter? PW-14

….Ensuring that corrective action is taken and effective If you say it. Do it! Be careful of your choice of words Dangerous: Words like “trained” and “all” Don’t use words like “all” or “training” unless you mean it and can prove you did it. You must check up on yourself because: -The ISO auditors will check up on you. -You don’t want to be in a position to have to explain to them why you didn’t do what you said.

Mill Fire Exercise Determine the Corrective Actions Needed to Fix the Causes (What) Perform the Preventive Corrective Action Test Develop the Implementation Plan Who……What……When