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Practical

Problem Solving

The Toyota Way


Scott Davis
Managing Partner
Lean Associates, Inc.
Lexington, KY 40517
All materials copyright Lean Associates, Inc. No part of this presentation may be
copied or reproduced without written permission of Lean Associates, Inc.

EVERYTHING we do is for the


purpose of showing us where the
problems are. We must constantly
identify problems, find their
causes, and solve them in order to
improve for the long-term.
Toyota Trainer

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When is the Best Time to Find a Problem?


Before it BECOMES a problem!
If you discover a potential problem you
are able to take corrective action
Fire Prevention
If you discover a situation AFTER it is
a REAL problem you can not prevent
the problem
Fire fighting
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What We Are Trying To Do


Core Philosophy: Elimination of WASTE
(COST) (Increase the amount of value)
Why we
do it!
How we
do it!

Creating Continuous Flow

Surface
Problems

Measure the Throughput Time


How we know
we did it! (Indicator
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of success)

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Correct Flow of Lean Thinking


Purpose, Values, Philosophies (Beliefs)
The things we are taught and believe
Principles and Concepts (Ideas and Way of Thinking)
Thinking that orients our beliefs

Strategies for execution


(The approach to things guided by our principles and values)
The method of executing our principles
Tactical (HOW to apply Lean Tools)
The doing part (the solutions)

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P hilo s o p hy
W as te E lim inatio n

P e rf o rm anc e Me as ure
R e d uc e d L e ad T im e

P rinc ip le
C re ate C o ntinuo us
P ro c e s s F lo w

S trate g y
C re ate I nte rd e p e nd e nt
"C o nne c te d " P ro c e s s e s

L e an T o o ls
K anb an, S up e rm arke ts ,
D e f ine d F I F O L ane s

R e s ult
W as te is
R e d uc e d !

Me tho d
P ull S ys te m

R e as o n
P ro b le m s are S urf ac e d
Q uic kly and are C ritic al

C o ntro l Me tho d
Utilize V is ual C o ntro ls s o
T hat no P ro b le m s are
Hid d e n

Effect
P ro b le m s Mus t b e
C o rre c te d Q uic kly
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The Four Step Process


Step One: Find and Clarify
the Problem
Understand the current
situation
Set standards as the
foundation for PPS
Surface the problems
Build consensus and
alignment
Clarify goals and targets

Step Two: Find the Root


Causes
Ask clarifying questions
(when, where, how)
Narrow the focus
Brainstorm possible causes
Determine the most likely
contributors
Determine the greatest
actual contributors
Confirm the root causes

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The Four Step Process


Step Three: Identify and
Implement Countermeasures
Brainstorm
countermeasures
Evaluate and prioritize
countermeasures
Develop the
Implementation Plan

Step Four: Confirm and


Follow Up
Verify plan effectiveness
Modify implementation
plan
Confirm the results
Standardize effective
countermeasures
Develop Future Steps

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Why are we here?


1. Recognize the importance of
Practical Problem Solving.
Purpose
Process
Payoff
2. Skills development: learn the
Practical Problem Solving Process!

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Do we have problems?
What are some of the problems you have here?
List problems on the board
There are NO SHORTAGE of problems in ANY
work area!
Can we SEE problems?
Accidents, near misses, defects, scrap,
performance to schedule/budget, attendance??

Problem Solving skills are essential for all


employees!

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Why use Practical Problem Solving?


Because No Problem is a problem!!
Problems are opportunities to learn and develop.
Hiding problems undermines the continuous
improvement philosophy.
Solving problems is necessary for achieving our
goals.

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The Goal
The ultimate goal of PPS is not
just to solve the problem at
hand!
The goal is to make problem
solving transparent and
teachable in order to create an
organization of problem
solvers.
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Problem Solving Opportunities


Strategic
Initiative

Strategic
Initiative

Strategic
Initiative

Project

Project

Project

Project

Very
few big
problems

Few
medium sized
problems

Project
Many
small
problems

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Focus of the Problem Solving Method


Problem Solving Opportunities
(Large, Vague, Multiple Problems)

Point of Pain

Clarify the Problem


Problem Defined
Most Likely Contributors
Five Whys?
Investigation to
Root Cause

Genchi Genbutsu Shugi


= principle of the
real place and real
thing

Go
and
See
Why?
Why?
Why?
Why?
Why?

Basic Cause/
Effect Investigation

DirectCause
Cause

Root
Cause

Countermeasure
Share Best
Practices
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Step 1: Find and


Clarify the Problem

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Junk Words

It is a long way to the store


How many blocks? ______
There are a lot of people waiting in line at Wal-Mart.
How many people in line? ______
There are a lot of mistakes.
How many mistakes are there? ______
It takes a lot of work to do lean activities.
How many hours does it take each week? ______
We have a big problem with defects.
How many defects is that? _______
These things take too much time to do.
How much time do these things take per day? ______

Inspired by: Sammy Obara


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17

The Four Step Process


Step One
Step One: Find and Clarify
the Problem
Understand the current
situation
Set standards as the
foundation for PPS
Surface the problems
Build consensus and
alignment
Clarify goals and targets

Step Two: Find the Root


Causes
Ask clarifying questions
(when, where, how)
Narrow the focus
Brainstorm possible causes
Determine the most likely
contributors
Determine the greatest
actual contributors
Confirm the root causes

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How do we typically find a Problem??


Things are
working
well?

Yes

No

Yes

Dont touch it!


IDIOT!!

Does anyone
know?

Yes

No
Yes

No
Can you blame
someone else?

Have you
touched it?

No

Will it
blow up in
your face?
No
Pretend you havent seen it

Yes
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No Problem

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Understanding the Current Situation


What is a Problem?
Ideal Situation
or

Standard
Where you want to be.

Quantifiable

G
A
P

Problem

Current Situation
Where you are now.

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Problem or Opportunity
What do we do?
Standard or
Goal

KAIZEN ZONE
The
Problem

Actual
Performance
Problems MUST be corrected
Kaizen is opportunity for improvement
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Criteria for Problem Definition


What do we need for a problem to exist?
1. An Actual Current Situation
2. A Desired Situation (Goal or Standard)
3. A Gap between actual situation and goal
4. Extent of the problem
How long has the condition existed?
Is it getting better or worse?
What are the characteristics?
(Consistent/Variable)
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Setting Standards: foundation


for practical problem solving
CURRENT SITUATION VS. STANDARD
Seek facts relating to when the standard is achieved and
when it is not.
Define important details about the current situation vs. the
standard situation.

Whats different?

How often?

When is the problem

Where is the problem located

occurring (not occurring)?

Whats changed?

(not located)? Find the POC

When did it start?

What is the trend?

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Problem Relationships
Higher cost is a result of
poor operational capability,
quality and service

COST

Why you do what you do,


and who you do it for.
Right thing
Right time
Desirable products
Internal customers (others
doing their jobs

CUSTOMER
SERVICE
OPERATIONAL
CAPABILITY
Productivity
Efficiency
Equipment
People
Materials

QUALITY
What you have to do
well to provide service

Defects
Scrap
Rework

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Surface the Problems


Select Problems Using The 80/20 Rule
20 % of Problems

Lead To

80% of the
Opportunity
80% of Problems

Lead To

20% of the
Opportunity

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Surface the Problem


Problem Identification
Guidelines to Gather relevant facts:

Go to the actual location where the


problem is occurring (the GEMBA)
You MUST GO SEE for yourself
(Genchi Gembutsu Shugi)
Get facts yourself by observing, dont
make assumptions
Do not rely upon data gathered by
other individuals or reports

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Case Study Example:


The Current Situation

Actual: Average just over 3% paint


defects
Standard: Less than 1% paint
defects
Gap (Problem): Paint defects are
2% over the standard
Extent: Problem has been consistent
for long-term (over 1 year)
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Case Study Example

Rationale for solving the problem:


Defect is found after paint is cured
and repair is more difficult.
Rework requires additional set-up
of paint system.
Rework affects cost and delivery

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Team Exercise Part One:


Surfacing Problems

Lets go find some problems


Look for facts, not feelings
Understand the current situation
30 minutes
Go where the problem occurs
Select teams
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Exercise One Review


What did you see?
Did you see problems?
How do you know they were
problems?
How do the things you saw prevent
you from achieving desired
results?
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Learning to
Present your
Thinking Using
A3
Lean Associates, Inc.
P.O. Box 5448
Berkeley, CA 94705
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All materials copyright Lean Associates, Inc. No part of this presentation may be
copied or reproduced without written permission of Lean Associates, Inc.

What is an A3?

Communication tool
Tool to develop logical thinking
Provide a common language
Way to organize vast amounts of
information in concise format

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Typical A3 Report
Whats Included
1. A clear reason for the report (story)
2. A clear presentation of facts, not opinions
3. An objective analysis of data
4. A specific, rational conclusion
5. Recommended actions:
Short term / Long term
6. Monitoring activity/ next steps /follow up
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A3 Thinking
Understanding Causality
Seeking Predictability
Ensuring Ongoing, Unending Learning

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What is the Story You are Telling?


An effective way to communicate is
to tell a persuasive story

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36

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Case Example:
Understand the current situation
1. Problem Statement

- Paint defects on the Powder Coat Line are 2% over the standard and

Actual Current Situation

have been for over 1 year


Average just over 3% paint defects

Desired Situation (Goal or Standard)

Paint defects should be less than 1%

Gap between actual and desired

Paint defects are 2% over the standard

Extent of the problem

Problem has been consistent for long-term (over 1 year)

Rationale for solving the problem


-Defect is found after paint is cured and is more
-Rework requires additional set-up of paint system
difficult to repair
Other Comments
- Rework has potential impact on customer delivery and increases cost

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Team Exercise Part Two:


Build Consensus and Alignment
Complete the Problem Statement (section 1)
of the A3
Make sure you can verify the four criteria.
List the rationale for solving the problem.
List any other issues related to the problem.
20 minutes

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Exercise Two Review


Each team share their problem with the
other teams
Discuss and clarify the problems
Does everyone agree that The problem is correctly defined
Facts were presented
The problem should be solved

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Clarify Targets and Goals


Target characteristics
Do What? (Improve/Increase or
Reduce/Decrease)
To What? (Defects, productivity, cost,
etc.)
How Much? (By a specific amount and
get back to standard)
By When? (Set an aggressive date)
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Case Example:
Clarify targets and goals

2. Target / Goal

20
09

6/

26
/

20
09

6/

19
/

20
09
12
/

00
9
6/

5/
2

6/

20
09

5/

29
/

20
09

5/

22
/

20
09
15
/

00
9
5/

8/
2
5/

4/

17
/

20
09
10
/
4/

00
9

26-Jun-09

1/
2

By When

5/

2%

20
09

How Much

24
/

Paint Defects

4/

To What

20
09

Reduce

Do What

Paint Defect Reduction Target

3.5
3
2.5
2
1.5
1
0.5
0

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Team Exercise Part Three:


Clarify Targets and Goals
Complete Section Two (targets and goals)
of A3
15 Minutes
Set Targets and Goals
Do What
To What
How Much
By When

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Exercise Three Review


Each team share their targets and goals with
the other teams.
Discuss and clarify the targets and goals.
Does everyone agree that The the targets and goals are appropriate for the
problem
They are specific and measurable
Targets and goals are aggressive but realistic

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Step 2: Finding the


Root Cause

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The Four Step Process


Step Two
Step One: Find and Clarify
the Problem
Understand the current
situation
Set standards as the
foundation for PPS
Surface the problems
Build consensus and
alignment
Clarify goals and targets

Step Two: Find the Root


Causes
Ask clarifying questions
(when, where, how)
Narrow the focus
Brainstorm possible causes
Determine the most likely
contributors
Determine the greatest
actual contributors
Confirm the root causes

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Analysis to Find Root Causes

The key to effective problem


solving is to find the root cause(s)
of the problem.
This step requires detailed study
and observation!
This is where the majority of time
is spent in problem solving.
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Finding Root Causes of Problems


Root Causes are things that are
happening that lead to the problem.
Root Causes are at the bottom of
every problem.
The Root Causes are often hidden
from view.
Finding Root Causes requires
digging.
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Watch out for traps


Not clearly understanding the needs of the organization or
area
Not clearly stating the needs (defining the situation)
Knowing the answers prior to exploration
Just listing the problems and getting started doing
something
Jumping from problem to solution without clear
understanding and analysis
Putting too much on the to do later list and not doing
enough now

Revision 9

Copyright 2003 Lean Associates, Inc.


859-552-5326

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Steps to finding the


Root Causes of a Problem
1. Ask Clarifying Questions: What, when,
where or how the problem happens
2. Narrow the focus
3. Brainstorm Possible Causes
4. Determine Most Likely Contributors
(develop your theory)
5. Determine Greatest Actual Contributors
(conduct your experiment)
6. Confirm the Root Cause.
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Narrowing Focus
L A R G E P R O B L E M
Many Possible Causes
Most Likely Causes
Point of Cause
5 Why Process
Root Causes

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Copyright 2005 Jeffrey K. Liker and David Meier

Ask Clarifying Questions:


Where to Look for Root Causes

Point of
Cause

The Point of
Cause may not
be at the Point of
Occurrence

Point of
Occurrence

Where the problem


physically occurs

Point of
Recognition

The problem is often


detected at a later
time. The worst is
when it is at the
customer.

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Relationship of
Problem/Symptom/Cause
PROBLEM
(Virus)feel well)
(Don't

THESE
SYMPTOMS
EXIST

AS A RESULT OF
THE PROBLEM

ANALYSIS
LEADS TO

(Aches and Fever)

ROOT CAUSES

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Copyright 2005 Jeffrey K. Liker and David Meier

Relationship of
Problem/Symptom/Cause
SYMPTOMS:

PROBLEM

Quality Issue
Causes

(Reduced Efficiency)

AS A RESULT OF
THE PROBLEM

Increased Cost,
Poor Customer
Service

Therefore

Quality
(Errors and
Omissions)

Revision 9

Copyright 2007 Lean Associates, Inc.


859-552-5326

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Examples: What/Where/When
Machines, equipment and tools
Precision
Reliable and Repeatable
Cycle time fast enough (too fast)
Correct settings
Fixtures / Tooling
Any other issues like hitting things with a
hammer to get them into the machine.
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Examples: What/Where/When
Environment (Workplace Layout)
Lighting
Temperature
Work Position (Reaching / Overhead)
Extreme Effort
Noise
Any other issues like extra effort or
difficulties with work.
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Examples: What/Where/When
Work Method and Procedures
Standard method defined and
followed
Correct pace
Over-processing
Evidence of correction or rework
People (Man)
Skills and Training
Absenteeism
Turnover

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Examples: What/Where/When
Materials, parts, products
Incoming quality
Size, shape, tolerances
Material shortages, or outages
Extra effort required to make parts
work

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Narrow the Focus using Data


Problem Tracking Data Collection Sheet
Problem: Paint Defects on the powder coat line are 2% over the standard
Why? Quantity of Surging defects is high
Reason: Need to brainstorm possible causes for surging

Possible Causes for Problem

Paint Surging (Splatters)

Heavy Paint

Thin Paint

Contamination

Frequency

Total

17

12

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Other

Narrow the Focus (Closing the Gap)


20 % of Causes
(Critical Few)

Lead To

80% of the Gap


80% of Causes
(Lots of
Miscellaneous)
Lead To

20% of the
Gap
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Other

Contamination

Heavy Paint

Thin Paint

18
16
14
12
10
8
6
4
2
0

Analysis of Paint Defects by Type

Paint Surging
(Splatters)

# Defects

Case Example:
Narrowing the Focus

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Brainstorm Possible Causes


Go and See to completely understand.
Develop possible causes based on
experience (educated guesses) and
observation.
Group and Organize (Example:4 Ms 1 E)
After Brainstorming, clarify to ensure
complete understanding (list then clarify).

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Case Example:
Brainstorm Possible Causes
Defect Rate in Powder Paint

Why?

Paint Surging (Splatter)


Why?
Man

Method

Machine

Material

Environment

Lack of
Training

Operator
Technique

Worn
Gun

Paint
Clumps

Poor
Lighting

Dont
Care

Motion
Up Down

Set Up
Wrong

Wet
Powder

Faraday
Trap

Side to
Side

Hose
Kink

Defects on
Parts

Mask and
Suit

Wrong
Hose

Dirt in
Parts

Worn
Venturi
Pump
Worn
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Brainstorm Possible Causes


Brainstorming Worksheet
Problem Statement:
Possible Causes:

List all possibilities without judgement

People

Method

Material

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Team Exercise Part Four:


Brainstorm Possible Causes
Brainstorm Possible Causes for the Problem
Use the brainstorming worksheet as a guide
Go and See to make sure you are not
missing any possibilities.
Use your knowledge and previous
experience to gather ideas.
Narrow, group, and organize your ideas.
40 minutes
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Exercise Four Review


Focus review on the brainstorming process
rather than specific causes generated.
What were the challenges of brainstorming?
What were the benefits?
Discuss any main ideas generated by
brainstorming.
Dont review every item- just some of the
more surprising or perhaps previously
unknown ideas that you believe warrant
further investigation.
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Determine the Most Likely Contributors


Based on your facts, narrow the list of possible
causes and decide on three (3) items you consider to
be the Most Likely Contributors.
Narrow the focus based on actual results.
Use logic-do the results make sense?
Look for consistency/variability: can we
isolate the cause?
Are we closing the gap between Point of
Recognition and Point of Occurrence?
Consensus Rules in making decisions.
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Determine the Most Likely Contributors


To determine Greatest Actual Contributors
investigate the Most Likely Contributors
further:
We must PROVE or DISPROVE
through experimentation.
We can always change our theory if we
prove these are not actual contributors.

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Determine the Most Likely Contributors:


The Scientific Method
Observation Go see problem at the point of occurrence
Theory Ask what, when, how, and who to find possible
causes

Hypothesis Identify what you believe are the Most Likely


Contributors

Experiment Conduct experiments to verify Most Likely


Contributors are ACTUAL causes

Results Evaluate and verify Greatest ACTUAL Contributors


Conclusions Prove or disprove your theory and
hypothesis based on results of experiments
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Why Experiment To Prove Theories?


The Culture of Problem Solving
Galileo gravity experiment

Which falls faster?

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Example of Worksheet
Most Likely Contributor Selection Worksheet
1. Review list of Possible Causes.
2. Combine any items that are the same or similar
3. Clarify any items to ensure all members understand the meaning
4. Use a voting method to decide which are the 3 Most Likely Contributors
5. Select items that happen most often or contribute the most to the gap (problem)
Most Likely Contributor #1

Why do you believe this is a Most Likely Contributor? (List any obsevations or data)

What ideas do you have to prove that this is an actual contributor to the problem?

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Case Example:
Determine Most Likely Contributors
Determined that the defect is actually a clump of
paint on the surface (not contamination).
Found that the hoses and venturi were in
specification.
Faraday Trap is inside corners and defect is on the
outside of parts.
Tested up-down motions and could not duplicate
problem.
Tested old and new guns- no difference.
Operators showed concern and desire to solve
problem.
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Case Example Continued:


Process of Elimination
Defect Rate in Powder Paint
People

Method

Machine

Material

Workplace

Lack of
Training

Operator
Technique

Worn
Gun

Paint
Clumps

Poor
Lighting

Dont
Care

Motion
Up Down

Set Up
Wrong

Wet
Powder

Faraday
Trap

Side to
Side

Hose
Kink

Defects on
Parts

Mask and
Suit

Wrong
Hose

Dirt in
Parts

Experimentation
allows us to prove or
disprove our
theories.

Worn
Venturi
Pump
Worn

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Most Likely Contributors:


Team Exercise Part Five
Use the Most Likely Contributor Worksheet as a
guide.
Narrow your list of Possible Causes to three (3)
items that have a high likelihood of being actual
contributors to the problem.
List your thinking as to why you believe your
selections are Most Likely Contributors (theory).
List any ideas to prove your thinking (hypothesis)
20 minutes

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Exercise Five Review


Focus review on the selection process
used to narrow to the Most Likely
Contributors
Do the reasons listed sound
reasonable?

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Go See and Experiment:


Determine the Greatest Actual Contributors
Defect Rate in Powder Paint
Method

Machine

Operator
Technique

Set Up
Wrong

Point of
Occurrence

Go to the Point of Occurrence and experiment

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Factors to Verify With Experiments


Operator Technique
Theory
Excessive wiggling
Rapid movement

Incorrect Equipment
Set Up Theory
Air Pressure
High/Low
Powder Flow
High/Low
KV Setting High/Low
Fluidization of Powder

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Results of Experiments
Set Up Test
Air Pressure

KV

Powder

Result

+ 10 PSI

No Change

No Change

No Problem

+ 20 PSI

No Change

No Change

X
Problem

+ 20 PSI

+ 2.O

No Change

X
More Problem

+ 10 PSI

+2.O

No Change

X
Problem

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Case Example:
Greatest Actual Contributors

3. Cause Analysis
Method
Spraying Technique

Greatest Actual Contributors (Top 3)

Set-Up
Air Pressure Setting too high

Set-Up
KV Setting too high

Why?

Why?

Why?

Root Causes

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Team Exercise Part Six:


Greatest Actual Contributors
Go to the workplace to observe the Most Likely
Contributors
Determine experiments to prove Greatest Actual
Contributors
Conduct experiments if possible.
Complete section 3 (Cause Analysis) of the A3 to
this point (Greatest Actual Contributors only)
Dont try to identify ROOT CAUSES at this time!
30 minutes
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Exercise Six Review


Each team:
Share their process with the other teams.
Explain the 3 Greatest Actual Contributors and
why they were chosen (results of your
experiments).

Does everyone agree on the following


items:
The logic from the problem to the Greatest
Actual Contributors makes sense?
The team should pursue these actual
contributors through root cause analysis?
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Confirm the Root Cause:


Five Why Investigation
Why did that happen?

Therefore!

Why did that happen?

Therefore!

Why did that happen?

Therefore!

Why did that happen?

Therefore!

Why did that happen?

Therefore!

Root Cause

Work backwards from the root cause to the problem


statement saying Therefore between each Why
statement
If you can proceed logically from the last Why statement
to the problem statement, the process was done correctly
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Case Example:
Confirm the Root Cause
Defect Rate in Powder Paint

Why?

Paint Surging (Splatter)

Why?
Spray Technique

KV Setting High

Air Setting High

Why?
Rapid
Movement

Incorrect

Incorrect

Setting

Setting

Why?
Cause

Cause

Cause

Cause

Cause

Why?
Keep digging to get to root causes!
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Why ask why 5 times


If you stop short, you have only detected a partial cause
and not a root cause
For example:
In the old Cavalry days a battle on the frontier was lost
The general at the time only asked why one time and he
was told because our soldiers became dismounted from
their horses
He immediately ordered his men to undergo rigorous
riding remedial training

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Why ask why 5 times


If the general knew about 5 Why Analysis and had
asked why a few more times, he would have
discovered:
Why did the soldiers become dismounted?
Because the horses were going lame
Why were the horses going lame?
Because they were throwing a horse shoe
Why were they throwing a shoe?
Because they only had 3 of the required 5 nails installed
Why were there only 3 nails installed?
Because the blacksmith ran out of nails and spread the
remaining nails as far as he could

By not asking enough Whys the action taken didnt


address the true root cause.

85

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Common Five Why Mistake


Problem Statement: The defect rate is over goal
Why?
Too many defective parts
Why?
Parts are assembled incorrectly
Why?
Operator error
Why?
Parts don't align correctly
Why?
Poor design
Why?
Root Cause??
Designer didn't design correctly

The root cause points responsibility to someone else.


It may be true, but it does not help us solve the problem.
The root cause cant be corrected.
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Effective Root Cause Analysis


Problem Statement: The defect rate is over goal
Why?
Too many defective parts
Why?
Parts are assembled incorrectly
Why?
Operator error
Why?
Parts don't align correctly
Why?
Parts can be oriented incorrectly
Why?
Root Cause??
No error proofing device

We can correct the root cause.


The solution is obvious!
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Case Example:
Confirm Root Cause

3. Cause Analysis

Greatest Actual Contributors (Top 3)

Method
Spraying Technique

Set-Up
Air Pressure Setting too high

Set-Up
KV Setting too high

Why? (Does spraying technique cause splatter?) Why? (Is the air pressure set high?)
Someone set incorrectly
Gun moved rapidly causes paint to surge

Operator believes that moving back and forth

Why? (Is the KV setting high?)


Someone set incorrectly
Why? (Did someone set incorrectly?)
Why? (Did someone set incorrectly?)
It is not clear what the correct setting is It is not clear what the correct setting is
Why? (Is the setting not clear?)
Why? (Is the setting not clear?)
Proper setting not marked on the
Proper setting not marked on the
gauge
gauge

increases coverage

Root Causes

Why? (Is the gun being moved rapidly?)


Operator uses a wiggling back and forth motion
Why? (Does the operator use this motion?)

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Team Exercise Part Seven:


Confirm the Root Cause
Continue asking Why? to find root cause.
Confirm that you have found the root causes
(Can you make the problem occur or stop?)
Test using the therefore test.
Complete the Cause Analysis (section 3) of
the A3.
Show any information related to the root
cause analysis.
Highlight the root causes identified.

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Exercise Seven Review


Each team share their root cause analysis
with the other teams.
Explain the Five Why process used to
verify the root causes.
Does everyone agree that the logic of the Five Whys make sense?
the root causes have been verified and proven?

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Wrap Up Step Two


HOMEWORK:
Work on previous team assignments.
Complete or update sections 1, 2, and 3.
Do you need to conduct any
experiments?
The Facilitator will be available for
coaching.
Questions?
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Step 3: Identify and


Implement Countermeasures

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The Four Step Process


Step Three
Step Three: Identify and
Step Four: Confirm and
Implement Countermeasures Follow Up
Brainstorm
countermeasures
Evaluate and prioritize
countermeasures
Develop the
Implementation Plan

Verify plan effectiveness


Modify implementation
plan
Confirm the results
Standardize effective
countermeasures
Develop Future Steps

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Brainstorm Countermeasures
Problems are never truly solved, they
are merely kept in control (minimized).
This control is called a countermeasure.
The countermeasure must be used
constantly to control the problem and
remain effective.
Failure to use the proper countermeasure
will allow for reoccurrence (defects).
There is no absolute countermeasure.
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Brainstorm Countermeasures

Emphasize quantity over quality.


Suspend judgment-let ideas flow.
Let one idea build upon the next.
Record ideas rapidly for as long as you can
without stopping.
The Rule: The countermeasures must relate
to the problem!!

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Evaluate Countermeasures
Countermeasure(s) should always be evaluated on
their ability to achieve your target/goal.
They should be effective:
Can you test the countermeasure?
Will this countermeasure be enough to achieve the
target/goal?

Will this countermeasure prevent recurrence of the


problem?
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Evaluate Countermeasures
They should be feasible.
To Determine how feasible the countermeasure may be,
ask the questions:
Can it be done by the team?
Can it be done now?
Is it low cost?

Must it be done by outside resources?


Will management/others buy into the solution?

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Evaluate Countermeasures
They should have impact!
Ask what impact might this countermeasure have on:
Other processes and people?
My job?
My team?

Other operations?
The company as a whole?

Will the countermeasure create new problems?

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Prioritize Countermeasures
High

Potential Value

High Priority
o Second wave

First Priority
Just Do Its
o Evaluate these first &
implement ASAP

Defer

Second Priority
Just Do Its

o Evaluate later

o Second wave

Prioritized
list of ideas
to be further
evaluated

Low
Difficult

Easy

Ease of Implementation

o
o
o

Operational Risks (irreversible?)


Need for capital
Timing/resources required
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Prioritize Countermeasures
Keep both a short term and a long term
perspective in mind.
Short Term Countermeasures
What can fix the problem immediately?
Does it help achieve the target or goal?
Implement Short Term Countermeasures while
developing Long Term Countermeasures.

Long Term Countermeasures


Offer the best combination of results.
Does it really deal with the root cause of the
problem?
Does it really achieve your target or goal?
Will it prevent recurrence of the problem?
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Case Example:
Evaluate and Prioritize Countermeasures

4. Countermeasures
Testing showed that it is possible to recognize the defect at the point of occurrence. Developed spot check procedure
Short-Term (Temporary)
Mark gauges with correct settings
Implement process confirmation of gauges 4 times per shift by line leader
Long-Term (Permanent): Use JI to re-instruct operators correct spray speed, distance, etc.
Build in Spot Inspection at paint booth to prevent defect from going into oven. Repair can be made easily at paint booth.
Put lock on gauge setting to prevent changing without line leader awareness

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Develop the Implementation Plan


In the Problem-Solving Process, effective implementation
cannot be assumed. Proper planning IS REQUIRED.

Develop a Plan to implement


countermeasure(s)
Define necessary actions
List actions required
Sequence of actions required
Specify who will do what, when, and where
Test your thinking.

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Develop the Implementation Plan


Evaluate the Implementation Plan
Ask what if? to anticipate problems with the plan (Impact)
Critical areas to question/validate include:
Tight deadlines
Costs
Unclear responsibilities
Possible adverse reaction
Commitment by others to follow through

Modify the plan if necessary


Communicate the Plan
Use the A3 format.
Discuss with management, peers, and
others affected

Execute the Plan


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Case Example:
Develop the Implementation Plan

5. Implementation Plan
What will be implemented

Who

When

Where

Status

Behind
1 Color gauge face green showing proper setting range

Kora S

4/30/2009

Paint Booth

Complete

In front of
2 Develop visual cards indicating gauges checked 4 times per shift

Kim M

5/5/2009

Paint Booth

Complete

3 Add spot inspection of problem area into standard work

Michael M

5/5/2009

Paint Booth

In Process

4 Install lock out on gauges

Matthew M

5/20/2009

Gauges

Scheduled

5.

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Team Exercise Part Eight: Evaluate & Prioritize


Countermeasures; Develop Implementation Plan
Identify potential countermeasures (short-term and long-term)
If possible, test effectiveness of temporary countermeasures.
If a problem cant be stopped, can it be controlled? (Example:
presort incoming material so that defects dont get to the line)
Prioritize countermeasures and complete Countermeasures (section
4) of the A3.
Complete the Implementation Plan (section 5) on the A3.
Define necessary actions
List the actions required
Sequence of actions required
Specify who will do what, when, and where
30 Minutes

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Exercise Eight Review


Each team share their countermeasures and
implementation plans with the other teams.
Explain how the countermeasures were
determined and prioritized.
Share the results of any tests.
Use the A3 to show the plans.

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Step 4: Confirm and


Follow Up

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The Four Step Process


Step Four
Step Three: Identify and
Implement Countermeasures
Brainstorm
countermeasures
Evaluate and prioritize
countermeasures
Develop the
Implementation Plan

Step Four: Confirm and


Follow Up
Verify plan effectiveness
Modify implementation
plan
Confirm the results
Standardize effective
countermeasures
Develop Future Steps

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Verify Plan Effectiveness


Monitor the progress of the
implementation plan
Was the implementation plan
completed?
Was the target or goal achieved?
Is it necessary to go back to
identify additional
countermeasures?
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Verify Plan Effectiveness

Verify the effectiveness of the


countermeasures
Did the countermeasures
effectively control the root
causes?
Has the problem been
controlled?
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Modify Implementation Plan


Evaluate results
Was the experiment successful?
Decide upon appropriate action(s)
Modify implementation plan if
necessary
Select new Countermeasures

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Confirm the Results


Countermeasures only control the
causes of problems
They must be constantly applied to
prevent recurrence of a problem
Countermeasures must be regularly
confirmed to make sure they are still
in place and being followed

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Confirm the Results


Identify what must be monitored
How will it be checked?
Identify the frequency to check
Who will be responsible?
How will you make it visible so
that everyone knows the
countermeasure is working?

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Confirm the Results:


Follow Up and Tracking

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Confirm the Results:


Countermeasure Follow Up & Tracking

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Standardize Effective
Countermeasures

Build countermeasures into the standard


work
Make countermeasures visual and easy
to see and confirm
Apply error proofing thinking so that
countermeasures can not be omitted

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Case Example:
Confirm and Follow Up

6. Follow-Up and Verification

Weekly Number of Paint Surge Defects

Check Method
Visual check of gauges and confirm inprocess inspection

Check Frequency
Once at start of shift and any time the problem is detected

Who will Check?


Line Leader will check and will turn process confirmation card
over to indicate that the check has been complete

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Develop Future Steps


1. Wrap up any remaining items
2. Request for assistance for issues outside
control
3. Hand off responsibility for problem to
owners

Sustaining Countermeasures
Continuous Improvement

4. What problem will be tackled next?

Ensure alignment and agreement


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Develop Future Steps:


The Art of Hansei

Hansei means deep reflection and


self learning.
build on past success/learn from failures
What did not work according to plan?
Why?
What will you change next time?

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Case Example:
Develop Future Steps

7. Future Steps and Recommendations


Currently the team needs to continue to monitor the results and verify the countermeasures. One countermeasure remains to be
implemented and is scheduled.
Line Leader will have daily responsibility to confirm countermeasures and to confirm any time the surging defect occurs.
The Team plans to go back and work on the thin paint issue which is the next highest defect category

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Confirm and Follow Up:


Final Team Exercise
As a group, discuss what might be required to complete
section 6 (Follow Up) of the A3 report.
Will it track progress to the target set in section 2 of the A3?
Identify who will check, how, and when will results be tracked and
reported?

Discuss how we might complete Future Steps and


Recommendations (section 7) of the A3 report.
List any recommendations needed to further reduce the problem
(help from others, etc.)
How will we do Hansei? Based on our learning, discuss what you
would do differently next time and why.

20 minutes

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A3 Example

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Wrap up and Report Out


Present A3s to management team.
Share your thoughts on the class
Lessons Learned
Benefits

What you will do next? What now? What


will we do TOMORROW?
How can we transform from Externally
Driven to Internally Focused?
How will we support each other? Teach
others?

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