Goals and Objectives 2 What is Root Cause? • Root Cause is the fundamental breakdown or failure of a process which, when resolved, prevents a recurrence of the problem. Or, in other words • For a particular product problem, Root Cause is the factor that, when you fix it, the problem goes away and doesn’t come back. • Root Cause Analysis is a systematic approach to get to the true root causes of our process problems. 3 Philosophy of Relentless Root Cause Analysis • Each problem is an opportunity; because it can tell a story about why and how it occurred • It is critical that everyone take a personal and active role in improving quality • The “true” problem must be understood before action is taken – Problems are often masked for a variety of reasons • To do this well, we must be – Both focused and open-minded – Above all, we must be relentless 4 We Perform Root Cause Analysis to Prevent Rejects and Customer Escapes from Recurring Defects Own Next Later Before Found found at: Process Process Process Reaching By Step Step Step Customer Customer Cost: Impact on Very Minor Rework Significant Warranty Cost a Company: Minor Delay Rework Re- Admin. Cost schedule Delay in of Work Delivery Reputation Additional Loss of Inspection Market Share $1 $10 $100 $1,000 $10,000 5 Symptom Approach vs. Root Cause Root Cause • “Errors are the result of defects in the system. People are only part of the process.” • “We need to find out why this is happening, and implement mistakeproofs so it won’t happen again.” • “This is critical. We need to fix it for good, or it will come back and haunt us.” • If we do a poor job of identifying the root causes of our problems, we will waste time and resources putting band-aids on the symptoms of the problem. Symptom Approach • “Errors are often a result of worker carelessness.” • “We need to train and motivate workers to be more careful.” • “We don’t have the time or resources to really get to the bottom of this problem.” 6 How do we do Root Cause Analysis? • Said simply, Root Cause Analysis is asking why the problem occurred, and then continuing to ask why that happened until we reach the fundamental process element that failed. • In its most common, Root Cause Analysis is done as part of the Six Sigma, but the tool applies to all problems. Why??? 7 Example: The (now famous) Washing Machine Problem Description “Machine is 2 weeks old (Serial #2345017). When doing the fourth load of clothes, I heard a loud noise and the machine stopped! It wouldn’t re-start.” 8 Verify the Complaint Problem Verification Service technician checks washing machine operation to test procedure (#8496). The machine does not operate. Determine the Cause. 9 Investigate Why Machine Doesn’t Work Fuse Missing? Machine Unplugged? Power Off? Fuse Blown? Fuse Blown Determine the Cause. 10 Investigate Why Motor Overheated Determine the Cause. Fuse Blown Lightning Storm? Electrical Overload? Power Surge? Motor Overheated? 11 Investigate Why Shaft Damaged Determine the Cause. Motor Overheated Motor Mis-Installed? Fly-Wheel Loose? Cooling Fan? Shaft Damaged? 12 Investigate Why Bearing Destroyed Determine the Cause. Shaft Mis Damaged -Handled? Mis-Installed? Wrong Belt? Bearing Destroyed? Incorrect Tolerance/Fit? 13 Investigate Why Loss of Lube Cause of Failure: Seal Omitted Corrective Action for Specific Deficiency: Replace the Motor Was Seal Omitted?? Bearing Destroyed Bad Bearings? Bearing Loads? Seal Omitted? Wrong Bearings? 14 But..... is it? Root Cause of our Example? Inadequate Appropriate Root Cause - Inadequate Work Instructions Seal Omitted Missed Operation? Operator Error? Parts Shortage Inadequate Work Instructions? Fell Out? 15 But..... is it? Root Cause of our Example? Root Cause - Inadequate Work Instructions Seal Omitted Missed Operation? Operator Error? Parts Shortage Inadequate Work Instructions? Fell Out? Can the design be changed to eliminate the need for a seal? Can the design be changed to make it impossible to omit the seal? Can a fixture be made to make it impossible to omit the seal? 16 Asking Why: Sometimes Simple, Sometimes Complex Root Cause Analysis sometimes requires the additional resources Complexity 1 Person (Brainpower) Simple Tools Sophisticated Tools or Analysis Equipment Failure Analysis Lab, More Sophisticated Equipment Expert Lab Complex, High-Tech Equipment Resources Not Plugged In Hose Disconnected Component Failed Circuit Board Malfunctioned Controller Failed 17 Suggested Root Cause Analysis Approach • Identify the top problems based on quality data • Involve the right people • Define the problem (be specific) • Use appropriate tools to analyze problem – Flow chart, Brainstorm, fishbone, etc. • Evaluate and rank clues / physical data • Determine most likely root cause(s) • Create action plan, post and implement corrective actions (solutions) • Verify implementation and effectiveness of actions 18 Summary • Root Cause Analysis is a method to focus our efforts on the true “Root Causes” of our rejects and escapes, so that we truly prevent their reoccurrence. • Root Cause Analysis helps us reduce rejects and frustration, maintain customer satisfaction, and reduce costs significantly. • Each problem is an opportunity. It contains the information needed to eliminate the problem. But to identify the root cause, we have to ask “Why?” over and over, until we reach it. 19 DMAIC Roadmap Problem Resolution Understand the Problem Gather Reliable Information Identify Root Cause Fix the Root Cause Sustain Improvement Six Sigma DMAIC Define Measure Analyze Improve Control Six Sigma DMAIC Questions Do you understand the scope and severity of the problem? Do you know the potential root causes and have enough reliable data to test them? Can you statistically validate what are the root causes? Do you know what improvements will fix the root causes and by how much? Did the improvements successfully and permanently fix the original problem? 20 Intro to LSS Lean Six Sigma 21 Intro to LSS Who is Responsible for LSS? CHAMPION Senior manager responsible for overall success of project. MASTER BLACK BELT Train/coach/mentor BBs, monitor progress. BLACK BELT Full-time LSS employees, Lead, track project, mentor GBs. GREEN BELT Work part-time on LSS in their work areas. OTHER BELTS Team Members, Data Collectors, Subject Matter Experts (SMEs). Defining Roles and Responsibilities 22 Intro to LSS What is Quality? • Meeting Our Customer’s Requirements • Doing Things Right the First Time; Freedom from Failure (Defects) • Consistency (Reduction in Variation) • Continuous Improvement • Quality in Everything We Do 23 Intro to LSS What is Six Sigma? Proactive Management Structured Methodology (DMAIC) Genuine Focus on the Customer Culture for Quality and Change Analytics Driven Management Comprehensive Management Philosophy Goal of 3.4 defects per million opportunities (DPMO) Empowerment and Quality at the Source 24 Intro to LSS What is Six Sigma? • Comprehensive Management Philosophy • Proactive Management • Empowerment and Quality at the Source • Genuine Focus on the Customer • Culture for Quality and Change • Structured Methodology (DMAIC) • Goal of 3.4 defects per million opportunities (DPMO) • Analytics Driven Management 25 Intro to LSS The “Voices” of Six Sigma Voice of the Customer – The most important “voice” – Customer requirements/ specs/tolerances/satisfaction Voice of the Employee – Employee satisfaction – Employee Empowerment/Self Measurement Voice of the Process/Voice of the Data – Determine if process is predictable and capable – Elimination of blame/fear 26 Intro to LSS Six Sigma Improvement Methods Define Measure Analyze Design Validate Improve Control Six Sigma accommodates both Improvement and Reengineering 27 Intro to LSS Six Sigma Improvement - Role of Tollgates • Ensure Sequence – Obtain formal approval to move to the next DMAIC phase – Prevent team from skipping steps • Enable Communication – Provide management with project updates at each level • Allow Charter Updates – Make modifications to project scope Define Measure Analyze Design Verify Improve Control 28 Intro to LSS DMAIC Six Sigma - Define Objectives • Identify Customers • Complete Charter • Understand Process Measure Control Analyze Improve Define Tools Charter, VOC, VSM, CTQ SIPOC, Scorecards 29 Intro to LSS DMAIC Six Sigma - Measure Objectives • Identify Inputs and Outputs • Measure Process Capability • Revise Charter Measure Control Analyze Improve Define Tools Brainstorming, MSA, Walkthrough, C&E, 5S, KPOV, KPIVs, RTY, Benchmarking 30 Intro to LSS DMAIC Six Sigma - Analyze Objectives • Determine Variation Sources • Prioritize Key Outputs and Inputs • Revise Project Benefits Measure Control Analyze Improve Define Where are the key leverage points for driving breakthrough performance? Tools Fishbone Diagram, Pareto Chart, Process Capability, Control Charts, Layout and Process Flow Analysis FMEA, Statistical Analyses 31 Intro to LSS DMAIC Six Sigma - Improve Objectives • Develop Potential Solutions • Develop Future State • Evaluate and Mitigate Risk Measure Control Analyze Improve Define How do we get there? Tools Kaizen Event, Contingency Planning, Pilot, DOE, Optimization. 32 Intro to LSS DMAIC Six Sigma - Control Objectives • Implement Controls • Standardize • Evaluate Benefit Measure Control Analyze Improve Define Tools Standardization, Training, Visual Aids, Mistake Proofing, Documenting Benefits 33 Intro to LSS DMAIC Six Sigma - Design Objectives • Design Product/Process • Evaluate Product/Process Structure • Evaluate Risk/Benefit Measure Verify/ Validate Analyze Design Define How do we create and implement a new process that will delight the customer and provide outstanding business results? 34 Intro to LSS DMAIC Six Sigma - Verify Objectives • Beta test • Plan Implementation • Implement Solution Measure Verify/ Validate Analyze Design Define How do we determine if the new process is successful? 35 Intro to LSS What is Lean? Elimination of NonValue Add Activity Customer Pull Genuine Focus on the Customer Culture for Lean Lean Tools, Methods and Measures Kaizen Events JIT Delivery Increase Offering/Decrease Changeover Visual Management LEAN - Like water running downstream - more speed with less effort! Continuous Flow 36 Intro to LSS The Four Rules of the Toyota Production System (TPS) 1. All work shall be highly specified 2. Direct customer-supplier connection 3. Visual Management 4. Use scientific method for improvement 37 Intro to LSS 7 Sources of Waste Sources of Waste Example Projects Overproduction JIT Production Waiting Time Time Value-Add Improvement Transportation Process Flow Improvement Inventory Inventory Reduction Motion Layout Changes Processing Pull Implementation Product Defects Quality at the Source 38 Intro to LSS Seiri (Sort) Seiton (Straighten) Seiso (Shine) Shitsuke (Sustain) Seiketsu (Standardize) Prerequisite for Lean Simplifies the workspace Eliminates non-value activity Quick Results Enhances Buy In Fast Standardization of work process Benefits of the 5S Philosophy: • Get rid of clutter • Separate out what is needed for the operations • Red tag unneeded items • Discard unnecessary materials “When in doubt, throw it out.” • Organize work area • Draw current state map; identify WIP • Make it visible and self explanatory - “simplify” • Label areas • Map new locations for tools, materials, and documents “A place for everything, and everything in its place.” • Clean the work area daily • Make it shine • Sweep the workspace • Remove dust, dirt, spills, and trash • Establish procedures “The best cleaning is not to need any cleaning’ • Implement best practices • Empower employees to determine standards • Create checklists and schedules to be followed • Publish new locations and procedures Make the workplace “talk to us” • Achieve self discipline • Define new status • Train all staff on new procedures • Monitor performance • Promote selfdiscipline on cleanliness and organization • Celebrate The less self-discipline you need, the better” The 5S Philosophy 39 Intro to LSS The Lean Six Sigma Approach Define Scope / Opportunity Current State Future State Gap Process cleanup 5S and other Lean Tools Known Solution Lean Project 6 Sigma Project New Design? DMADV DMAIC Yes No Yes No 40