EVENT: An all-inclusive term for any of the following: MODULE 2 Collection EVENT: An all-inclusive term for any of the following: Product failure  Out of control process  Audit finding  Accident  Customer Complaint  Pleasant Surprises Module 2 PW page 1

NATURAL TEAM: A group of people having vested ownership of the problem to be solved. People to consider when forming team: Those that have to respond to the event. Those responsible for the area, equipment, processes, and personnel. Those immediately involved with the event. #1 Killer of the Process! The worst thing that can happen is to form a team that doesn’t have ownership of the problem. If nobody immediately involved with the event is trained in the Root Cause Analysis and Corrective Action process, then add someone who is trained. Module 2 PW page 2

IMPORTANCE OF NATURAL TEAM A team should never be less than two people. Even on simple problems, the synergy that comes from two people sharing ideas adds greatly to the process. Team members from different backgrounds and responsibilities bring different Ideas Needs Experiences Procedural Requirements Team members’ experience affects Areas Investigated Methods of Collection Methods of Analysis How Corrective Action Is Identified Module 2 PW page 3

QUALIFIED TEAM: The natural team, including other individuals, who can provide necessary resources to understand the problem or can help in the root cause analysis and corrective action process. Once the natural team is selected, other people may need to be added to the team, people may need to leave the team, or people may want to have ad hoc members that are advisors rather than actual team members. All these people are resources to keep the team qualified. The natural team must know when to expand to a qualified team and identify the resources available for use on the qualified team. The natural team can be expanded to a qualified team at any time. However, you do not want the team to get too large and become uncontrollable. Module 2 PW page 4

If you cannot say it simply, STATE THE PROBLEM Understand the Problem Carefully look at the event. What is the problem to be solved? What is the customer’s concern? More Than One Problem? Many events have more than one problem, with a root cause for each. If you cannot say it simply, you do not understand the problem. Module 2 PW page 5

When writing a event question, remember: An event question is Short Simple Concise Focused on one problem A question (starting with “Why..?”) An event question does NOT Tell what caused the event State what to do next Explain the event Event: At 9:15 last night, a fire swept through a two story frame house at 2904 Walnut. The fire completely destroyed the home. No one was hurt during the fire. Event question: Why did the fire start? Module 2 PW page 6

Write an event question, then identify natural and qualified team members for each event. Event 1. Kid surprises parents by coming home with an A on a test. (Kid normally gets average grades.) Event Question _______________________________ ____________________________________________ Natural team _________________________________ Qualified team ________________________________ Event 2. A nasty situation developed at Fred and Mary’s house when the in-laws overstayed husband’s welcome. _____________________________________________ Event 3. Parents took a night off to dine out and see a movie. They came home to find large hole in the south east corner of the living room ceiling. Module 2 PW page 7

Gathering data starts at the scene. Data has a shelf life. The longer you wait, the harder it is to get good data. When possible, go to the scene and take note of who is present, what is in place, when the event occurred, and where the event happened. If the event was in the form of an audit finding, try to recover as much of the scene as possible. Most of the time there will be one or more future team members at the scene of the event before the team is formed. They will begin collecting data on the spot. The team must review what data they have and make sure it is correct and complete. Normally, the team will need more data before they can move on to analysis and may have to stop and collect data several times. The goal is to have all the information necessary for the Root Cause Analysis and Corrective Action Process and that is needed to complete any required reports. If the event was of the type that is covered by a procedure, you will have data that is required to be in the report. Check the requirements to ensure you get the data you need when working on those types of problems. Module 2 PW page 8

Information to Consider (see master Forms under tab 8) Location - the site, building, lab, office, or field location where the event took place. Names of Personnel - associates, visitors, contractors. Date and Time Specifications - what are the requirements? Operational conditions - Startup, shutdown, and normal operation. Environmental Conditions - noise levels, visual distractions, lighting, temperature, humidity, rain, wind, etc. Communications - verbal and written, what orders were being followed? Sequence of Events - in what order did things take place? Equipment - what was being operated? Physical Evidence - damaged equipment or parts, medical reports. Recent Changes - in people, equipment, procedures. Training - classroom or on the job. Other Events - have there been events similar to this one? Module 2 PW page 9

Write the event question from the event, and identify the data you might want to collect for each event. Event 4. Mom came home from visiting next door to find that the window in front room was broken. Event Question _______________________________ ____________________________________________ Data to Collect________________________________ Event 5. Dad got up late, ate breakfast in a hurry, and thought things were going OK till he found he couldn’t get the automatic car door locks to operate. Event 6. After the wife finished her shower, she walked back into the bedroom to get dressed. Her bare feet detected that the oak floor near the waterbed was rough and damaged. Module 2 PW page 10

DON’T BE AFRAID TO BACK UP VERIFY DATA Accuracy - Was information copied from a document or from memory. Were interviews done immediately after the event or was there a lapse in time? Second Source - Whenever possible, get corroboration from another source. Conflicting Information - Note data that disagrees with other data. This can include data from interviews/statements or documents/procedures. This includes conflicting interpretations. DON’T BE AFRAID TO BACK UP Your data may often show you that multiple problems exist. The data may also lead you to rewrite your event question. Module 2 PW page 11

INSTRUCTIONS FOR MILL FIRE EXERCISE Write an event question Select team members (Natural and Qualified) Is there more than one problem? One way to check is to figure out who the “customers” of the event or final report might be. What would they want you to focus on? Module 2 PW page 12