5-WHY PROBLEM SOLVING PROCESS

PRACTICAL PROBLEM SOLVING

Introduction In the Delphi organization, a common problem solving process is used to analyze and solve quality problems. There are four major parts of the process: Grasp the ituation !ause Investigation "roblem !orrection "revention through #rrorproofing

Grasp the Situation During the first part of the process, you: Identify the "roblem !larify the "roblem $ocate the "oint of !ause %"o!& Cause Investigation In the second part of the process, you: !onduct a '()*hy+ investigation to identify the root cause for the specific problem for ,hy the problem ,as not detected for ,hy the 'system+ allo,ed the problem to occur Pro !e" Correction In the third part of the process, you: Ta-e specific action to correct the problem. .t a minimum, short)term temporary measures are required to protect the customer. Prevention Thru Errorproo#ing In the fourth part of the process, you: Ta-e specific action to ma-e sure the problem cannot recur, typically through errorproofing !apture $essons $earned

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5-WHY PROBLEM SOLVING PROCESS

PRACTICAL PROBLEM SOLVING MO$EL % &h' (unne!

G S R I A T S , P A T T I + O E N C A , S E I N V E S T I G A T I O N

"89:$#; ID#<TI=I#D %$arge, >ague, !omplicated& "roblem !larified .rea of !ause $ocated &here in the process is pro !e" occurring* "oint of !ause %"o!& -Go See. the pro !e" *hy7 / !ause Basic Cause)E##ect Investigation *hy7 6 !ause *hy7 1 !ause % &h'* *hy7 2 Investigation o# Root Cause !ause *hy7 ( *hy did ,e *hy did it
have the problem7 get to the customer7

*hy did our 'system+ fail7

8oot !ause !orrective .ction $essons $earned

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BASIC STEPS O( PRACTICAL PROBLEM SOLVING Part I / Grasp the Situation Step 01 Identi#' the Pro !e" In the first step of the process, you become a,are of a problem that may be large, vague, or complicated. ?ou have some information, but do not have detailed facts. .s-: *hat do I -no,7

Step 21 C!ari#' the Pro !e" The ne@t step in the process is to clarify the problem. To gain a more clear understanding, as-: *hat is actually happening7 *hat should be happening7

Step 31 Brea4 $o5n the Pro !e" .t this point, brea- the problem do,n into smaller, individual elements, if necessary. *hat else do I -no, about the problem7 .re there other sub)problems7

Step 61 Locate the Point o# Cause 7PoC8 <o,, the focus is on locating the actual point of cause of the problem. ?ou need to trac- bac- to see the point of cause first)hand. .s-: *here do I need to go7 *hat do I need to see7 *ho might have information about the problem7

Step %1 Grasp the Tendenc' o# the Pro !e" To grasp the tendency of the problem, as-: *ho7 *hich7 *hen7 Ao, often7 Ao, much7

It is important to as- these questions before as-ing '*hy7+

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Part II1 Cause Investigation Step 91 Identi#' and con#ir" the direct cause o# the a nor"a! occurrence: If the cause is visible, verify it. If the cause is not visible, consider potential causes and chec- the most li-ely causes. !onfirm the direct cause based on fact. .s-: *hy is the problem occurring7 !an I see the direct cause of the problem7 If not, ,hat do I suspect as potential causes7 Ao, can I chec- the most li-ely potential causes7 Ao, can I confirm the direct cause7

Step ;1 ,se %<&h' investigation to ui!d a chain o# cause)e##ect re!ationships that !ead to the root cause: As41 *ill addressing the direct cause prevent recurrence7 If not, can I see the ne@t level of cause7 If not, ,hat do I suspect as the ne@t level of cause7 Ao, can I chec- and confirm the ne@t level of cause7 *ill addressing this level of cause prevent recurrence7 If not, continue as-ing '*hy7+ until you find the root cause. top at the cause that must be addressed to prevent recurrence. .s-: Aave I found the root cause of the problem7 !an I prevent recurrence by addressing this cause7 Is this cause lin-ed to the problem by a chain of cause5effect relationships that are based on fact7 Does the chain pass the 'therefore+ test7 If I as- '*hy7+ again, ,ill I be into another problem7

:e sure you have used ()*hy Investigation to ans,er these questions: *hy did ,e have the problem7 *hy did the problem get to the customer7 *hy did our 'system+ allo, it to occur7

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% &+= CA,SE INVESTIGATION

.bnormal 9ccurrence *hy7 7cause)e##ect re!ationship8

Direct !ause *hy7 7cause)e##ect re!ationship8

!
*hy7

!ause 7cause)e##ect re!ationship8

!
*hy7

!ause 7cause)e##ect re!ationship8

!
*hy7

!ause

8oot !ause

There#ore Test

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5-WHY PROBLEM SOLVING PROCESS

Step >1 Ta4e Speci#ic Action to Address the Pro !e" Bse temporary measures to eliminate the abnormal occurrence until the root cause can be addressed. .s-: Does it contain the problem until a permanent solution can be implemented7

Implement corrective actions to address the root cause to prevent recurrence. .s-: Does it prevent the problem7

=ollo,)up and chec- results. .s-: Is the solution ,or-ing7 Ao, do I -no,7

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5-WHY PROBLEM SOLVING PROCESS

PRACTICAL PROBLEM SOLVING C+EC?LIST To be sure you have follo,ed the problem solving model, use this chec-list as you complete the problem solving process. Grasp the situation DDD "ic-)up the problem. DDD !larify the problem. DDD :rea- do,n the problem. DDD $ocate the "oint of !ause %"o!&. DDD Grasp the tendency of the problem. Cause Investigation DDD Identify5confirm the direct cause. DDD .s- ( *hyEs to identify the root cause. DDD .s- ( *hyEs for '*hy the problem ,as not detected and reached the customer7+ DDD .s- ( *hyEs for '*hy did the system allo, the problem to occur7+ Pro !e" Correction DDD Implement corrective actionF at a minimum, implement temporary measures Prevention DDD #rrorproof the root cause. DDD !apture $essons $earned.

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5-WHY PROBLEM SOLVING PROCESS

ACTIVIT=1 (LE@ IN$,STRIES CASE ST,$= $irections1 Bse the Delphi "roblem olving "rocess to evaluate the =le@ Industries !ase tudy belo, and on the follo,ing pages. 8evie, the ()*hy Investigation results on "age //. Bse the ,or-sheets on "ages /1 and /2 to record your ,or-. Bse only the information provided. Do not try to re)engineer the rivets or solve the technical problems in the case study. The purpose of this activity is to use the "roblem olving model to organize the given data. (LE@ IN$,STRIES CASE ST,$= Bac4ground Ha-e 8yan is the Iuality ;anager at =le@ Industries. =le@ 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. eldom has there been a customer complaint. =le@ has Iuality representatives called !ustomer upport #ngineers %! #Js& at every customer assembly plant. The ! #Js report any problems to Ha-e for investigation and follo,)up. .t G:33 a.m. this morning, Ha-e received a call from Hanet, ! # at the *inding 8iver .ssembly "lant. Hanet informed him that the customer had found five defective stabilizing brac-ets on second shift last night. he chec-ed the remaining inventory and there ,ere no defects in the remaining 16C pieces. The manufacturing stic-er on the bac- of the brac-ets indicated that they ,ere made by the second shift operator. <ormally, the stabilizing brac-et is fastened to the regulator motor ,ith three rivets. The five defective brac-ets had only t,o rivets in them. The lo,er set of rivets on all five brac-ets ,as missing a rivet. This ,as the first time that the problem occurred.

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GOO$

BA$

Ha-e set)up containment procedures at the plant ,arehouse to sort for discrepant materials. .s of this morning, t,o more defective brac-ets had been found in the remaining 63/0 pieces of inventory at =le@. Cause Investigation Ha-e ,ent out to the floor to tal- ,ith the team leader of the t,o rivet lines %#ast and *est& and the area quality assurance auditor. Ae informed am %the team leader& of the quality problem and as-ed him to identify the line ,hich runs the stabilizing brac-et assembly. am directed Ha-e to the #ast line ,hich runs *inding 8iver assembly brac-ets only. .t the #ast $ine, he spo-e ,ith Hudy %the I. .uditor for the area& and as-ed to see the quality log sheets. Ha-e and Hudy revie,ed the <ov. // th log sheet and could not find anything out of the ordinary. Ae as-ed her to set)up in)house containment procedures to sort for any discrepant material in the finished goods area. <e@t, Ha-e tried to locate the second shift operator ,hose cloc- number ,as on the defective parts. ince that operator ,as gone, Ha-e spo-e ,ith the current machine operator %:en&. Ae as-ed :en about any recent difficulties ,ith the rivet machine. :en said that he hadnJt noticed anything out of the ordinary. :en also mentioned, ho,ever, that there had never been any quality bulletins posted in the t,o years that this particular part has been running. Ha-e decided to stay in the area to ,atch the machine run for a ,hile. .fter about /( minutes, he ,atched :en dump rivets into the feeder bo,l to prepare for the ne@t run.

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hortly after restarting rivet operations, :en ,al-ed over to another riveter and came bac- ,ith a steel rod. :en po-ed around the rivet chute and then continued ,or-ing. Ha-e approached :en and as-ed him about the steel rod. :en replied that from time to time the chute gets jammed and he has to clear it out. This happens t,o or three times during a shift. Ae didnJt mention this in his earlier conversation ,ith Ha-e because the problem has e@isted ever since he started ,or-ing ,ith this machine. The previous operator sho,ed him ho, to clear the chute. .ll the rivet machines are li-e this. Ha-e called the ;achine 8epair Department and as-ed that someone loo- at the rivet trac-. . slight gap in the trac- ,as found and removed, and :en continued to ,or-. T,o hours later, Ha-e got a call from :en saying that the trac- ,as still jamming. .s far as Ha-e could see, only rivets ,ere in the bo,l. <e@t, Ha-e loo-ed into the rivet supplier containers. There ,as some foreign material in the blue container, but none in the red container. The label on the blue container sho,ed that it ,as from .ja@ 8ivet, Inc., and the label on the red container indicated that it ,as from =ran-Js =asteners. 9bviously, the foreign material ,as entering the rivet feeder bo,l and jamming the trac-. Ha-e called ;aintenance and requested that the bo,l be cleaned. Ae also added the cleaning operation to the preventive maintenance schedule on the equipment. Ae then called both .ja@ 8ivet, Inc. and =ran-Js =asteners. Ae as-ed about the cleaning procedures on the returnable containers. =ran-Js did a full container purge and clean. .ja@ just re)introduced the containers bac- into their system. *hen Ha-e as-ed ,hy .ja@ did not clean their containers, he ,as told that .ja@ ,as not a,are that such a policy ,as needed. Bpon further investigation, Ha-e learned that =ran-Js =asteners supplies other major automotive companies. ince these companies require that all returnable containers be cleaned, =ran-Js instituted the purge as part of its practice for all customers. .ja@ 8ivet, ho,ever, depends primarily on =le@ as its major customer. <o such policy has ever been required of them. Ha-e called the ;aterial !ontrol Department and requested that a container maintenance policy be drafted ,hich ,ould apply to all their suppliers. Ae also as-ed that a machine modification be developed to sense for the presence of rivets. Aopefully, this ,ould error) roof the process. ?E= PLA=ERS
Ha-e Hanet am Hudy :en Iuality ;anager ! #, *inding 8iver "lant Team $eader, #ast $ine I. .uditor, #ast $ine ;achine 9perator

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5-WHY PROBLEM SOLVING PROCESS %<&h' Cause Investigation

Corrective Actions $ate

8eference <o. DDDDDDDDDDDDDDD % pill, "858K& Date: DDDDDDDDDDDDDDDDDDDD

$e#ine Pro !e"

Missing rivets on rac4ets shipped to custo"er &+=* Auto"ated rivet "achine did not p!ace rivet in position &+=* (eed!ine had o struction

,se this path #or the speci#ic noncon#or"ance eing investigated

Root Causes

,se this path to investigate 5h' the pro !e" 5as not detected
No reCuire"ent on contro! p!an to sa"p!e rac4ets continuous!'D on!' at set<up &+=*

&+=* (oreign "ateria! #ound in dunnage o structing #eed!ine &+=* Supp!ier had no "aintenance progra" #or dunnage &+=*
Not identi#ied on P(MEA as possi !e #ai!ure "ode eEcept at set<up

A < Revise pac4ing speci#ication #or dunnage to re#!ect no #oreign "ateria! reCuire"ent

Supp!ier not a5are o# reCuire"ent a out #oreign "ateria!

B F C < Revise scope o# P(MEA to inc!ude entire process #ro" doc4 to doc4

,se this path to investigate the s'ste"ic root cause

B < ,pdate P(MEA and Contro! P!an to re#!ect continuous sa"p!ing p!an #or rac4ets

Potentia! #ai!ure "ode not identi#ied on P(MEA &+=* (ai!ure "odes associated 5ith inco"ing dunnage not addressed &+=* Scope o# P(MEA !i"ited to "anu#acturing process on!'

B / Modi#' "achine to sense #or presence o# rivets

Lessons Learned1 0: Ma4e supp!ier part o# APAP activities: /0(121312.doc 34563532 2: Ma4e P(MEABs co"prehensive o# entire s'ste" //

5-WHY PROBLEM SOLVING PROCESS

$e!phi %<&h' Te"p!ate to e used #or a!! %<&h' Investigations

%<&h' Ana!'sis
Re#erence No: GGGGGGGGGG 7Spi!!H PR)RI8 $ate1 GGGGGGGGGGGGGGGGGGGG
$e#ine Pro !e"
,se this path #or the speci#ic noncon#or"ance eing investigated
&+=*

Corrective Actions

$ate

Root Causes

&+=*

,se this path to investigate 5h' the pro !e" 5as not detected

&+=*

&+=*

B
&+=* &+=*

A
,se this path to investigate the s'ste"ic root cause
&+=* &+=*

&+=*

&+=*

B
&+=*

&+=*

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5-WHY PROBLEM SOLVING PROCESS

(LE@ IN$,STRIES &OR?S+EET

GRASP T+E SIT,ATION Activit' % tep& Identi#' the pro !e" &hat did the' 4no5* &hat did the' do*

C!ari#' the pro !e"

Brea4 do5n the pro !e"

"89:$#; ID#<TI=I#D %$arge, >ague, !omplicated& "roblem !larified .rea of !ause $ocated "oint of !ause %"o!& *hy7 / !ause *hy7 6 !ause *hy7 1 !ause *hy7 2 !ause *hy7 (

Locate point o# cause 7geographic !ocation8 Grasp tendenc' o# the pro !e" 7&hat Cuestions are 'ou as4ing*8

8oot !ause !orrective .ction $essons $earned

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5-WHY PROBLEM SOLVING PROCESS

CA,SE INVESTIGATION Activit' % tep& Identi#')con#ir" the direct cause As4 % &h'Bs to identi#' the speci#ic root cause associated 5ith the pro !e" As4 % &h'Bs #or 5h' the pro !e" 5as not detected and reached the Custo"er As4 % &h'Bs #or 5h' the -S'ste". a!!o5ed it to happen I"p!e"ent te"porar' "easures to protect the Custo"er I"p!e"ent corrective actions to prevent the pro !e" #ro" recurring (o!!o5<up and chec4 resu!ts
"89:$#; ID#<TI=I#D %$arge, >ague, !omplicated& "roblem !larified .rea of !ause $ocated "oint of !ause %"o!& *hy7 / !ause *hy7 6 !ause *hy7 1 !ause *hy7 2 !ause *hy7 (

&hat did the' 4no5*

&hat did the' do*

8oot !ause !orrective .ction $essons $earned

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