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HBC 8D Process for Problem Solving

Finding and eliminating (forever) the root


cause of a problem.

Course Duration: 4.0 hours

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Slide 1

Course Objectives

At Completion YOU should:


Understand HBCs 8D process
Know when to use the 8D Process
Be able to write an 8D Summary Report
Be comfortable using typical problem solving tools
Know how to get additional help/training
I hear...I forget
I see...and I remember
I do...and I understand
Ancient Chinese Proverb

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Slide 2

Agenda

Origin of HBCs 8D process


Fit with:

Hawker Beechcraft Performance System (HBPS) Initiatives


Existing processes

Overview of the 8 Steps


0 - Decide to use the HBC 8D Process
1 - Describe the Problem
2 - Assemble a Team
3 - Implement Interim Containment
4 - Find Root Cause
5 - Develop Corrective Action
6 - Implement Permanent Fix
7 - Prevent Recurrence
8 - Recognize the Team

Additional Information contacts, reference material


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Slide 3

Round Robin Introductions


Your Name
Where you work position/responsibilities
Personal objectives for this course

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Slide 4

Definitions

Root Cause: The very basic reason why, how, & when the condition
occurred.
A Root Cause Mentality: An insatiable desire to understand why things go
wrong, why people do what they do, and how things got into their present
state. (C. Robert Nelms)
This takes persistence

Interim Containment Action: This is the action taken which should


address and correct the actual nonconforming condition.

Permanent Corrective Action: This should address the root cause of


a nonconformance and prevent future occurrences of the problem
which caused the nonconformance.

Contributing Cause: This factor contributed to the problem, but it is


not the root cause. Keep going to get to Root Cause.

Verification: Making sure that something is going to work prior to


implementation.

Validation: Checking to make sure that the change is working (after


implementation)
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Slide 5

More on Root Cause


Root Cause / Corrective Action (RCCA) is:
A systematic approach to effectively identify the
cause chain of a nonconformance and to
permanently eliminate the source(s) of problems.
Directed at reducing, and if possible eliminating,
quality system escapes and the costs associated with
poor quality.

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Slide 6

Origin of HBCs 8D Process

8D (8 Disciplines) first standardized by the U.S.


government during World War 2

Military Standard 1520: Corrective action and disposition


system for nonconforming material

Popularized by Ford Motor Company in the 1960s and


1970s (called Global 8D or G8D)
8D now a standard in the Auto Industry
8D fills a void we currently have at HBC

We reference root cause (internally, with our suppliers and


customers)

BUT, we dont provide a standard process to get to root cause

HBC 8D a Structured Process (and Tool Set) for Root Cause Corrective Action
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Slide 7

HBPS Initiative Positioning

Goal solve the problem


Smooth land (drain the lake,
remove boulders)
No leaks in the boats (rental
income while lake is here)

Pick the best fit methodology


Drain the lake (remove waste)
use LEAN Six Sigma
Remove boulders (variation
reduction) use Lean SIX SIGMA
Leaks (immediate problems that
must be fixed) use HBC 8D

Use the right tools for the job


Common tools will be used by all
methodologies
This Analogy: Bucket can be
used to empty the lake, remove
rubble, and bail out the boat

In general, Lean Six Sigma projects take longer; 8D is for everyday, immediate problems.
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Slide 8

HBPS Initiative Positioning (alt. view)


Control (During Production)

Planning

Sporadic Spike
(Special Cause: HBC 8D)
40

Common cause
(random)
variation/waste
(LEAN Six Sigma)

Special cause
(assignable) variation

Significant Shift
AND/OR
Variation Reduction
(Lean SIX SIGMA)

Time

Lessons Learned

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Slide 9

8D Process Fit

Policy & Procedures 12 0008 Corrective Action


System

Quality Assurance Instruction (QAI) -- QAI 03-01-015


Corrective Action Response and Review Requirements

Corrective Action requests resulting from:

Nonconforming material
Out of control processes
Internal audits
Supplier issues
Customer complaints
Operator self-verification process
Other nonconformances in product or process

Via:

PCAS - Production Corrective Action System


FCAS - Field Corrective Action System
IQAG - Internal Quality Audit Group
OSV - Operator Self Verification
+ Management Directive

8D adds structure (defined steps, language) to what we already have.


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Slide 10

8D Process Fit (cont.)

Changes being made to:

Documents Created in SAP:

WI 04-09-009 Creating and Updating


Corrective Action Records in SAP
WI 04-09-014 Responding to the Corrective
Action in SAP
WI 04-14-005 issuing Corrective Action
Requests for Major Noncompliances
Q1 Customer Complaint
Q2 Vendor Product Non-Conformance
Q3 HBC Product Non-Conformance
Q4 Vendor Product CA
Q5 HBC Product CA
Q6 Vendor Audit CA/PA
Q7 HBC Audit CA/PA

HBC 8D form will be attached to the


appropriate Q1-Q7 record in SAP

Reference Hard Copy of HBC 8D Form


handouts

Work Instructions are being modified now to incorporate 8D.


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Slide 11

What is 8D?

1. Corporate Standard
2. Standardized Problem Solving
Process

3.

Language, Methodology

Reporting Format

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Slide 12

8 Disciplines (8Ds)
D-0
D-1
D-2
D-3
D-4
D-5
D-6
D-7
D-8

Decide to use the 8D Process existing processes


Describe Problem
Establish Team
Implement Interim Containment
Find Root Cause
Choose Corrective Action
Implement Permanent Corrective Action
Prevent Recurrence
Congratulate Team

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Slide 13

What can trigger an 8D analysis?


Problem with Cause Unknown
Need to Cure - Not Mask Problem
Justifies a Structured/Team Approach

When do we
use the
8D Process?

Factors Severity, Cost, Time, etc.

Examples:

Whenever you open a QN, ask yourself if Root Cause/8D should be done.
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Slide 14

Who can initiate an 8D analysis?


Request for an 8D analysis can be made by:
Customer
Current Sales/Support Interface

HBC Employee
Initially, by contacting QA reps
Eventually, anyone
Working out details defining when it makes sense
Not all problems need an 8D level of analysis

HBC Supply Chain


Supplier will perform the 8D

Management

Anyone can use the process. Using SAP makes sure we capture/share knowledge.
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Slide 15

Place in 8D Process
D-0 Decide to use the 8D Process

D-1 DESCRIBE THE PROBLEM


Why is it important for a Problem Solving
team to start with Describe the Problem?

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Slide 16

8D Step 1 Describe the Problem


A problem well stated is a
problem half solved!

What is the problem?


This should be a short, simple and concise definition.
REMEMBER:

IF YOU CANNOT SAY IT


SIMPLY, YOU DO NOT
UNDERSTAND THE
PROBLEM

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Slide 17

Information about the problem

What is the problem?


Where was it detected?
How serious is the problem?
How many occurrences?
Who is affected?
When did it surface?

Remember:

on the problem.

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Slide 18

Problem Definition/Analysis Prompts


Who?
Who notified you of the problem?
- Manufacturing, Engineering, SAP QN Review, QA
Audit, etc.
Who are the people involved with the problem? (for step 2 team formation)
- Supplier, customer, material handlers, assemblers, supervisors,
engineers, QA personnel, etc.

High Level information belongs in the Problem Description, Investigate all others in Step 3 & 4.
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Slide 19

Problem Definition/Analysis Prompts


What?
What is the part name/number/other identification?
What type of product or process?
- Detail, assembly, vendor part
- Part manufacturing process, assembly process?
What is the type of nonconformance?
- Scratch, Dent, Oversize hole, Fit?
- Lack of communication, waiting too long for info/parts?
What characteristic of the part/process is having the failure
- hole radius, linear dimension?
- manufacture of the part, movement, inspection?
What method of measurement was used to identify the failure?
What are special circumstances surrounding the problem?
- new personnel, equipment move, new tool, etc.?
What environmental conditions existed?
- extremely cold/hot, rainy, humidity, lighting, etc.?
What is the design/nonconformance criteria in question?
- Drawing, Spec, Task Planning, Policy, Process?
What training has been done or is available?
What hardware or software is associated with the issue?
Have there been recent administrative, program or equipment changes?
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Slide 20

Problem Definition/Analysis Prompts


When?
When in the build process/production schedule/work shift did the problem
occur?
- note: occurrence point and detection point may
(and usually arent) at the same time
When in the task did the problem occur? (what step?)
When in the functional test did the problem occur (what step?)
When in the day, week, month did it/has it occurred (patterns)?

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Slide 21

Problem Definition/Analysis Prompts


Where?
Where is the part being contained?
Where is the part being used?
Where is the geographical location of the failure?
What plant/line/station cell?
Is the problem in-house or external (supplier) or external (in the field)?
Where are similar nonconformance records located?

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Slide 22

Problem Definition/Analysis Prompts


Impact?
How many times and in what period?
Cost of nonconformance in dollars?
Safety impact?
Cost of delay?
Warranty cost?
Impact to worker morale/productivity?
Has this issue been fixed before?
Impact on Business processes?
- production
- delivery
- product use
- field reliability
Impact on Customer Satisfaction?

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Slide 23

Importance of Problem Description

Focuses team on same objective


Direction set here is used throughout the HBC
8D process (foundation)
Forces all to agree on the scope and goal
Note: Operational Definitions MUST
accompany the Problem Description
What does failure mean?
What is bad?
What does success look like?

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Ice-scraping
video

Slide 24

Tool: Is/Is Not for Problem Definition

Reasons to use IS - IS NOT

Establishes points of comparison


Leads to a more complete problem description
Provides a Test base for Root Cause
Gives you a fingerprint of the problem
Draws better boundaries around the problem
SCOPE whats in, whats out

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Slide 25

Tool: Is/Is Not for Problem Definition


Development of IS:
Identity - What is the problem?
Space - Where is the problem?
Time When is the problem happening?
(also When did it start?)
Mass -

How Big is the problem?

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Slide 26

Development of IS NOT
IS

IS NOT

(What, Where, When, How Big) would you EXPECT to..


SEE, HEAR, FEEL, SMELL, OBSERVE . . .
.....but DO NOT? (close cousins)

<<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>>>>>>>>>>>>
(What, Where, When, How Big) IS it?
(What, Where, When, How Big) could it be but it IS NOT?

Once you have the Problem Defined, get feedback from others
(coworkers, manager, others) who have done 8D/RCCA
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Slide 27

Reasons to use IS - IS NOT

Establishes points of comparison


Leads to a more complete problem description
Provides a Test base for Root Cause
Gives you a fingerprint of the problem
Draws better boundaries around the problem
SCOPE whats in, whats out

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Slide 28

Document Your Work


1) Open a QN in SAP
2) Fill Out Section 1 of the 8D Summary Report
- go to the Quality Forms link on the QA home page
3) Attach the 8D Summary Report file to the QN

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Slide 29

Step 2 in the HBC 8D Process

D-0 Decide to use the 8D Process

D-1 Define the Problem

D-2 Form the Team

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Slide 30

8D - Step 2: Form a Team


A Team may be:
formal (scheduled meetings, for ex.) or
informal (consulted as needed)

Agree on work group guidelines


Customer
Complaint

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Slide 31

Advantages/Disadvantages of Teams

WHAT ARE THE BENEFITS


OF A TEAM APPROACH?

WHY DO TEAMS FAIL?

What have been your experiences with teams??


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Slide 32

Major Problems with Team Problem


Solving
Problem incorrectly described ! ! !

(biggest inhibitor)

Make sure Problem Description is accurate and team


members agree

Problem solving process rushed


Poor team participation
No logical (group) process
Lack of technical skills
Management impatience
Permanent Corrective Action Not Implemented

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Slide 33

Typical Team Organization


Champion/Sponsor
Leader
Recorder rotate this role
Team Members

Are we having
fun yet?

(SMEs - Subject Matter Experts)

Facilitator (optional)
Customer/Supplier

Recommend: 4-7 members


(10 max.)
<4, consider leader driving
results by consulting with
SMEs
>10, consider subteams

Ask the initial team: Who else needs to be involved, but isnt here?
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Slide 34

Step 3 in the HBC 8D Process

D-0 Decide to use 8D Process


D-1 Define the Problem
D-2 Establish a Team

D-3 CHOOSE, IMPLEMENT AND VERIFY


INTERIM CONTAINMENT ACTION
- basically youre Dispositioning the
QN

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Slide 35

8D Step 3: Implement Interim


Containment Action

Tools

Ideal

Effort

Decide whether you need to use one


Choose the best (benefits vs. risks)
Brainstorming to generate ideas
Pros/Cons lists; Effort (or cost or time) vs.
Benefit (or risk) graphic.
Action Plan

Test feasibility of the containment action


(Verify it will work)
Commit to it
Implement
Validate containment action effectiveness

Benefit

Action
Plan

ALWAYS +s and s to every decision. BALANCE (and action) are the Keys!
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Slide 36

Purpose of Interim Containment


Used to buy time to find root cause while
protecting your customer (external or
downstream operation) from the problem
Authorized first aid, but. . . . .
can be costly
attacks symptoms (not the cause)
has a masking effect

Purpose of this step:


Enforce SCOPE and EFFECTIVENESS of customer
protection needed
Its OK to not have containment, its NOT OK to not THINK about it.
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Slide 37

Int. Cont. Action vs. Typical BAND AID


Interim
Containment
Action

__X__
__X__
__X__
__X__
__X__
__X__

BANDAID

Attacks Symptoms
Added Costs
Monitored while being used
Documented &Data Collected
Verified for effectiveness
Replaced by Perm. Correction

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__X__
__X__
_____
_____
_____
_____

Slide 38

Key Points of Step 3: Interim Containment


Act quickly (and carefully)
Use the team to come up with the list of potential actions
Minimizes risk, results in better ideas

Pick the best overall Containment Action(s)


Consider actions that may be needed to address other areas:

Product in the field


WIP Work In Process
Product in transit/at the Supplier
Spares

Use Action Plan to make sure nothing falls through the cracks
Examples:

VERIFICATION and VALIDATION


Airworthiness Directives
Service Bulletins
Kits for field

DONT STOP HERE!!!

Action
Plan

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Slide 40

Fill Out Section 3 of the 8D


Summary Report

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Slide 41

BREAK FOR 10 MINUTES

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Slide 42

Where are We?


Place in the HBC 8D Process

D-0 Decide to use 8D Process


D-1 Define the Problem
D-2 Establish a Team
D-3 Choose, Implement and Verify Interim Containment
Action (I.C.A.)

D-4 FIND ROOT CAUSE

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Slide 43

Root Cause Analysis Common Tools


Your Brain
Especially the Collective Brain of your team

Data
Thought Map
Process Map
Brainstorming
5 Whys
Cause and Effect (Fishbone) Diagram
Graphical Analysis (misc. graphs)
+
Thought Map

What tool to use? Problem ->Questions->Data/Tools ->More QuestionsROOT CAUSE


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Slide 44

General Information about Step 4


OUR DESIRE TO ACT, OVERPOWERS OUR NEED TO UNDERSTAND
(Brad Baker, CONOCO)

Dont try to do solutions before the analysis is


complete.
It is futile to continue doing things the same way while
expecting different results.
Dont fall into the trap of jumping to conclusions.

This cant be a part time job. Assign a


Point Of Contact (POC) to focus on closure.
The RCCA response ECD must be based
on a planned list of things to do (Action Item
Lists).
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Slide 45

Data Collection
Insufficient data can result in solving only the specific instance.
1.
2.
3.
4.
5.
6.
7.
8.
9.

Types of data to collect:


Location: where problem was detected
Personnel: who found problem
Specifications: what are the requirements
Environment: noise, lighting, temperature, etc
Sequence of events
Challenge the basis for why its been
Equipment
determined to be an isolated event
and why it couldnt potentially be a
Training
systemic problem
Other occurrences
Recent changes: personnel, process, weather

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Slide 46

Tools: Thought Map


Once the problem is defined, natural tendency is to rush forward
RESIST THE URGE!!
Take a few minutes to plan your journey to root cause
1)
2)

Write your Problem Statement at the top of the page


Capture questions that you have

3)
4)
5)

Assumptions, potential causes, sources of the problem that dont belong in


the problem statement SHOULD be captured as questions

Answer each question with data


Questions (and data) will lead to more questions
Capture dead-ends as well as fruitful paths
1) Why?

NOTE: Review the Problem Definition (Step 1) often!


Used: When? ________________________ Why?__________________
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Slide 47

Thought Map example: Drill Bit Quality


Is the perceived
bit quality difference
real or just perception?

LEGEND:
Dashed Lines
Indicate Links

What specific features


of the bit performance
are perceived as
the problem?
1 - Penetration Sharpness
2 - Straightness
3 - Centering

What other factors


contribute to manual,
hand drilling performance?

Bruckner provides a
standard, such as
Michigan Twist

What is the current


bit brand
and quality used?

What are the bit


performance
indicators?

What is considered
the premium bit?

Precision Twist
Brand

1 Number of holes drilled


2 - Straightness
3 Centering
4 Penetration
What
5 QNs Resulting

is the difference
in cost for the bits?

Is there a statistically
significant difference
in the number of holes
drilled before dull?

Is it possible to
attribute QNs and other
sheet metal defects to
bit quality?

How much is
the difference?

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Slide 48

Transport

Storage

Machine

Transport

Assembly

Transport Inspection

Graphical Depiction of How Its Done


Terminator (start/stop)
Process Step
Decision Point
Connector (off-page)
General Rules:

Outputs

Inputs

Tools: Process Mapping/Value


Stream Mapping

?
?

?
?

Left to Right
Yess/Nos consistent
How would you map out the process for 8D so far?
Used: When? ________________________ Why?__________________
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Slide 49

Tools: 5 (OK, maybe just 3) Senses

Talk to, Listen to, Observe:


People performing the job
Suppliers
(internal/external)
Customers
(internal/external)

You are a root cause detective. Use all the tools you can.

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Slide 50

Tools: Brainstorming
When the best solution isnt obvious, one technique for
generating ideas (possible root causes, potential interim
corrective or permanent actions) is brainstorming.
1.
2.
3.
4.
5.
6.

Generates a large number of ideas


Encourage free-thinking
Dont criticize
Encourage everyone to participate
Record all ideas. There is no bad idea.
Let ideas incubate give it a little time
A minimum group of at
least three people to make
this work

Used: When? ________________________ Why?__________________


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Slide 51

Tools: 5 Whys
An employee in the plant
slipped and fell while
performing their regular duties.
1.
2.
3.
4.
5.
6.

Peel the onion- challenge the basis for root


cause. Most people can only support 1-2
layers of questions with their basis for root
cause or corrective action.

Why? There was oil on the floor.


Why? The machine in that cell was leaking oil.
Why? A pressure fitting on the machine failed.
Why? Inspection of hoses and fittings is not part of the preventive
maintenance (PM) schedule.
Why? The PM system does not consider Equipment Manufacturers
recommendations to develop PM schedules.
Why?- Theres check to make sure this is done.

Dont stop with Because we dont have enough people, money, time
its a fact of life.
Solve the problem with the people, money, time you DO HAVE.
Used: When? ________________________ Why?__________________
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Slide 52

Tools: Cause and Effect Diagram


A Cause-and-Effect (fishbone or Ishikawa) diagram
an easily applied tool used to analyze possible causes to a
problem.
Manpower

Methods
- incorrect prep of
metal surface

- inexperienced
-not following the frozen
coating parameters

MUST BE TESTED AND


VERIFIED!

-inadequate technique

- inadequate training
Non-conforming coating
- poor quality of
standards

- microscope
- microscope setting not
optimized to detect the
smearing

Machinery

Materials

5 Ms and an E - add
Measures and
Environment for 6 Bones

Used: When? ________________________ Why?__________________


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Slide 53

Tools: Graphical Analysis

Histogram

Used to show patterns/distribution in ordered data


Categories on the x-axis, # of occurrences on the
y axis.

Pareto Chart (80/20 rule)

Used when many problems or causes and you


want to focus on the most significant
Causes on x-axis, Results on the left (primary) yaxis, Cumulative % on the right (secondary) yaxis.

Scatter Diagram

Used to illustrate relationships between 2


variables. 1 variable on each axis.
"Correlation does not imply causality."

Ex. Shark Bites and Ice Cream

Purpose of Graphical Analysis: ________________________________


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Slide 54

Word of Caution: Stay on Track!


Side
Issue

Use Common Sense:


1.

The more significant or involved


the problem, the more detail may
be needed to identify the Root
Cause
1.

2.

Goal

Side
Issue

Also more advanced tools

Avoid data that leads to other


problems.
1.

Dont get sidetracked


1.

Side
Issue

Start

Review Step 1 Problem


Description.

2. Use the Thought Map


Complex problems usually require at least a fishbone diagram of the potential
root causes sorted from the brainstorm list
Define the actions to validate or dismiss each one
Technical problems usually require a structured FMEA
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Slide 55

Document Your Findings

Fill Out Section 4 of the 8D


Summary Report

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Slide 56

8D Step 5: Choose Corrective Action


Place in the HBC 8D Process:

D-0 Decide to use 8D Process


D-1 Define the Problem
D-2 Establish a Team
D-3 Choose, Implement and Verify Interim Containment Action
(I.C.A.)
D-4 Find Root Cause

D-5 DETERMINE PERMANENT CORRECTIVE


ACTION

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Slide 57

Decision Making Steps


(note: can also be used in Step 3)
1.

Define end result (action verb & object)

2.

List decision criteria

3.
4.
5.
6.

Eliminating/Preventing/Reducing (verbs)
Errors/Safety Incidents/QN/s (objects)
GIVENS - Mandatory
WANTS - Desirable

Decide relative importance of wants 1-10


Identify the possible choices
Compare possible choices against the decision criteria
Analyze risk
IF/THEN terms:
If we choose to___________,
Then _________ will happen.

7.

Make the final BALANCED choice and VERIFY

Action
Plan

NOTE: Use the Action Item Tracking Sheet to


Capture and Track Actions
ALWAYS +s and s to every decision. BALANCE (and action) are the Keys!
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Slide 58

Track Action Items to Completion


and Summarize Results

Use the Corrective Action Plan Worksheet


in the 8D File and Summarize in Section 5
of the 8D Summary Report

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Slide 59

8D - Step 6: Implement the Fix


Place in the HBC 8D Process:
D-0
D-1
D-2
D-3
D-4
D-5

Decide to use D8 Process


Choose team members
Define problem
Choose Interim Corrective Action(s) & verify
Find Root Cause
Choose & verify Permanent Corrective Action

D-6 IMPLEMENT PERMANENT


CORRECTIVE ACTION

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Slide 60

Goals of Permanent Corrective Action


Permanent Corrective Action MUST:
MUST
Address the systemic problem (in addition to this
specific instance)
Eliminate the Root Cause
Prevent recurrence
Be implemented in a timely manner
Include a detailed plan (especially if it will take
considerable time and people)
Be comparable to the risk involved
Risk to the customer, employee, organization, public, etc.

Be verified Objectively
Three knowledgeable people must agree

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Slide 61

Keys to Successful Corrective Action

Persistence
Natural Tendency to slack off once the Fix is determined
and partially implemented
Follow the Action Plan to Completion

Involve Do-It-Level people


Key to preventing recurrence

Review Interim Containment Action(s)


Remove/discontinue any not needed adds cost, time, etc.

VERIFY IT!!!
VALIDATE IT!!!

Action
Plan

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Slide 62

More than Just Do It


Why should we do planning and NEW
problem prevention when considering
implementing a permanent corrective action
for THIS problem? see next slide.

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Slide 63

Why Planning and Problem Prevention?


Many of our current problems are the result of
not following through with previous plans
Must allocate limited resources effectively
Optimize implementation
Dont waste Time/$$

Prevent other problems from occurring


With change comes risk of creating NEW
problems
Control Mr. Murphy

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Slide 64

Summarize the Key Permanent


Corrective Actions
Fill Out Section 6 of the 8D Form

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Slide 65

8D - Step 7: Prevent Recurrence


D-0
D-1
D-2
D-3
D-4
D-5
D-6

Decide to use D8 Process


Choose team members
Define problem
Choose Interim Containment Action(s) & verify
Find Root Cause
Choose & verify permanent corrective action
Implement Permanent Corrective Action(s)

D-7 PREVENT RECURRENCE

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Slide 66

Steps to Preventing Recurrence


Identify what systems, practices, or
procedures allowed the problem to occur
The whys

Identify and implement improvements


VALIDATE the results

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Slide 67

Tool: Mistake-Proofing

Poka-yoke is the Japanese term that means fail-safing or


"mistake-proofing"
Examples:
Cant start car until in park, Child-proof caps, laser beam shutoffs for machinery
Others??

One of the best ways to prevent problems from


occurring/recurring
Use mistake-proofing techniques when there are:
Process steps where human intervention is required
Decision points in the process
Repetitive tasks where physical manipulation of objects
is required
Steps where errors are known to occur
Opportunities for predictable errors to occur
Training Materials For Reference Only

Slide 68

Mistake-Proofing Levels of Prevention

More Proactive

Defect is the
evidence of an
error

Training Materials For Reference Only

Slide 69

Beware of Root cause was Human


Error
HUMAN ERRORS do not make a root cause
How does HBC approach human error?
Positive
Defects can be eliminated
Create a mistake-proof environment
Ask Why?
Focus on the Process/Product NOT the Person

Apply Mistake-Proofing device for 100% inspection

Negative

Defects are inevitable


People make mistakes
Place blame
Detect at final inspection
Sampling inspection
Some are bound to reach the customer

Training Materials For Reference Only

Slide 70

Once Root Cause is Determined,


Broaden your Thinking
How Can We Standardize Lessons Learned & System
Improvements?

Communication
Same/similar problem other plants
Same/similar problem different
systems
Effect
Content Quality
Appropriate Quantity Potential Causes
Root Cause
Current/Future Problems in other areas

Training Materials For Reference Only

Slide 71

Fill Out Section 7 of the 8D Form


Prevention of Recurrence

Training Materials For Reference Only

Slide 72

8D - Step 8: Congratulate the Team


D-0
D-1
D-2
D-3
D-4
D-5
D-6
D-7

Decide to use D8 Process


Choose team members
Define problem
Choose I.C.A., verify
Find Root Cause
Choose & verify P.C.A.
Implement P.C.A.(s)
Prevent recurrence

D-8 CONGRATULATE THE TEAM


Training Materials For Reference Only

Slide 73

How to Congratulate the Team

Review significance of contribution


Provide appropriate recognition for all members
Document the efforts & results
Celebrate successful completion

Celebrations dont have to be


elaborate/expensive
Be creative

Training Materials For Reference Only

Slide 74

How Would You Congratulate Your


Team?
What are some things that have worked well in the
past?
What are some things that didnt?

5 minutes
Training Materials For Reference Only

Slide 75

Fill Out Section 8 of the 8D Form


(and attach completed file to the
appropriate QN)

Training Materials For Reference Only

Slide 76

Comments, Suggestions??
Please fill out class/instructor
Evaluation Forms

Training Materials For Reference Only

Slide 77

Reference Material

Training Materials For Reference Only

Slide 78

QA Intranet Website

Training Materials For Reference Only

Slide 79

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