1. 1.1Purpose and Scope: 1.1.1This training presentation is intended to serve as development training for HEB Manufacturing Partners that need to identify why problems are occurring. 1.1.2Partners tasked to facilitate are Manufacturing Partners and Leaders that have had prior training on the 5 Why Method. 1.2Definitions: 1.2.1Listed in MQA-QF-62-01-1-15, Terms Definitions, Acronyms and Abbreviations 1.3References: 1.3.1MQA-QF-62-01-1-15, Terms Definitions, Acronyms and Abbreviations Link 1.5Records, Reports and Forms Related Documentation: 1.5.1MQA-QF-62-01-1-2 (Record of Partner Training) or facility equivalent form 1.5.2MQA-QF-85-01-7-1 5 Why Root Cause Analysis Template 7.0 Equipment & Materials: None 8.0 Safety Requirements: None 9.0 Attachments: None 10.0 Document History: The first revision (A) of this document was developed by Continuous Improvement Managers, 10/1/2013 11.0 Approval: by David Petrosky, Senior Quality Manager, 1.0Administrative Notes for Instructors: 5 Why’s for RCA Training MQA-QS-85-01-7-1

2. 5 Why’s for Root Cause Analysis

3. Objective Understand the 5 Why’s Method for problem solving. Apply the 5 Why’s Method to identify root cause. 3

4. The 5 Why’s The 5 Why’s approach to root cause analysis is described as asking the question “why” five times. This technique is attributed to a Japanese method of determining the root cause. The 5 Why’s method can be used to determine the root cause for ANY problem. 4

5. Advantages of 5 Why’s Simple - It’s easy to use. Effective – separates symptoms from the cause. Flexible – works well alone, but can be used with other CI Tools. Engaging – creates TEAMWORK! Inexpensive – just the cost of your brain power! 5

6. CI Tool Overview 6

7. Template 7

8. Example Problem COLO Event at SAB. Over-baked product: Classic Chip Galores Cookies. 8

9. Why’s 9 Why are the cookies over baked? Why is there less volume? Why did we reduce the cuts per min? Why was the oven slowed down? Why are there doubles? Why are the wires loose? Why is the clamp loose? Why is the bolt stripped? Less volume in the oven We reduced the cuts per minute The oven was slowed down We were seeing a lot of doubles The cutting wires are loose The clamp holding the wires is loose The bolt that tightens the clamp is stripped It was over tightened and the PM has not been completed to replace the bolt

10. Solution 10 The PM was missed therefore the bolt has not been replaced. Add the bolt to the CI&L Matrix for the line so that if a defect occurs, the bolt is replaced.

11. Example – Jeffersonian Memorial 11 Problem: The stone of the memorial was decaying.

12. Why’s 12 Why the decay? The building is frequently washed Why does the building have to be washed so often? To remove all the bird droppings from the abundance of birds around the monument Why are there so many birds? There are 1000’s of spiders there for the birds to eat. Why are there so many spiders? There are 1000’s and 1000’s of midges there for the spiders to eat. Why are there so many midges? The midges are attracted to the spotlights that have come on and it creates a mating frenzy every evening.

13. Solution 13 The National Parks turn on the spotlights that illuminate the building every evening at dusk and millions of these midges emerge in a mating frenzy. The excited midges are attracted to the light. The Parks service has delayed the turning on of the spotlights to one hour after sunset

14. The Result The midge population is down 90% The food chain has been broken There are now less frequent washings 14

15. Group Exercise for 5 Why’s What problem is your team facing? COLO, shrink, downtime, overtime, missed PPPH, etc. Apply the 5 Why’s Method to find the root cause. 15

16. Questions? 16