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Page 1: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

© 2013 Eaton, All Rights Reserved.

8D Corrective Action & Root Cause Analysis

Page 2: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

© 2012 Eaton Corporation. All rights reserved.

Overview of 8D Definitions Review of 8D steps Review of examples of 5-Why Questions

Agenda

Page 3: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

3© 2013 Eaton, All Rights Reserved.

Training Ground Rules

Please interrupt and ask questions at any time

Please turn off your cell phones

DO NOT place your phone on hold at any time

Please mute your phone if possible to minimize noise

Let us know if you lose the webinar screen during the presentation

Please share personal experiences and questions throughout the training

You will get a copy of this training for reference

Page 4: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

4© 2013 Eaton, All Rights Reserved.

What is 8D

8D is a structured corrective action process; 8D stands for the Eight

Disciplines of Problem Solving

Root Cause Analysis(RCA) is an integral part of the 8D process

This session will:

Define 8D

Demonstrate 8D process

Train in Root Cause Analysis (5 Why’s)

Objectives of this training:

You will become familiar with the 8D steps

You will become more proficient at Root Cause Analysis using 5 Why’s

Page 5: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

5© 2013 Eaton, All Rights Reserved.

Vocabulary

Containment – Actions taken to isolate the problem from any internal/external customer. Usually expected to be completed within a 24hr – 48 hour period.

Corrective Action – The action taken to eliminate the cause of the nonconformity.

Error proofing – When a process is designed to prevent an error from occurring.

Preventive Action – The action that is taken to eliminate conditions that could produce a nonconformity.

Root Cause – At its simplest form, you can turn off and on the problem in a controlled environment. The root cause should explain 100% of the unwanted problem/defect and that there are no additional reasons that the problem exists.

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6© 2013 Eaton, All Rights Reserved.

Definition – Preventive Action

Preventive Action is the action taken to eliminate the conditions that could produce a nonconformity.

Kaizen events, FMEA’s, 6S events and similar activities

are types of preventive actions.

This training session will not cover Preventive actions as defined above, but the concept of Preventing recurrence is a key part of the Corrective Action process.

In Corrective Action, the money is already gone, Preventive Action gives you the opportunity to salvage some of it.

In Corrective Action, the money is already gone, Preventive Action gives you the opportunity to salvage some of it.

Page 7: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

7© 2013 Eaton, All Rights Reserved.

8D – Eight Disciplines to Problem Solving

8D, which was initiated in the automotive industry, is a structured problem solving method for product and process improvement.

8D is short for “8 Disciplines”

The steps do not all start with “D”

8D is structured in 8 steps and emphasizes

Team problem solving

Ford’s Team Oriented Problem Solving (TOPS) systems was the precursor to 8D

Team work and not skipping steps is critical!!!Team work and not skipping steps is critical!!!

Page 8: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

8© 2013 Eaton, All Rights Reserved.

Steps in an 8D

The steps in 8D:• D#1 Establish the team

• D#2 Define the problem

• D#3 Take Short Term Action (Containment)

• D#4 Determine Root Cause

• D#5 Develop/Verify Corrective Action

• D#6 Implement/Validate Corrective Action

• D#7 Prevent Recurrence/Share the Solution

• D#8 Recognize the Team

Day 1Day 1

24 – 48hrs24 – 48hrs

2 weeks2 weeks

30 days30 days

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9© 2013 Eaton, All Rights Reserved.

Public Location of Form

Supplier Information (8D)

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10© 2013 Eaton, All Rights Reserved.

Example of 8D Form

The form steps you through the 8D processThe form steps you through the 8D process

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11© 2013 Eaton, All Rights Reserved.

Check your knowledge

What does the “D” in 8d stand for?A. Degree

B. Discipline

C. Decidedly Bad

The correct answer is B – Disciplines. 8D stands for the Eight Disciplines of Problem Solving

Page 12: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

12© 2013 Eaton, All Rights Reserved.

Check your knowledge

Typically how long is the containment phase of an 8D?

A. 24 – 48 hours

B. 2 weeks

C. 30 days

D. As long as it takes

The correct answer is A – Containment is typically expected to be completed within the first 24 – 48 hours after you have

received notification that a defect has been produced.

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13© 2013 Eaton, All Rights Reserved.

Check your knowledge

Typically what is the expected time to complete and close the 8-D?

A. 24 – 48 hours

B. 2 weeks

C. 30 days

D. As long as it takes

The correct answer is c – Closure is typically required within 30 days of the initial notification. This means that a root cause has

been selected and the problem was able to be turned on and off. Final verification may go on past 30 days depending on the

situation.

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14© 2013 Eaton, All Rights Reserved.

D1 Establish The Team

CHAMPION

Location Name Team leader

Part Number SCA#Description Issue Date

Email Phone RMA#Cell Cell NCR#Buyer Email STATUS DATA

Team Members :

CPS Supplier

Contact

Supplier Corrective Action

1.0 Team Contact/General Information: (If information is not applicable, please indicate by writing N/A or crossing out.)

Phone

Additional tabs are available in the form for referenceAdditional tabs are available in the form for reference

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15© 2013 Eaton, All Rights Reserved.

8D – Establish Team (D#1) Typically the Quality Manager will assign the person

responsible to lead the corrective action. That Team Leader will then select the team members.

The Team should include all functions with knowledge of the problem (including “process owner”).

Team Leader or Quality Manager should train team members as needed, but leading the team through the process is the best form of training.

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16© 2013 Eaton, All Rights Reserved.

D1 Checklist

D1: Establish the Team Checklist : Are the people affected by the problem represented? Does each individual have a reason for being on the team? Is the team large enough to include all necessary input, but

small enough to act effectively? Who is designated Champion? Who is team leader? Are all team members responsibility’s clear?

Page 17: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

17© 2013 Eaton, All Rights Reserved.

Check your knowledge

What functions are typically on the 8D team?A. Quality

B. Engineering

C. Manufacturing

D. Process Owner

E. All of the above

The correct answer is E – For best results 8D teams are cross-functional in nature, not every team will need every function, but the objective is not to make it a one man or one function

event.

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18© 2013 Eaton, All Rights Reserved.

Steps in an 8D

The steps in 8D:• D#1 Establish the team

• D#2 Define the problem

• D#3 Take Short Term Action (Containment)

• D#4 Determine Root Cause

• D#5 Develop/Verify Corrective Action

• D#6 Implement/Validate Corrective Action

• D#7 Prevent Recurrence/Share the Solution

• D#8 Recognize the Team

Day 1Day 1

24 – 48hrs24 – 48hrs

2 weeks2 weeks

30 days30 days

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19© 2013 Eaton, All Rights Reserved.

D2 Define the Problem

Use pictures when they are availableUse pictures when they are available

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20© 2013 Eaton, All Rights Reserved.

8D – Define Problem (D#2)

Problem Definition is a positive statement that describes the “pain”

Good Definition is critical to determining Root Cause

Answers 4W2H – Who, What, When, Where, How, How Many

“Why” is not part of Problem Definition (this is answered in Root Cause Analysis - RCA)

Good Definition does not place blame

Avoids suggesting solutions (“Problem happened due to…”, or “Lack of adhesive resulted in…”)

Define what is or what is notDefine what is or what is not

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21© 2013 Eaton, All Rights Reserved.

8D – Problem Definition (D#2)

Take the time to clearly define the problem, with facts.

Good Problem Definition is the springboard to asking the right questions on RCA (Why, Why, Why,…)

Poor Problem Definition leads to symptom resolution rather than Root Cause Solution

“Is/Is Not” is a good method for Clear and Concise Problem Definitions.

If “lack of”, “insufficient”, “due to”… are in your Problem Definition…your team is in trouble!

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22© 2013 Eaton, All Rights Reserved.

8D – Problem Definitions: Good or Bad? “Lack of parts caused 10% miss in sales for May.”

Bad – Assumes cause of problem

“Marketing delays caused projects to be 2 months overdue on average.” Bad – Places blame and assumes cause

“Impulse test coil failures for all 3 phase transformers at Badger Dr increased from 10,000 ppm in Q1 to 15,000 ppm in Q2.” Good – Answers 4W2H

Research it first, only record the facts!Research it first, only record the facts!

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23© 2013 Eaton, All Rights Reserved.

D2 Checklist

D2: Describe the problem

Checklist:What type of problem is it?Can we list any resources and documents which might better quantify

this problem? Is there any evidence this problem has surfaced before?What is the extent of the problemHas the problem been increasing, decreasing or remaining constant?Do we have physical evidence of the problem in hand?Have failed parts been analyzed in detail? Is there an action plan to collect additional data if needed?Do we have the right team members to proceed to the next step?

Page 24: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

24© 2013 Eaton, All Rights Reserved.

Check your knowledge

What does 4W2H stand for?A. 4 Ways to handle

B. Why, What, When, Who, How, How Many

C. Who, What, When, Where, How, How Many

D. For workers to help

The correct answer is C – Who found the defect, What was the defect, When was the defect detected, Where was the defect found/located, How was the defect found, and How Many units

were defective? Why is not part of the equation in Step 1: Defining the problem. Why comes in during the root cause

analysis stage.

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25© 2013 Eaton, All Rights Reserved.

Check your knowledge

A good problem description? (select all that apply)

A. Assigns blame

B. Is based on facts

C. Suggests solutions

D. Positively describes the “pain”

The correct answer is B and D – Problem descriptions detail the issue in a positive, fact-based way, without assigning blame or

suggesting solutions.

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26© 2013 Eaton, All Rights Reserved.

Steps in an 8D

The steps in 8D:• D#1 Establish the team

• D#2 Define the problem

• D#3 Take Short Term Action (Containment)

• D#4 Determine Root Cause

• D#5 Develop/Verify Corrective Action

• D#6 Implement/Validate Corrective Action

• D#7 Prevent Recurrence/Share the Solution

• D#8 Recognize the Team

Day 1Day 1

24 – 48hrs24 – 48hrs

2 weeks2 weeks

30 days30 days

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27© 2013 Eaton, All Rights Reserved.

D3 Take Short Term Action

Did you get all of them – Include parts at Sup-Suppliers?Did you get all of them – Include parts at Sup-Suppliers?

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28© 2013 Eaton, All Rights Reserved.

8D – Contain Problem (D#3)

Containing the problem and Protecting the Customer must occur immediately. 24hrs is the industry norm for containment actions to take place. Max of 48.

Determine the scope (time period, material lot numbers, parts affected, etc)

Production and/or Shipping Hold to be implemented

8D system is used to report/track Holds and Containments

“Iron Wall” is a form of Containment (Prevent problems from shipping to Customers)

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29© 2013 Eaton, All Rights Reserved.

Definition - Containment

Containment is the systematic search and quarantine of suspected nonconforming product throughout the supply/delivery chain. (Warehouse, in process shelves, supplier stock, …) Make sure you get it all.

In our Containment step we also include a process to determine if it’s necessary to notify customers in the form of a recall, advisory or other

communication.

Did you get all of them?Did you get all of them?

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30© 2013 Eaton, All Rights Reserved.

Definition - Containment

Containment is more than just getting all the current product contained.

This step also includes what used to be called “Short Term Corrective Action”.

This could be sorting, layered inspection or rework. Make sure that implementation of the containment

action will not create other problems? i.e., part shortages or unchecked rework.

It also has to last until the permanent Corrective Action is in place.

What can you do until the Permanent Corrective Action is in place?What can you do until the Permanent Corrective Action is in place?

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31© 2013 Eaton, All Rights Reserved.

D3 ChecklistD3: Contain the Problem

Checklist: What containment actions have been identified? (For Parts in stock, Parts In

transit, Parts at the supplier location, Parts in process at the operators work station, Parts at the Customer location)

Have all quantities been accounted for and quarantined until disposition can be made? (BE CAREFUL that they do not end up back in stock)

Have we ensured that implementation of the containment action will not create other problems? i.e. part shortages, unchecked rework.

Will interim actions last long enough until the Corrective Actions are in place?

Are responsibilities for containment actions clear? When will the containment actions be complete? Have the containment actions been documented? Do we have the right team members to proceed to the next step?

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32© 2013 Eaton, All Rights Reserved.

24 - 48 Hours to Contain the Problem

Containment is required with in 24 - 48 hrs. Once the Supplier Corrective Action (SCA) is entered into our database (Q-

PULSE) you will get notification and reminders via e-mail.

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33© 2013 Eaton, All Rights Reserved.

Check your knowledge

What does containment mean? A. A systematic search and quarantine of suspected

nonconforming product throughout the supply/delivery chain.

B. Stopping the defect from being produced

C. Purging the defect from the warehouse

D. Recalling all potentially defective items

The best answer is A – Containment is a systematic search and quarantine of suspected nonconforming product throughout the

supply/delivery chain.

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34© 2013 Eaton, All Rights Reserved.

Check your knowledge

How long does containment need to be in place?

A. 24 – 48 hours

B. indefinitely

C. Until corrective action is implemented

D. 90 days

The correct answer is C – Containment starts within 24 – 48 hours of problem notification, but remains in effect until a

permanent corrective action is implemented, ensuring the true root causes of the defect has been corrected.

Page 35: © 2013 Eaton, All Rights Reserved.. © 2012 Eaton Corporation. All rights reserved

35© 2013 Eaton, All Rights Reserved.

Steps in an 8D

The steps in 8D:• D#1 Establish the team

• D#2 Define the problem

• D#3 Take Short Term Action (Containment)

• D#4 Determine Root Cause

• D#5 Develop/Verify Corrective Action

• D#6 Implement/Validate Corrective Action

• D#7 Prevent Recurrence/Share the Solution

• D#8 Recognize the Team

Day 1Day 1

24 – 48hrs24 – 48hrs

2 weeks2 weeks

30 days30 days

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36© 2013 Eaton, All Rights Reserved.

Ask: How did the problem occur?

Why? ….

Why? ….

Why? ….

Why? ….

Why = the true root cause (typically)

Detection and Occurrence

Ask: How was it missed?

Why? ….

Why? ….

Why? ….

Why? ….

Why = what controls need to be in place to prevent another escape

When identifying root cause the team should focus on why the issue occurred first, and then secondly on how the defect was missed. Therefore you do your 5 Why analysis on both pieces of the failure mode.

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37© 2013 Eaton, All Rights Reserved.

D4 Determine/Verify the Root Cause

Work through the problem, use your team and don’t skip steps!Work through the problem, use your team and don’t skip steps!

SCA Template

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38© 2013 Eaton, All Rights Reserved.

8D – Root Cause Analysis (RCA)

The CPSD SCA form includes a 5Why analysis

template as well as “Brainstorming” and “Cause/Effect” diagrams.

Other techniques (Process Map, DOE, Anova, Pareto, etc.) are also tools to aid in RCA.

The CPSD 8D process includes SCA for: Occurrence (Why did the problem occur?) Detection (Why did the problem escape detection?)

Acronyms:

CPSD – Cooper Power Systems Division SCA – Supplier Corrective Action

DOE – Design of Experiments ANOVA – Analysis of Variance

RCA – Root Cause Analysis

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39© 2013 Eaton, All Rights Reserved.

8D – Root Cause Analysis (D#4)

There are many techniques to determine Root

Cause Asking Why? 5 times is the simplest and most

powerful RCA technique. This is a simple process that is frequently done

poorly. The first Why starts directly from the Problem

Definition: “Why did the problem occur as

stated?” Each Why follows directly from the previous

response.

Keep asking! Don’t skip questions, 5 Is typical.Keep asking! Don’t skip questions, 5 Is typical.

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40© 2013 Eaton, All Rights Reserved.

8D – Root Cause Analysis (D#4)

RCA is the Heart and Soul of the Corrective Action process

There may be multiple contributing causes but there is only one

True Root Cause

Actions should be taken to address the contributing causes if appropriate…

But; The Root Cause must be eliminated or…

the problem will return!

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41© 2013 Eaton, All Rights Reserved.

Definition – Root Cause (RC)

The Root Cause is the most basic reason for a problem or defect. If this cause is eliminated, the problem would not occur.

If the cause of a problem is “operator error”, that’s not the real Root Cause. The Root Cause is more likely that the process is not “Error Proofed”.

Corrective Actions must address the Root Cause if the problem is to be eliminated.

You will know it is the Root Cause if you can turn the problem off and onYou will know it is the Root Cause if you can turn the problem off and on

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42© 2013 Eaton, All Rights Reserved.

Root Cause

Immediate causes are NOT root causes. Typical immediate causes you may see on Corrective Action reports are: Operator Error Failure to Follow Procedures/work instructions Inspection not recorded by the operator Gage Not turned in for calibration Operator not trained Inadvertent omission

These are NOT root causes, they may be a contributing cause but not the true root cause!

These are NOT root causes, they may be a contributing cause but not the true root cause!

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43© 2013 Eaton, All Rights Reserved.

Root Cause

Root causes are weaknesses (ineffective processes or controls) in the system that cause or allow (fail to prevent) errors and nonconformance's.

Effective corrective action will PREVENT recurrence or REDUCE THE FREQUENCY of occurrence.

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44© 2013 Eaton, All Rights Reserved.

Root CauseCorrective Action that addresses only the

immediate cause will NOT prevent recurrence.Example:

Nonconformance: Functional gage past due for calibration.

Immediate cause: Quality Assurance did not calibrate the gage before the due date.

Corrective Action: Calibrate the functional gage (fixes the immediate problem only)

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45© 2013 Eaton, All Rights Reserved.

Check your knowledge

What are the two areas of the Problem that the team wants to focus on during RCA?

A. Detection and Occurrence

B. Severity and Occurrence

C. Detection and Severity

The correct answer is a – Detection and Occurrence. Why did the issue occur and why was it not detected.

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46© 2013 Eaton, All Rights Reserved.

Check your knowledge

All of the following are examples of immediate root causes except?

A. Operator Error

B. Failure to Follow Work Instructions

C. Use of expired material

D. Gage missing calibration sticker

The correct answer is C – Use of expired material may be an actual root cause or the final why of the 5Whys assessment.

The other items are symptoms of a systemic issue.

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47© 2013 Eaton, All Rights Reserved.

5 Why Review

5 Why

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48© 2013 Eaton, All Rights Reserved.

5 Why’s

If you continue to ask Why? you will discover the systemic problem, rather than being satisfied with fixing a symptom. Symptoms that come from contributing causes

Review 5 Why example

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49© 2013 Eaton, All Rights Reserved.

The stone on the Jefferson Memorial was crumbling

Why #1: Why was it crumbling?Frequent washings were weakening the stone.

Why #2: Why was it washed so often?

Why #3: Why are there so many bird droppings?

Why #4: Why were there so many spiders?

Why #5: So why were there so many midges?

To remove the bird droppings.

Birds were eating the abundant spiders there.

Solution: Delay turning on the spot lights until one hour after sunset, by which time midge population is down 90%. By doing

this, the food chain is broken and less frequent washings are required.

Spiders were attracted to all the midges.

Every evening at dusk, midges emerge in a mating frenzy. At this same time, Park Services turns on its spotlights, which attracted all of the midges.

The 5 Whys

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50© 2013 Eaton, All Rights Reserved.

Back to the calibration example using the

5 Why5 WHYS? Analysis

5 Whys? Analysis consists of team members identifying a possible root cause by asking “Why?” until the root cause is uncovered. It may take more or less than five Whys? To get to the Root Cause: Five is typical in most cases.

Let’s consider the gage calibration nonconformance illustrated on the CA and Root Cause tab:

Nonconformance: Functional gage past due for calibration

Why? Gage Tech did not calibrate the gage before the due date.

Why? Gage didn’t show up on the gage recall list

Why? Calibration interval was not entered on the gage master record

Why? a.) Gage Tech didn’t know the interval when the gage was entered in the master list

b.) Gage Tech didn’t follow up to enter the interval later.

Why? GageTrak does not force entry of the interval when entering gages in the master list

Now that a possible Root Cause has been identified, generate a solution, implement it and check for proof that it’s effective.

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5 Why Summary

What if the team does not identify the Root Cause?

Possibly the problem was not defined well.

Possibly working on symptoms instead of the real problem (problem definition!)

Possibly some of the “facts” are not true – confirm with data.

Possibly the team doesn’t include the right people to fully understand the problem.

Possibly skipped a step or two, missing critical information – better to take “baby steps”.

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52© 2013 Eaton, All Rights Reserved.

How to get to the 5 Why if your not sure you have only one

Gather your team, identify the possible causes, select Top 3Gather your team, identify the possible causes, select Top 3

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53© 2013 Eaton, All Rights Reserved.

Now break out the 5 Why

Use one 5 Why worksheet for each of the top 3

suspect causes

Use one 5 Why worksheet for each of the top 3

suspect causes

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54© 2013 Eaton, All Rights Reserved.

5 Why ReviewEach response needs to be confirmed with data:

Run experiments to confirm that the team’s response to each “why” is accurate.

Don’t allow a dominant team member to state a “fact” without confirming it.

Read the “why responses” from the bottom to the top of the problem statement linking them with “therefore”.

All responses should link logically backwards with the word “therefore”.

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55© 2013 Eaton, All Rights Reserved.

D4 Checklist

D4- Define/Verify Root CauseChecklist:

• What sources/methods have been used to determine root cause?• Are all the potential caused listed in case at a future date you

need to refer back to them. • Can the root cause explain all we know about the problem

description?• Can the root cause be turned off and on?• Do we have the right team members to proceed to the next step?

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56© 2013 Eaton, All Rights Reserved.

Check your knowledge

What are some reasons we might not be able to identify root cause? (Check all that apply)

A. “Facts” are not true or unconfirmed

B. Problem statement not well defined

C. Working on symptoms only

D. All of the above

The correct answer is D – All of the above. The problem description needs to be accurately defined or the team can go down the wrong path. One dominant team member may state

authoritatively “facts” that remain unconfirmed, leading the team to work on symptoms such as operator error or training,

rather than getting to the systemic issue in play.

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57© 2013 Eaton, All Rights Reserved.

Check your knowledge

How to you know when you have reached true root cause? (Check all that apply)

A. Operator at fault has been named

B. Problem can be turned on and off

C. The selected cause explains all we know about the issue

D. The issue cannot be recreated

The correct answer is B and C – Root cause is looking for the reason the event occurs, and when found you should be able to turn the problem on and off , thus explaining all we know about

the issue.

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58© 2013 Eaton, All Rights Reserved.

Call for Backup

If you need help, please ask. We are here to help!

We can assist in: Facilitation Training Review

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59© 2013 Eaton, All Rights Reserved.

North American SQE Contact Information

Patti MorrisSupplier Quality Manager CPSD

Charlette Mueller

Transformers and PDD SQE

Eugenia Raigoza

QRO and PDD SQE

Dave Chovan

Electrical and EAS SQE

Tom CaravellaSwitchgear and

PRD SQE

Desk: 262-524-4369

Desk: 262-524-4421

Desk: 414-570-4757Desk: 414-768-8242Desk: 011-52-442-211-3411

Contact your Business Unit-Division Supplier Quality Engineer with questions!

Contact your Business Unit-Division Supplier Quality Engineer with questions!

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60© 2013 Eaton, All Rights Reserved.

Steps in an 8D

The steps in 8D:• D#1 Establish the team

• D#2 Define the problem

• D#3 Take Short Term Action (Containment)

• D#4 Determine Root Cause

• D#5 Develop/Verify Corrective Action

• D#6 Implement/Validate Corrective Action

• D#7 Prevent Recurrence/Share the Solution

• D#8 Recognize the Team

Day 1Day 1

24 – 48hrs24 – 48hrs

2 weeks2 weeks

30 days30 days

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D5 Develop /Verify the Corrective Action

List specific action with specific owners and specific dates!List specific action with specific owners and specific dates!

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8D – Corrective Action (D#5)

Once the Root Cause is found it’s usually clear what the Corrective Action needs to be.

The Corrective Action must address the Root Cause!!!

There may be multiple Corrective Actions and some actions may address Contributing Causes – this will make your solution more robust in case other factors change in the future.

Corrective Action for the problem itself (Occurrence) plus the “Detection” issues need to be implemented to address the full dimension of the issue.

Closing contributing actions is a good thing!Closing contributing actions is a good thing!

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Error Proofing

Error Proofing comes from a Japanese term “Poka Yoke”.

True Corrective Actions result in “Error Proofing ” in the Process or Design to prevent similar problems.

Successive layer Detection (Inspection) is a form of error proofing.

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8D – Corrective Action (D#5)

“Error Proofing” the process will accomplish both Corrective Action for the problem “Occurrence” and Corrective Action for “Detection”.

Error Proofing is an important tool that justifies a separate training session.

If “Retrained the Operators” is the Corrective Action, the team hasn’t really found the Root Cause and hasn’t implemented a Corrective Action that will prevent recurrence.

Operator Error is not a true root cause!Operator Error is not a true root cause!

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D5 Checklist

D5 Select and Verify the Corrective ActionChecklist:

Can the action be implemented? What risks are associated with this choice and how

should they be managed? Will this create other problems? What methods will be used to verify the effectiveness in

the short and long term? Have dates been set to verify the effectiveness? Has responsibility been assigned to verify the short and

long term effectiveness? What do you plan to do if this action does not

satisfactorily solve this problem? Do we have the right team members to proceed to the

next step?

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Check your knowledge

When selecting a corrective action what must it do?

A. Be implemented within 24 hours

B. Address the root cause

C. Be economical

D. Be simple

The correct answer is B – The corrective action must address the root cause.

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Check your knowledge

What does the term Poke-Yoke mean? A. Perfect

B. A soft boiled egg

C. Error-proof

D. Defect free

The correct answer is C – Error- proof, is the English translation of the Japanese term Poke-Yoke. It means the part/process has been designed to prevent defects from being produced and/or

escaping the production cell.

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Steps in an 8D

The steps in 8D:• D#1 Establish the team

• D#2 Define the problem

• D#3 Take Short Term Action (Containment)

• D#4 Determine Root Cause

• D#5 Develop/Verify Corrective Action

• D#6 Implement/Validate Corrective Action

• D#7 Prevent Recurrence/Share the Solution

• D#8 Recognize the Team

Day 1Day 1

24 – 48hrs24 – 48hrs

2 weeks2 weeks

30 days30 days

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D6 Implement /Validate the Corrective Action

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8D – Corrective Action Verification

It’s necessary that we “maintain the gain”

The Corrective Action has to address the Root Cause, so it’s important that a follow up audit verifies that the Root Cause was eliminated!

Someone with a vested interest who was not part of the Corrective Action team is chosen by the Quality Manager to follow up.

In some cases verification should be done soon after implementation and again after several weeks to verify that the change really is permanent.

Make sure it’s working long term, not just once!Make sure it’s working long term, not just once!

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D6 Checklist

D6 Implement/Validate the Corrective Action

Checklist:• Has an action plan been defined?• Have responsibilities been assigned to implement the

Corrective Action• Has timing been established?• Has required support been identified?• What indicators will be used to verify the outcome?• What controls are in place to assure the fix is as intended?• Do we have the right team members to proceed to the next

step?

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Check your knowledge

Why is it important to Verify the Corrective Action? (Select all that apply)

A. It isn’t

B. To make sure the root cause was addressed

C. To ensure no other issues were caused by the corrective action

D. To close the form

The correct answer is B and C – The verification step allows the team to review the implemented corrective action plan for

effectiveness in eliminating the issue and/or preventing it from escaping to the customer. It also lets the team decide if any

new issues were generated by the selected action plan.

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Check your knowledge

Who should complete the verification step? A. Independent but vested participant

B. Process Owner

C. Quality Manager

D. Company President

The correct answer is A – the verification process is completed by an independent but vested participant, not normally part of

the original corrective action team. Fresh Eyes are best.

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Check your knowledge

When is verification completed? A. Immediately after fix is implemented

B. Within 30 days of implementation

C. After 2000 pieces are produced

D. As determined by the team based on volume and criticality of defect

The correct answer is D – verification timing flexes depending on the criticality of the defect and the time it takes to

determine based on product volume if the root cause was eliminated. Normally a qauntity of pieces must be produced,

and depending on how often the part is ordered this may take a couple of shifts or a couple of months.

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Steps in an 8D

The steps in 8D:• D#1 Establish the team

• D#2 Define the problem

• D#3 Take Short Term Action (Containment)

• D#4 Determine Root Cause

• D#5 Develop/Verify Corrective Action

• D#6 Implement/Validate Corrective Action

• D#7 Prevent Recurrence/Share the Solution

• D#8 Recognize the Team

Day 1Day 1

24 – 48hrs24 – 48hrs

2 weeks2 weeks

30 days30 days

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D7 Prevent recurrence/Share the Solution

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8D – Prevent Recurrence & Share the Solution (D#7)

Addressing the Systemic issues is key to Preventing Recurrence (usually the 5th Why reveals the systemic problem) Follow up. i.e. did the implementation of the corrective action require any changes to other documents such as work instructions or control plans? Is the corrective action sustaining?

We need to share these best practice solutions, so others can learn from our work.

Our 8D includes a “systemic action” section as part of the CA close out process – this is a part of the “Solution Sharing” and “Prevention” process.

We need to continue developing means to share best practices

Others can learn from our work, share the information!Others can learn from our work, share the information!

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D7 Checklist

D7 Prevent reoccurrence/Share the solution

Checklist:

• Has the practice been standardized? • Have all appropriate personnel been notified of the changes?• Have all changes been integrated to our existing system (work

instructions, procedures, FMEA, Control Plans etc.)?• How will the practices be shared?

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Check your knowledge

Which of the following items may require updates to prevent future occurrences?

A. Employee Roster

B. Control Documentation (Control plans, pFMEA, Flow charts, Work instructions)

C. Quality Manager

D. Vendor Master

The correct answer is B – essentially all documentation that controls the production process needs to be reviewed for updates to incorporate any actions that resulted from the corrective action plan, to allow the fix to be sustainable.

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Check your knowledge

During the prevent recurrence step which of the following items are completed?

A. Containment

B. Root Cause Identification

C. Sharing Lessons Learned

D. Problem Definition

The correct answer is C – During the prevent recurrence step the team takes the opportunity to complete a left-to-right look

across the portfolio and share lessons learned with the organization, recording best practices.

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Steps in an 8D

The steps in 8D:• D#1 Establish the team

• D#2 Define the problem

• D#3 Take Short Term Action (Containment)

• D#4 Determine Root Cause

• D#5 Develop/Verify Corrective Action

• D#6 Implement/Validate Corrective Action

• D#7 Prevent Recurrence/Share the Solution

• D#8 Recognize the Team

Day 1Day 1

24 – 48hrs24 – 48hrs

2 weeks2 weeks

30 days30 days

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8D Recognize the Team

Remember to close out the paperwork!Remember to close out the paperwork!

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8D – Recognize the Team (D#8) Permanently eliminating problems is extremely satisfying in

itself

CA Team members are providing a very important service to us all, so everyone should recognize the efforts of the people participating in Corrective Actions

The Person Responsible for Closure Approval thanks and congratulates the members of the Team

Your team has done a lot of hard work, recognize this! E-Star!

Your team has done a lot of hard work, recognize this! E-Star!

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Summary of 8D

8D in the automotive industry has been very effective in driving improvements

Our 8D format must be utilized for all Corrective Actions Submitted to Cooper Power Systems: Quick Containment – Within 48 hours! True Root Cause determination

Use Effective Tools Utilized the 5 Why Address both Detection and Occurrence

Implement Systemic Corrective Actions to drive improvements!

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8D Checklist

D8 Recognize the Team

Checklist:

• Have we recorded the teams work appropriately so that others facing similar problems in the future may refer to them?

• What unfinished Business remains?

• Have individual team members been informed that it is now complete?

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Check your knowledge

Who holds the primary responsibility to complete the Recognize the Team Stage?

A. Quality Manager

B. OPEX VP

C. Person responsible for closure approval

D. Value Stream Manager

The correct answer is C – the person responsible for closure approval is the primary cheerleader for the team and expected

to acknowledge the efforts of all involved. In Eaton, a good method for team recognition is the E-Star program.

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Check your knowledge

During the Recognize the Team step which of the following items are completed?

A. All paperwork is completed

B. Root Cause Identification

C. Sharing Lessons Learned

D. Problem Definition

The correct answer is A – In addition to recognizing the team and their efforts it is vital that all associated documentation is

captured and stored for future reference during this step.

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Summary

We’ve covered: All steps of 8D Detailed discussion of RCA Training in 5 Why Analysis

The 8D Corrective Action process is necessary for continual improvement – immediate need is to drive reduction in Customer Complaints!

Everyone needs to use these tools – 8D needs to become part of our culture.

8D needs to become part of our culture, ingrained into our DNA!8D needs to become part of our culture, ingrained into our DNA!

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Review

Down load the form from the link

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Q-Pulse will send an automatic email notifying you an 8D is required.

Review

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Q-Pulse will send you reminders every other day until you summit your Corrective Action to your SQE and your SQE closes out the Corrective Action in the Q-Pulse system

Review

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System Maintenance

Make sure we have the right contact's in our system

The Quality Contact is the person who will be getting the email notification.

If you need to change a contact information you will need to GO to the same Cooper Supplier web site and open a “Change of Contact” information form

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Questions

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Acronyms

4W2H – Who, When, Where, What, How, How Many

ANOVA – Analysis of Variation

CPSD – Copper Power System Division

DOE – Design of Experiments

FMEA – Failure Mode and Effects Analysis

RCA – Root Cause Analysis

SCA – Supplier Corrective Action

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