Rocketdyne Propulsion & Power Corrective Action Problem Solving John DeGiovanni Quality Leadership Forum Johnson Space Center Sept 25, 2002 Quality Director Space Shuttle Main Engine Program Boeing Canoga Park

Rocketdyne Propulsion & Power Improving Product Decreasing Cost Improving Delivery Adding Value The Purpose of Corrective Action? ? Learning to Treat Corrective Action as a Business Case

Rocketdyne Propulsion & Power Considerations Timeliness Depth Generic Implications Effectiveness Interrelationship of Causes & Effects Consistency Problem Solving Tool Selection Weighing the Factors… NASA Code Q Suggestion to Try New Problem Solving Tool

Rocketdyne Propulsion & Power Every Toolbox has a First Tool The Problem Solving Tool Checklist-oriented Developed by Government and Industry System / Process Structured 22 Categories Failure Codes PossibilitiesPossibilities

Rocketdyne Propulsion & Power The Problem Solving Tool Sample Page

Rocketdyne Propulsion & Power Application & Evaluation Application Problem Solving Tool Applied to Over 20 SSME Corrective Actions Assessed for: – Usefulness – Accuracy – Timeliness – Integration Ability – Direction

Rocketdyne Propulsion & Power Easy to Use Time Saving/Efficient Covers Wide Array of Process Failures & Causes –“Human Performance Factors –“Systemic” Contributors Structure Identifies Factors Not Previously Considered Easy to Categorize Factors Structured Approach Consistent Programmable/Accessible System Approach Adaptable as a Comprehensive Audit Tool Initial Selection of Categories Adaptive Reasoning –Can Require Tailoring Checklist Culture Paper-based / Cumbersome Pro and Cons ConsConsProsPros

Rocketdyne Propulsion & Power Enhancing Implementation Adopted Tool for Web Access Accessibility User Friendly, On-line Edited Text Added Document Reference Ref. to NC, UCR, PR, etc Trending Availability Paperless

Rocketdyne Propulsion & Power Status Several Tools being Incorporated Into our CA Toolbox –Different Tools for Different Applications Consortium Checklist Cause Chains Reason & Other Software Tools Apollo Methodology –i.e., “One Tool Does Not Fit All” The Corrective Action Toolbox Developing Our Corrective Action Toolbox

Rocketdyne Propulsion & Power Cause Chain Value Line “The Theory” Form Team Immediate Cause Facts Relationship Root Cause Action Plan Value Value Tasks Cause Chain Designed To:

Rocketdyne Propulsion & Power Cause Chain 101 Analysis “Value Line Biorhythm” Value “Value” Changes Over Time, Given Certain Events Trouble Signs: 3 cause chain meetings Protests on cause Refuse to attend Push to a CAB deadline Problem weeks old - no action

Rocketdyne Propulsion & Power Corrective Action Factors Software“Tools” Hardware“Product” Liveware“People” Environment Outcomes depend on: Mindsets Priorities Values Knowledge Issues Environment is Critical… Interrelationships Create the Corrective Action Results

Rocketdyne Propulsion & Power What Is Necessary for Better CA? Team wants to do it Team wants to do it Excellent C&CA effort Team understands what to do Team understands what to do Team knows how to do it Team is capable of doing it No obstacles interfere Existing undesirable effects requiring C&CA effort Priorities Schedule Budget Mind sets C & CA Network Logic Diagram

Rocketdyne Propulsion & Power Criteria that Influences the Tool Selection Ease of Use Interactions Among Causes Probability of First Time Through (F.T.T.) Success Business Case for Intervention Immediate Applicability Accessibility Software Compatibility CA Effectiveness Measures Supplier Usefulness How Should the Tool Help?

Rocketdyne Propulsion & Power MORT Human Factors MORT S.O.U.R.C.E Seeking Out the Underlying Root Causes Fault Tree Analysis Logic Tree Analysis Apollo Reason IAT-M Incident Analysis Tool - Modified Cause Chain 5 Why’s Fishbone Diagram Existing Tools Does One Size Fit All? Events More Complex Cases Medium Complexity Cases Fairly Simple Cases

Rocketdyne Propulsion & Power Understanding and The Capability of People What We Are Doing? Studying the C&CA Network Logic Reviewing Tools Assessing Structure Investigating Training Options ENVIRONMENT Changes (From Apollo Root Cause Analysis) “ Only 2 or 3 out of 10 People Can Apply the Logic Effectively” (From Apollo Root Cause Analysis) “ Only 2 or 3 out of 10 People Can Apply the Logic Effectively”

Rocketdyne Propulsion & Power Environment Challenges Possible Environment Modifying Actions Real “People” Build Hardware (They Don’t Do C&CA) Fault-finding More Habitual Than Fact-finding C&CA Perceived As a “Nice-to-have” vs “Must Have” Group Interaction (Exercise)

Rocketdyne Propulsion & Power Moving Out How Are We Proceeding? Mentoring/Facilitation Mode Expanding our Tools Raising Visibility of System Performance Trends Timeliness / Status Accountability Shifting CABs: Review Mode Action Mode Investigating Restructuring of Relationships Developing a Plan to Address The Environment