Download - 5 Why Training
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November 6, 2001PRR Training
Step 1Step 1- Problem Identification – Give a detailed description of the problem and its impact
Step 2Step 2- Supplier’s Initial Response & Containment– Actions required to ensure that the customer is protected from receiving
further nonconformances
– Response required within 11 Business DayBusiness Day
Step 3Step 3- Delphi Accepts or Rejects Initial Response– Reply required within 11 Business DayBusiness Day
Step 4-Step 4- Supplier Determines the Root Cause– Detailed investigation of what caused the problem. Delphi prescribes 5 why as
the tool to determine root cause
Step 5Step 5- Supplier Develops Corrective Action/Solution– Actions taken to eliminate the root cause
What are the Key Steps of the Problem What are the Key Steps of the Problem Reporting &Resolution Process?Reporting &Resolution Process?
Problem Reporting & ResolutionProblem Reporting & Resolution
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November 6, 2001PRR Training
What are the Key Steps of the What are the Key Steps of the Problem Resolution Process?Problem Resolution Process?
Step 6 Step 6 - Supplier Implements and Verifies the Corrective Action– Detail of dates and plans for implementation and verification that the corrective action is effective
– Supplier Final Response required within 1515 calendar days– Supplier may submit an ExtensionExtension request
Step 7 - Delphi Accepts or Rejects Final Response– Reply required, including Extension request, within 2 business days
Step 8 Step 8 - Supplier Provides Verification Evidence– Data, gate charts, pareto charts, or others as requested
Step 9 Step 9 - Delphi Evaluates Verification Evidence– Accepts or rejects response based on the verification evidence
Step 10Step 10- Delphi Closes the PRR
Full PRR cycle within 30 calendar days!!!Full PRR cycle within 30 calendar days!!!
NewNew
Problem Reporting & ResolutionProblem Reporting & Resolution
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November 6, 2001PRR Training
Owner(Delphi) Issues PR/R
yes
no
Supplier Initiates Containment & Provide details
Owner Reviews Supplier’s Response
reject
accept
Owner Provides feedback to Supplier
Supplier’s Final Answer including 5 Why
Owner (with SQ for MD, Repeats, CI) reviews RC, CA, and Implementation
Plan
All accepted
Owner or SQ Provides feedback to Supplier
After Implementation, Supplier will provide at Delphi’s request 15 days of
Verification evidence
Owner reviews Data
accept
reject
Owner closes PRR
Start
1 business day
1 business days
15 calendar days
30 calendar days
Any item rejected
PRR Response FlowchartPRR Response FlowchartSupplier Problem Identified
Involve SQ, PC&L, Other Stakeholders as appropriate
Major Disruption, Repeats, Customer Impacted
Extension Request
Timing based on agreed upon Implementation Date
2 business days
SQ involvement also based upon plant requests
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November 6, 2001PRR Training
PRR Responsiveness
The new PRR process was designed to reduce the cycle time from PRR issuanceissuance to closureclosure
The new PRR system (Covisint Problem Solver) will monitor PRR responsiveness of the Supplier and Delphi
Supplier response requirements:
– Initial Response - 1 Business Day1 Business Day– Final Response - 15 Calendar Days15 Calendar Days– Extended Request - As approved by Delphi
Delphi response requirements:
– Supplier’s initial response reply- 1 Business Day1 Business Day– Supplier’s final response reply - 2 Business Days2 Business Days– Final Closure - 30 Calendar days if no extension30 Calendar days if no extension
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November 6, 2001PRR Training
Guidelines for Effective Problem Solving Guidelines for Effective Problem Solving
Become familiar with the situation and the related systems
Provide a sufficient amount of detail
Be clear and to the point
Be sure you eliminate the opportunity for misinterpretation
Documentation!
Communicate, communicate, communicate
Avoid using acronyms (e.g. PCP= Process Control Plan)
Problem Reporting & ResolutionProblem Reporting & Resolution
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November 6, 2001PRR Training
5 Why Analysis5 Why Analysis
Effective Root Cause AnalysisEffective Root Cause Analysis
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November 6, 2001PRR Training
5-WHY TRAINING AGENDA5-WHY TRAINING AGENDA
Where does 5-Why Fit within the PRR process
Understanding of 5-Why
Quick 5-Why Exercise as a group
Critique Sheet
5- Why Examples
Wrap Up/Discussion
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November 6, 2001PRR Training
5-WHY5-WHY
After a supplier has submitted an initial response and containment plan (Step # 2Step # 2 in the PRR process), a detailed investigation is necessary to determine what caused the problem. Step # 4Step # 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 Purpose of a PRRPRR “to facilitate problem resolution”, 5-Why is the prescribed tool for determining the root cause of the problem to facilitate problem resolution.
Where does it fit within the PRR process?
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November 6, 2001PRR Training
5-Why Analysis Three Paths5-Why Analysis Three Paths
5-Why:• 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?
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November 6, 2001PRR Training
5-Why Analysis Process5-Why Analysis Process
CAUSE
INVESTIGATION
Why? 1Cause
Why? 2Cause
Why? 3Cause
Why? 4Cause
Why? 5
Root Cause
Corrective Action
Lessons Learned
Basic Cause/Effect Investigation
Where in the processis the problem occurring?
“Go See” the problem.
PRACTICAL PROBLEM SOLVING MODEL5-Why Funnel
GRASP
THE
SITUATION
PROBLEM IDENTIFIED(Large, Vague, Complicated)
Problem Clarified
Area of Cause Located
Point of Cause(PoC)
5-Why AnalysisInvestigation of Root Cause
Why did we havethe problem?
Why did it getto the customer?
Why did our“system” fail?
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November 6, 2001PRR Training
5-Why Analysis Chart5-Why Analysis ChartCorrective Action
with Responsibility DateDefine Problem
Use this path forthe specific A
nonconformance being investigated
Root Causes
WHY?
WHY?Use this path toinvestigate why the
problem was notdetected.
WHY? B
WHY? WHY?
A
WHY?Use this path toinvestigate the
systemic root cause
WHY?
C
Ref. No. (Spill, PR/R…) WHY? WHY?
B
Date of Spill WHY?
Customer WHY?
Product / Process Delphi Location Content Latest Rev Date WHY?
C
Problem Resolution Complete Communicate to Customer Date: Process Change Break Point Date: Implement System Change Date:
Lessons Learned:
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November 6, 2001PRR Training
Quick 5-Why Exercise as a groupQuick 5-Why Exercise as a group•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 “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.
Generic Information for 5-Why Example: Regular Generic Information for 5-Why Example: Regular Cola Soft Drink vs. Diet ColaCola Soft Drink vs. Diet Cola
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November 6, 2001PRR Training
Bottling Process Flow for 5-WhyBottling Process Flow for 5-Why
INSPECT
LIDSBOTTLING
WATER
BOTTLES
SYRUP LABELS
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November 6, 2001PRR Training
5-Why Analysis Cola Example Chart5-Why Analysis Cola Example ChartCorrective Action
with Responsibility DateDefine Problem
Use this path forthe specific A
nonconformanceRegular Cola with DietCola Label.
being investigatedRoot Causes
Wrong Label.
WHY?
Changeover
WHY?Use this path toinvestigate why the
problem was notdetected.
Not followingprocedure.
WHY? B
Operator not certified.No formalizedprocedure.
WHY? WHY?
ANo formal certificationprocedure.
Expected to becovered with "on-the-job" training.
WHY?Use this path toinvestigate the
systemic root causeBudgetary constrains.
WHY?
Operator dependentprocess; nosupervision.
C
WHY? WHY?
BRelying of operator tofollow up procedure.
Ref. No. (Spill, PR/R…) WHY?
No formal process ofmonitoring adherenceto procedure.
Date of Spill WHY?
Failure not included inoriginal PFMEA.
Product / Process Delphi Location Content Latest Rev Date WHY?
C
Problem Resolution Complete Communicate to Delphi Date: Process Change Break Point Date: Implement System Change Date:
Lessons Learned:
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November 6, 2001PRR Training
5 Why Critique Sheet5 Why Critique Sheet General 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 Statement
Is 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 dimensional path ties back to issues such as design, operational, tier-n management, etc…?
-Does the detection path ties back to issues such as protect the customer, control plans, etc…?
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?
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November 6, 2001PRR Training
5 Why Critique Sheet (cont)5 Why Critique Sheet (cont)
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 what are the actions the supplier owns?
-How many iterations has the supplier gone through so far in preparing
this 5-why (It doesn’t happen on the first try!)
-Who prepared the 5-why?
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November 6, 2001PRR Training
•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 filters.
•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.
Generic Information for 5-Why Real Example:Generic Information for 5-Why Real Example:‘O” Ring Seal‘O” Ring Seal
Cutting Station
Mat’l Flow
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November 6, 2001PRR Training
5-Why Analysis: “O” Ring Example, Initial Response.5-Why Analysis: “O” Ring Example, Initial Response.Corrective Action
with Responsibility DateDefine Problem
Use this path forthe specific A
nonconformanceEnd-cuts mixed withgood parts.
being investigatedRoot Causes
End-cut misloaded onto "good" exitconveyor.
WHY?End-cut not properlyremoved from cutstation.
WHY?Use this path toinvestigate why the
problem was notdetected.
Operator failed toremove.
1. 100 % visual containment beforepacking.
2. Dock audit each lot.
3. Posted quality alert at cutting station.
12/01/00
12/01/00
12/01/00
WHY? B
Operators not able todetect.
Operator mistake.
WHY? WHY?
AParts not 100%inspected(2 PPM issue).
WHY?Use this path toinvestigate the
systemic root causeAudit and SPC.
WHY?
1. Posted quality alerts at cutting andpacking operations.
2. Modified operator instructions toinclude the quality alerts.
12/01/00
12/01/00
Mixed end-cuts notidentified in PFMEA.
Produce millions of"O" rings per year.
CWHY? WHY?
BLow frequencyproblem (2PPM).
Ref. No. (Spill, PR/R…) WHY?
12340000
Date of Spill WHY?
11/30/00
Product / Process Delphi Location Content Latest Rev Date WHY?
1. Added "improper end-cut removal" tothe PFMEA.
12/01/00
C"o" ring seal Flint, MI.
Problem Resolution Complete Communicate to Delphi Date: 11/28/00 Process Change Break Point Date: Implement System Change Date:
Lessons Learned: PFMEA(S) TO INCLUDE END CUT REMOVAL.
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November 6, 2001PRR Training
5-Why Analysis: “O” Ring Example, Initial Response Path A5-Why Analysis: “O” Ring Example, Initial Response Path A
•Problem definition, is it as the customer sees it?- customer stated “mixed/foreign material in shipment.”•Is the 5 Why response acceptable?- Process of removing end-cut is operator dependent, yet no actions taken for error-proofing this area.•Is this as far as the Why’s lead? Is the last statement within each path the root-cause?•Does the analysis tell the entire story?- Low frequency/intermittent problem, though no actions identified to address issue from ever re-occurring. Actions still dependent upon “the hope” that an operator finds the problem.
End-cuts mixed with
good parts.
Define the Problem
End-cuts misloaded
on “good” exit
conveyor.
End-cuts not properly
removed from cut
station.
Operator failed to
remove.Operator mistake.
Root Cause
Corrective ActionsA1. 100 % visual containment
before packing.
2. Dock audit each lot.
3. Posted quality alert at
cutting station.
Use this path for the
specific nonconformance
being investigated.
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November 6, 2001PRR Training
5-Why Analysis: “O” Ring Example, Initial Response Path B5-Why Analysis: “O” Ring Example, Initial Response Path B
•Problem definition, is it as the customer sees it?- customer stated “mixed/foreign material in shipment.”•Is the 5 Why response acceptable?- Process of removing end-cut is operator dependent, yet no actions taken for error-proofing this area.•Is this as far as the Why’s lead? Is the last statement within each path the root-cause?•Does the analysis tell the entire story?- Low frequency/intermittent problem, though no actions identified to address issue from ever re-occurring. Actions still dependent upon “the hope” that an operator finds the problem.
End-cuts mixed with
good parts.
Define the Problem
Operators not able
to detect.
Parts not 100 %
inspected.
(2 PPM issue).
Audit and SPC.
Produce millions of “O” rings per year.
Root Cause
Corrective ActionsB1. Posted quality alert at
cutting and packing stations
2. Modified operator instructions
to include the quality alerts.
Use this path to
investigate why the
problem was not detected.
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November 6, 2001PRR Training
5-Why Analysis: “O” Ring Example, Initial Response Path C5-Why Analysis: “O” Ring Example, Initial Response Path C
•Problem definition, is it as the customer sees it?- customer stated “mixed/foreign material in shipment.”•Is the 5 Why response acceptable?- Process of removing end-cut is operator dependent, yet no actions taken for error-proofing this area.•Is this as far as the Why’s lead? Is the last statement within each path the root-cause?•Does the analysis tell the entire story?- Low frequency/intermittent problem, though no actions identified to address issue from ever re-occurring. Actions still dependent upon “the hope” that an operator finds the problem.
End-cuts mixed with
good parts.
Define the Problem
Mixed end-cuts not
identified in
PFMEA.
Low frequency
problem (2PPM).
Root Cause
Corrective ActionsC1. Added “improper end-cut
removal” to PFMEA.
Use this path to
investigate the
systemic root cause.
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November 6, 2001PRR Training
Corrective Actionwith Responsibility Date
Define ProblemUse this path for
the specific AnonconformanceMixed/foreign material.
being investigatedRoot Causes
End-cut misloaded onto "good" exitconveyor.
WHY?End-cut not properlyremoved from cutstation.
WHY?Use this path to
investigate why theproblem was not
detected.
Operator failed toremove.
1. 100 % visual containment beforepacking.
2. Dock audit each lot.
3. Posted quality alert at cutting station.
4. Add closed end-cut chute with partspass sensors to single proper end-cutremoval, cutting station stops if not.
5. Added lock box to hold end-cuts.
6. End-cuts made larger than "good" O-rings; no pass bar installed on exitconveyor to stop any end-cuts.
12/01/00
12/01/00
12/01/00
12/08/00
12/08/00
12/08/00
WHY?
Use SPC and audits.Problem is 2 PPM.
Operator mistake.
WHY? WHY?
AAssumed 2 PPM isgood enough.
No errorprevention/detectioninplace.
WHY? WHY?Use this path toinvestigate the
systemic root causeFew customercomplaints.
WHY?
B1. Added end-cut mishandling toPFMEA.
2. Added verification of error detectionmethods to Process Control Plan(PCP), Set-up, and PreventiveMaintenance (PM) instructions.
12/08/00
12/08/00
Operator dependentprocess (end-cutremoval) notaddressed with errorprevention.
C
WHY? WHY?
BMixed end-cuts notconsidered in PFMEA.
Ref. No. (Spill, PR/R…) WHY?
12340000Occasional mixedend-cuts had not beena noteworthy problem.
Date of Spill WHY?
11/30/00
Product / Process Delphi Location Content Latest Rev Date WHY?
1. Process design standard nowincludes end-cut handling best practice.
2. APQP process to identify andaddress all customer quality issues andprocess causes.
12/08/00
C"O" ring seal Flint, MI.
Problem Resolution Complete Communicate to Delphi Date: 11/28/00 Process Change Break Point Date: Implement System Change Date:
Lessons Learned: 1.) Operator dependent process must be supported by error prevention methods. 2.) PFMEA must include all process failure modes and associated causes.
NotConsidered.
5-Why Analysis: “O” Ring Example, Final Response.5-Why Analysis: “O” Ring Example, Final Response.