2 Where does 5-Why Fit within the PRR process Understanding of 5-Why 5-Why Training AgendaWhere does 5-Why Fit within the PRR processUnderstanding of 5-WhyQuick 5-Why Exercise as a groupCritique Sheet5- Why ExamplesWrap Up/DiscussionAs indicated previously, 5-Why is the prescribed tool to determine the root cause.13
3 Where does it fit within the PRR process? 5-WHYWhere does it fit within the PRR process?After a supplier has submitted an initial response and containment plan (Step # 2 in the PRR process), a detailed investigation is necessary to determine what caused the problem. Step # 4 (Supplier determines the root cause) requires a 5-Why analysis to help in identifying the root cause of the problem.Going back to one of the elements within the Purpose of a PRR “to facilitate problem resolution”, 5-Why is the prescribed tool for determining the root cause of the problem to facilitate problem resolution.Mention how the effective use of this tool can create the discipline needed in the process with Delphi and its supplier base.13
4 Is the powerful question… own it!! WhyIs the powerful question… own it!!
5 Search for speed limit sign) Power of Asking QuestionsSpeedLimitStrictlyEnforcedNoReactionHowFastAre YouGoing?CauseReaction(Look at speedometer)HowFastShouldYou BeGoing?CauseReaction & Research(Look at speedometer;Search for speed limit sign)
6 Who are the best at asking questions to solve problems? Power of Asking QuestionsWho are the best at asking questions to solve problems?
7 When working with people to solve a problem, Power of Asking QuestionsChildren!Why?…because they keep asking objective, open-ended questions until the answer is simple and clearWhen working with people to solve a problem,it is not enough to tell them what the solution is. They need to find out and understand the solution for themselves. You help them do this by asking open-ended , thought provoking questions.
8 Close-Ended vs. Open-Ended Questions Structures the response to be answeredby one word, often “yes” or “no”. Usuallygives a predetermined answer.Example: “Did the lack of standardization cause the incorrect setup?”Open-Ended:Leaves the form of the answer up to theperson answering which draws out morethought or research.Example: “How is setup controlled?”
9 Benefits of Open-Ended Questions Requires thoughtPromotes additional researchEnhances problem solving skillsDoes not assume there is one right answerAvoids predetermined answersStimulates discussionEmpowers the person answeringIn many circumstances, it is not only the answer itself,but the process by which the answer was determinedthat is important when asking an Open-Ended question
10 More Examples Example 1: “Did the lack of a PM system cause this tool to break?”(Close-Ended question, can be answered by a “yes” or “no”, gives theperson a predetermined answer that PM is to blame)“What could have caused the tool to break?”(Open-Ended, probing question forces the person to think about allpossibilities, not just PM)Example 2:“Would improving material flow help reduce lead times?”(Good question but it’s still Close-Ended, focuses the person on materialflow as a means to reduce lead time. Is this the best improvement?)“What are some options on improving lead time?(Open-Ended, triggering more thought and research on all variablesimpacting lead time.)Example 3:“Is equipment capability causing the variation in your process?(Close-Ended, can be answered by a “yes” or “no”, focuses the person onequipment being the source of variation)“What could potentially cause variation in your process?(Open-Ended, triggering more thought and research, opens up possibilitiesof variation with man, material & method, not just machine)
12 5-Why Analysis Three Paths Specific problem:Why did we have the problem?Problem not detected:Why did the problem reach the Customer?System failure:Why did our system allow it to occur?Once the problem has been defined (as the customer sees it) a cause/effect relationship investigation for each path will help in determining the root cause.
16 Grasp the Situation Part I – Grasp the Situation Step 1: Identify the ProblemIn the first step of the process, you become aware of a problem that may be large, vague, or complicated. You have some information, but do not have detailed facts. Ask:What do I know?Step 2: Clarify the ProblemThe next step in the process is to clarify the problem. To gain a more clear understanding, ask:What is actually happening?What should be happening?Step 3: Break Down the ProblemAt this point, break the problem down into smaller, individual elements, if necessary.What else do I know about the problem?Are there other sub-problems?
17 Grasp the Situation Step 4: Locate the Point of Cause (PoC) Now, the focus is on locating the actual point of cause of the problem. You need to track back to see the point of cause first-hand. Ask:Where do I need to go?What do I need to see?Who might have information about the problem?Step 5: Grasp the Tendency of the ProblemTo grasp the tendency of the problem, ask:Who?Which?When?How often?How much?It is important to ask these questions before asking “Why?”
18 5-Why Analysis Step 1: Problem Statement Step 2: Three Paths Is the problem statement clear & accurate?Is the analysis on the problem as the customer sees it?Step 2: Three PathsAre all three legs filled in?Are there any leaps in logic?Can you ask one, two, or three more Whys?Is there a cause-and-effect relationship in each path?Can the problem be turned “on” and “off”?Does the path make sense when read in reverse?Do the whys relate to the actual error?Does the non-conformance path tie to design, operations, dimensional issues, etc.?Does the detection path tie to the customer, control plans, etc.?Does the systemic path tie to management issues or quality system failures?
19 5-Why Analysis Step 3: Corrective Actions Step 4: Lessons Learned Is there a separate action for each root cause?Is it possible to implement each corrective action?Do corrective actions require Customer approval? If so, how will they be communicated to the Customer?Is there evidence to support verification of corrective actions?Are corrective actions irreversible?If not, do actions address ongoing containment?Is there a plan to standardize lessons learned across products, departments, etc?Step 4: Lessons LearnedHow could the problem have been foreseen?How will information be implemented?On the line or in the plant?At the point of detection?Cross functionally at the Supplier?Other products/plants?
20 5-Why Analysis Step 5: Overall Are there gaps or “holes?” Are there things missed or not documented?Do corrective actions address actions the Supplier owns?How many iterations of 5 Why Analysis have there been?Who prepared the 5 Why Analysis?One person?Sales representative ?Clerk?The best answer is a cross functional team that understand the product and process!
22 5-Why Analysis Problem Therefore Why? Root Cause The problem is stated through the eyes of the customerProblemThe first why is the main causeEtc.You have root cause if youcan demonstrate:cause on, problem oncause off, problem offRoot CauseThe second why is what causes the main causeWhy?Therefore
24 5-Why Example - PPAP Submittal (Non-conformance) PPAP submitted lateProblemTest lead time not consideredNo system to accurately assesslead times of all PPAP elementsRoot CauseValidation testing not completePPAP package not completeWhy?Therefore
25 5-Why Example - PPAP Submittal (Detection) PPAP submitted lateProblemNo requirement to follow-up on target submittal datesNo standard system to manage PPAP submittal timelinessRoot CauseDid not know the target submittal date had passedDid not react to the target submittal dateWhy?Therefore
26 5-Why Example - Business Plan (Non-conformance) Did not meet the annual business plan goal of a 10% increase in salesProblemDid not anticipate requiredresourcesDid not develop a plan as to“how” the goal would be reachedRoot CauseDid not have adequate resourcesDid not thoroughly evaluatemarket/competitionWhy?Therefore
27 5-Why Example - Business Plan (Detection) Did not meet the annual business plan goal of a 10% increase in salesProblemDid not develop a plan to monitorthe status of reaching the goalRoot CauseDid not know the goal was notgoing to be metWhy?ThereforeDid not have alarms limits identified at strategic intervals(monthly, quarterly, etc.)Did not evaluate the status ofthe goal until December
28 Flex Industries Case Study-Background Jake Ryan is the Quality Manager at Flex Industries. Flex is a component supplier that manufactures metal stampings and light assembly products. The company has a reputation for supplying high quality parts on a consistent basis. Seldom has there been a customer complaint. Flex has Quality representatives called Customer Support Engineers (CSE’s) at every customer assembly plant. The CSE’s report any problems to Jake for investigation and follow-up.At 7:00 a.m. this morning, Jake received a call from Janet, CSE at the Winding River Assembly Plant. Janet informed him that the customer had found five defective stabilizing brackets on second shift last night. She checked the remaining inventory and there were no defects in the remaining 326 pieces. The manufacturing sticker on the back of the brackets indicated that they were made by the second shift operator. Normally, the stabilizing bracket is fastened to the regulator motor with three rivets. The five defective brackets had only two rivets in them. The lower set of rivets on all five brackets was missing a rivet. This was the first time that the problem occurred.
29 BackgroundGOOD BADJake set-up containment procedures at the plant warehouse to sort for discrepant materials. As of this morning, two more defective brackets had been found in the remaining 2019 pieces of inventory at Flex.
30 Cause InvestigationJake went out to the floor to talk with the team leader of the two rivet lines (East and West) and the area quality assurance auditor. He informed Sam (the team leader) of the quality problem and asked him to identify the line which runs the stabilizing bracket assembly. Sam directed Jake to the East line which runs Winding River assembly brackets only.At the East Line, he spoke with Judy (the QA Auditor for the area) and asked to see the quality log sheets. Jake and Judy reviewed the Nov. 11th log sheet and could not find anything out of the ordinary. He asked her to set-up in-house containment procedures to sort for any discrepant material in the finished goods area.Next, Jake tried to locate the second shift operator whose clock number was on the defective parts. Since that operator was gone, Jake spoke with the current machine operator (Ben). He asked Ben about any recent difficulties with the rivet machine. Ben said that he hadn’t noticed anything out of the ordinary. Ben also mentioned, however, that there had never been any quality bulletins posted in the two years that this particular part has been running.Jake decided to stay in the area to watch the machine run for a while. After about 15 minutes, he watched Ben dump rivets into the feeder bowl to prepare for the next run.
31 Cause InvestigationShortly after restarting rivet operations, Ben walked over to another riveter and came back with a steel rod. Ben poked around the rivet chute and then continued working. Jake approached Ben and asked him about the steel rod. Ben replied that from time to time the chute gets jammed and he has to clear it out. This happens two or three times during a shift. He didn’t mention this in his earlier conversation with Jake because the problem has existed ever since he started working with this machine. The previous operator showed him how to clear the chute. All the rivet machines are like this.Jake called the Machine Repair Department and asked that someone look at the rivet track. A slight gap in the track was found and removed, and Ben continued to work.Two hours later, Jake got a call from Ben saying that the track was still jamming. As far as Jake could see, only rivets were in the bowl. Next, Jake looked into the rivet supplier containers. There was some foreign material in the blue container, but none in the red container. The label on the blue container showed that it was from Ajax Rivet, Inc., and the label on the red container indicated that it was from Frank’s Fasteners. Obviously, the foreign material was entering the rivet feeder bowl and jamming the track.
32 Cause InvestigationJake called Maintenance and requested that the bowl be cleaned. He also added the cleaning operation to the preventive maintenance schedule on the equipment. He then called both Ajax Rivet, Inc. and Frank’s Fasteners. He asked about the cleaning procedures on the returnable containers. Frank’s did a full container purge and clean. Ajax just re-introduced the containers back into their system. When Jake asked why Ajax did not clean their containers, he was told that Ajax was not aware that such a policy was needed.Upon further investigation, Jake learned that Frank’s Fasteners supplies other major automotive companies. Since these companies require that all returnable containers be cleaned, Frank’s instituted the purge as part of its practice for all customers. Ajax Rivet, however, depends primarily on Flex as its major customer. No such policy has ever been required of them.
33 Cause InvestigationJake called the Material Control Department and requested that a container maintenance policy be drafted which would apply to all their suppliers. He also asked that a machine modification be developed to sense for the presence of rivets. Hopefully, this would error-roof the process.Key PlayersJake Quality ManagerJanet CSE, Winding River PlantSam Team Leader, East LineJudy QA Auditor, East LineBen Machine Operator
34 Generic Information for 5-Why Example: Regular Cola Soft Drink vs Generic Information for 5-Why Example: Regular Cola Soft Drink vs. Diet ColaThe plant received a PR/R from a customer. (We use 5-Why Analysis to answer every PR/R.)The PR/R states that the customer received “Regular Cola in the right container (same for both products) with the Diet Cola label”. The order called for Regular Cola.The plant has two identical lines that are capable of running either of our two products. The lines are located immediately beside each other. The only differences in the products are the syrup and the labels.The plant runs both lines 24 hours per day. There are three shifts that run 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m.The date code indicates that the defective product was manufactured at 3:03 p.m.Defective product has been contained and sorted.Objective: To use the 5-Why Problem-Solving Process in conjunction with brainstorming to investigate, solve, and report corrective actions in a problem-solving activity.- Use only the information provided. The purpose of this activity is to use the 5-Why analysis chart to build a chain of cause/effect relationships that lead to the root cause, corrective actions and lessons learned.- After the first attempt in using the 5-Why tool, reference the 5-Why Critique Sheet that follows to help you evaluate your work.
35 Bottling Process Flow for 5-Why INSPECTLIDSBOTLINGWATERBOTTLESSYRUPLABELSGraphical representation of the 5-Why sample exercise as a group.
36 Generic Information for 5-Why Real Example: “O” Ring Seal The plant received a PR/R from a customer. (We use 5-Why Analysis to answer every PR/R.)The PR/R states that the customer received “Mixed/Foreign Material in Shipment”.The supplied part is an “O” Ring seal for oil filter.A cutting operation produces the part to specified size. As the raw material (cylindrical component) goes through the cutting operation, the irregular end-cuts are removed from the station.Second example describing, in general terms, an actual quality situation at one of Delphi’s divisions.Cutting StationMat’l Flow
37 This is still a systemic failure but it’s not the root cause. Is this a good or bad “Non-Conformance” leg?Missing o-ringon part numberK10001JParts missed theo-ring installationprocessParts had to be reworkedOperator did not returnparts to the proper process step after reworkNo standard rework procedures existWHY?Why did theyhave to rework?This is still a systemic failure& needs to be addressed,but it’s not the root cause.
38 Is this a good or bad “Detection” leg? Missing threadson fastener partnumber LB123Did not detectthreads weremissingSensor to detectthread presence was not workingSensor was damagedNo system toassure sensors areworking properlyWHY?What causedthe sensor toget damaged?This is still a systemic failure& needs to be addressed,but it’s not the root causeof the lack of detection.
39 A good 5-Why will answer “Yes” to the five PDCA questions: “A problem well definedis a problem half solved”ACTPLANStandardizeUnderstand the problem5. Has a plan been identifiedto STANDARDIZE and takeall lessons learned acrossproducts, processes,plants, functional areas, etc.?1. Is the problem statementCLEAR and ACCURATE?2. Has the SYSTEMICroot cause(s) beenidentified for all legs?CHECKDOFollow-upExecute the Plan4. Has a plan been identifiedto verify theEFFECTIVENESSof all correctiveactions?3. Has IRREVERSIBLECORRECTIVE ACTION(s)been implemented forALL root causes?
40 Is this a good Corrective Action plan? w/ ResponsibilityPlanDateFastener P/N would not assembleADo1. Replace worn tool(K. Jones)6/1/03WHY?Burrs on the threadDo/Act2. Begin conducting PM on alldies after every run, minimum1 x / day, to collect history(L. Burg)6/1/03WHY?Worn stamping toolDo/Act3. Assess & adjust PM intervalsfor all dies based on history& mfg recommendations(B. Clark)7/31/03WHY?Tool exceeded recommended wearlife4. Track PM completion %to assure 100% conformance(C. Beckett)6/1/036. Track FTQ at stamping tomonitor PM improvement(S. Boland)5. Check for burrs on threadsfor 60 days to verify c/a(M. Mendoeous)6/1/03 -7/31/03CheckWHY?PM interval not adequatePlanWHY?PM failure; No system to strategically setPM intervalsA
41 5-Why Critique SheetGeneral Guidelines: A.) Don’t jump to conclusions!; B.) Be absolutely objective. C.) Don’t assume the answer is obvious. D.) If you are not thoroughly familiar with the process yourself, assemble a cross-functional team to complete the analysis.Step 1: Problem StatementIs the analysis being reported on the problem as the Customer sees it?Step 2: Three Paths (Dimensional, Detection, Systemic)-Are there any leaps in logic?-Is this as far as the Whys lead? Can you still ask one, two, three more why’s)?-Is there a true cause-and-effect path from beginning to end of each path? Is there statistical data/evidence to prove it? ---Can the problem be turned off and on?-Does the path make sense when read in reverse from cause to cause? (e.g.—We did this, so this happened, so this happened, and so on, which resulted in the original problem.)-Do the why’s go back to the actual error?-Does the systemic path tie back to management systems/issues?-Does the nonconformance path ties back to issues such as design, operational, tiered supplier management, etc…?-Does the detection path ties back to issues such as protect the customer, control plans, etc…?For reviewing suppliers’ 5-Why as part of the PRR root cause analysis.
42 5-Why Critique Sheet (cont) Step 3: Corrective Actions-Does each corrective action address the root cause from a path?-Is there a separate corrective action for each root cause? If not, does it make sense that the corrective action applies to more than one root cause?-Is each corrective action possible to implement?-Are there corrective actions that affect the Customer or require customer approval? How will they be communicated to the Customer?-Is there evidence and documentation to support the validity of the corrective actions?-Are the corrective actions irreversible? If not, are there corrective actions in place that address containment?Step 4: Lessons Learned-How could this problem have been foreseen?-How will this information be implemented:a.) on the line or in the plant?b.) at the point of detection?c.) cross-functionally at the Supplier?d.) other product/plants?-Are there lessons learned for the Customer?Step 5: Overall-Do there seem to be big holes where ideas, causes,corrective actions, or lessons learned are being avoided?-Where things are missed or not documented?-Do the corrective actions address the actions the supplier owns?-How many iterations has the supplier gone through so far in preparingthis 5-why (It doesn’t happen on the first try!)-Who prepared the 5-why?
49 Problem Case Audit Standards 5-Why Analysis: Green, Yellow, RedG: Can follow logic and flow of all 3 legs of 5 why's. The legs all differentiate "What is the problem, why wasn't it detected, and what happened systemically."Y: All 3 legs filled out, some leaps of logic, needs minor corrections to improve.R: 1 or 2 legs missing, Leg 1 repeated as leg 2 or 3, not understanding what the different legs mean--typically missing what the systemic leg is. Poor answers on 2 or more legs.