Nightmare scenario: The phone rings and you learn with dread that the problem you thought you had gotten rid of a month ago is\u00a0back and bigger than ever.<\/b> Your stomach sinks and your pulse quickens, as you scramble to find out exactly what is happening. AND you know it is only a matter of time before plant management will be showing up at your door to have a \u201cserious\u201d discussion.<\/p>\n
This happens all too often and takes precious time away from what we get rewarded for \u2013 getting product out the door.\u00a0 Worse, it moves us into what we get penalized for \u2013 fixing, again, <\/em>what we were told was fixed for good.<\/p>\n Before we get to what to do now, let\u2019s take a quick look to see what happened when we thought we got it right and what, in fact, went wrong.<\/p>\n Most day-to-day root cause analyses (RCA) follow one or a combination of the several steps noted below:<\/p>\n So what happens in this process when they don\u2019t get it right?\u00a0 It typically starts with the problem statement.\u00a0 In many cases Operators tend to jump to cause and record the problem in such vague terms that only they know what they mean.\u00a0 When you try to give them some structure, i.e., use the Five Why process, it goes something like this:<\/p>\n Question: \u201cWhy is production on line three slow?\u201d \u2026 Question: \u201cWhy don\u2019t the new tubes fit?\u201d \u2026 Question: \u201cWhy is the hole too small?\u201d \u2026 Question: \u201cWhat happened since yesterday?\u201d \u2026 Typically at this point the operator talks with others around him and with the shift supervisor and they come up with some \u201cfixes\u201d using a verbal fishbone discussion for ideas.\u00a0 Then they make the changes, document what they did \u2013 hopefully \u2013 and move on.<\/p>\n So what went wrong?<\/em>\u00a0 First, five is not a magical number in the Five Why Process. Sometimes it requires additional questions to get to a valid possible cause.\u00a0 Ending up with \u201cI don\u2019t know\u201d does not provide valid data to define a cause. It just indicates that more information is needed. \u00a0It is important when using 5 Whys to isolate and focus on confirming \u2013 not just brainstorming \u2013 answers that come from the previous question.\u00a0 Brainstorming, rather than focused, pinpointed questioning implies all answers are valid, which encourages Operators to apply many \u201cfixes\u201d to address all the answers.\u00a0 This just masks the real root cause and clutters up the data for future analysis should the problem return.<\/p>\n And here\u2019s another thing that can go wrong.\u00a0 It is just as important to not<\/em> define an intermediate cause as the \u201croot\u201d cause without FIRST testing it, based on the facts and data, to determine if it is the true cause. The pitfall of not checking the possible cause against the facts first is that it can cause Operators to drive their troubleshooting effort towards \u201cknown cause\u201d fixes, which in many cases are unrelated to the original problem.<\/p>\n In the end, you can get better results if your Operators drive deeper in their RCA questioning and look for the cause of the cause<\/em> like this:<\/p>\n Question: \u201cWhy is production on line three slow?\u201d \u2026 Question: \u201cWhy don\u2019t the new tubes fit?\u201d \u2026 Question: \u201cWhy is the hole to small?\u201d \u2026 Question: \u201cWhat happened since yesterday?\u201d \u2026 Question: \u201cWhat is specified for the hole?\u201d \u2026 Question: \u201cWhat is specified in the tooling set up?\u201d \u2026 Question:\u00a0 \u201cDid we check what was set up for the tooling?\u201d \u2026 Question: \u201cLet\u2019s check\u201d. \u2026 By asking focused questions to isolate data that is specific to the problem, you CAN reduce your wicked<\/em> problems to a critical few and avoid that nightmare scenario \u2026 \u201cIT\u2019S BACK!\u201d \u2026<\/p>\n","protected":false},"excerpt":{"rendered":" Nightmare scenario: The phone rings and you learn with dread that the problem you thought you had gotten rid of a month ago is\u00a0back and bigger than ever. Your stomach sinks and your pulse quickens, as you scramble to find out exactly what is happening. AND you know it is only a matter of time […]<\/p>\n","protected":false},"author":5,"featured_media":821,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[1],"tags":[],"ppma_author":[112],"class_list":["post-24721","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-other"],"acf":[],"yoast_head":"\n\n
\nAnswer: \u201cThe new tubes don\u2019t fit\u201d<\/p>\n
\nAnswer: \u201cThe hole is too small to allow easy insertion\u201d <\/p>\n
\nAnswer: \u201cI don\u2019t know, it was fine for us yesterday\u201d<\/p>\n
\nAnswer: \u201cI don\u2019t know\u201d<\/p>\nWhen Confirmation Should Replace Brainstorming<\/h2>\n
Keep Going: Find the Cause of the Cause<\/h2>\n
\nAnswer: \u201cThe new tubes don\u2019t fit\u201d<\/p>\n
\nAnswer: \u201cThe hole is too small to allow easy insertion\u201d<\/p>\n
\nAnswer: \u201cI don\u2019t know, it was fine for us yesterday\u201d<\/p>\n
\nAnswer: \u201cI don\u2019t know.\u201d<\/p>\n
\nAnswer: \u201cIt is specified in the tooling setup\u201d<\/p>\n
\nAnswer: \u201cWhatever is in the tooling setup SOP\u201d<\/p>\n
\nAnswer: \u201cNo we assumed it was good to go\u201d<\/p>\n
\nAnswer:\u00a0 \u201cLooks like there is an error in the data entry for set up during programming.\u201d<\/p>\n