Fault Tree Analysis

For Root Cause Analysis of Sporadic Events

Debra Detwiler, Bridgestone Americas November 18, 2010
Copyright 2010 MoreSteam.com www.moresteam.com

Agenda
Welcome Introduction of MBB Webcast Series Larry Goldman, MoreSteam.com “Fault Tree Analysis for Root Cause Analysis of Sporadic Events” Debra Detwiler, Bridgestone Americas Open Discussion and Questions

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Copyright 2010 MoreSteam.com www.moresteam.com

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cfm more information about curriculum.moresteam.moresteam. and schedule 4 Copyright 2010 MoreSteam. prerequisites.com .com www.com/master black belt.Master Black Belt Program Offered in partnership with Fisher College of Business at The Ohio State University y Employs a Blended Learning model with world-class instruction delivered in both the classroom and online Covers the MBB Body of Knowledge with topics ranging from advanced DOE to Leading Change to Finance for MBBs Go to http://www moresteam com/master-black-belt cfm for http://www.

B id M t Bl k B lt Bridgestone Americas t A i Responsible for Six Sigma training and coaching espo s b e o S S g a t a g a d coac g primarily for North American sites 33 years experience training. auditing.S.B. g y.com . q y g Certified Quality Engineer (CQE) B.com www. g .moresteam. operations. and quality consulting p . M.Today’s Presenter Debra Detwiler Master Black Belt. from the University of Akron 5 Copyright 2010 MoreSteam.A. management. in Statistics from Bowling Green University. coaching.

Bridgestone’s Integrated Quality Strategy Problem Solving Challenges The use of Fault Tree Analysis The Challenger Case Study Event Fault Tree Analysis Process Tire Manufacturing Example Keys to Success .

: Tire Technical Center/Akron .47 factories in 23 countries 3 facilities in 3 countries Head Office Bridgestone Corporation :Plant For Diversified Products . Inc.93 factories in 11 countries Bridgestone Americas Technical Center For Diversified Products/Yokohama / Tire Technical Center /Tokyo /T k Bridgestone Europe N.A. : Tire Technical Center/Rome Bridgestone Americas Holding.:Tire Plant :Tire Technical Center .V/S.

.200 Tire & Vehicle Service Centers across the U.S.BFSBridgestone Retail & Retail & Commercial Operations Commercial Operations 2.

Sporadic Event Chronic Process Variation Three Components of IQS h f enabling Bridgestone Americas to pursue Continuous Improvement by : • Reducing Variation • Creating a data driven culture • Using proven consistent tools Daily y Control .

Lack of defined problem solving methodology Lack of appropriate triggers and level of activity necessary Lack of management attention and critique Jumping to conclusions without data and evidence Formulating cause and countermeasures before analysis has been conducted Focus on physical causes. with little regard to human causes Behavior is difficult to modify .

Problems encountered and application of FTA Misproductions Accidents Environmental Releases Explosions l Product Freezes Major Customer Concerns Spec Errors Mold Problems Production Delays Manufacturing Errors M f t i E Quality Issues Near – miss Accidents or Injuries .

.for Root Cause Analysis of Sporadic Events Define & Measure Analyze Improve Control 5 Confirm Results and Change Standards The Use of FTA Event 1 Define Problem 2 Develop Timeline 3 Conduct Fault Tree Analysis 4 Implement Countermeasures D&M A I C The thought process resembles DMAIC. We are addressing the sporadic event (isolated incident) rather than the chronic variation. but we use a different set of tools.

“The Challenger Case Study” .

Ellison Onizuka Christa McAuliffe Greg Jarvis Judy Resnik Michael Smith pilot Dick Scobee commander Ronald McNair .Challenger STS 51-L : 11:38 A M 51A.M.

At 58 seconds into the flight … Telemetry data showed that there was a loss of pressure in the right Solid Rocket Booster (SRB) .

1986 11:38 A.Challenger STS 51-L: 51- Jan 28.M. 28 AM Do you remember what the root cause was reported as ? y p .

At 73 seconds seconds… Oxygen and Hydrogen Escaped at 44.000 ft .

Challenger Ch ll Exploded Combustible C b tibl Material Oxygen O Ignition I iti Source

Why TreeTM - as presented by Bob Nelms, Failsafe Networks
http://failsafe-network.com/

Challenger Ch ll Exploded Combustible C b tibl Material Release of Hydrogen Hole burned in H2 tank Oxygen O Ignition I iti Source

Release of Oxygen

O2 tank punctured by right SRB SRB aft attachment point burned

Flame escaped from right SRB

Why did the Flame Escape ? ?…
Investigators ran the tape frame by frame from the launch pad …
• at t-3 seconds, orbiter engines ignited to create initial thrust • at t=0 seconds, Solid Rocket Boosters ignited (SRB’s + fuel = 2,400,000 lbs) • Attachment bolts are popped • “Wawa” effect begun ( 3 / sec.) Wawa • Multiple smoke puffs timed ( 3 / sec.) @ 0.5 sec. after 0 5 sec ignition, smoke appears

Why did the Flame Escape ? ?… Why the right SRB and not the left ? • Right SRB was in the shade (internal p ) temp estimated at 32°) • Left SRB was in the sun (internal temp estimated at 55°) Why was this launch different ? C a e ge Challenger was as doomed on the launch pad .

Cold temperature launch This was the launch tower in Cape Canaveral. Florida This Thi was th coldest l the ld t launch ever h • 32° at launch • 26 °earlier that morning .

It was the O-Rings O- • SRB’s are manufactured in segments • Shipped from Morton Thiokol (Utah) and sent by railroad to Florida • SRB segments assembled and sealed using two flexible O-rings .

It was the O-Rings O•1977 test using strain gauges at ignition ( 4 yrs before the first shuttle flight) • Booster segment walls were more flexible than expected and joints were stiffer than expected • We must have had an O-Ring leak but there was no leak. no smoke puffs • The O-Rings were damaged but no leak • The wall took 15 milliseconds for max deflection • It took the O-Rings 5 milliseconds to expand (3:1 safety factor) .

challenged NASA “What temperature did you run these tests ?” • Demonstration with a C-clamp a caliper. C-clamp. caliper and a bucket of ice • How long do you think it took the O-Ring to fully expand ? .It was the O-Rings O• NASA was presenting the test results to congress • Dr Richard Feynman . Noble physicist Dr.

Flame escaped from right SRB Hot gasses escaped through O-Ring O-Ring did not seal at ignition Too inelastic to fill void at ignition Temp too cold at launch Decision to launch despite cold temp .

Too inelastic to fill void at ignition Temp too cold at launch Decision to launch despite cold temp Act of God .

Launch Decision Flow 2 weeks prior to launch NASA Hqtrs Initiate FRR Flight Readiness Review Vendors Certify Ready NASA SFCs Certify Ready Space Flight Center NASA MMT Countdown Begins Mission Management Team .

Launch Decision Flow 16 hrs prior to launch ° NASA Hqtrs Initiate FRR Vendors Certify Ready NASA SFCs Certify Ready NASA MMT ° Countdown Begins .

NASA uses the Anomaly Feedback Flow f bl th A l F db k Fl NASA Hqtrs Initiate FRR Vendors Are we going to launch or scrub ? Certify Ready NASA SFCs Certify Ready • Every vendor consulted • All were OK except Morton Thiokol NASA MMT Countdown Begins .Launch Decision Flow 16 hrs prior to launch In I case of problems.

7 have experienced O-Ring damage • Thi i way b This is beyond th k d the known flight envelope of 53° fli ht l f • The worst O-Ring damage was at 53° Conclusion : No Go – delay launch until 53° .Go / No Go Decision on Low Temp Launch Morton Thiokol • We suspected O-Ring problems since 1977 • We confirmed it in 1981 after first shuttle launches had 30% O-Ring damage • Of 24 flights.

we’ll delay .Marshall Spaceflight Center – Huntsville. if they hold. Ala NASA • We’ve already had 4 major delays – here’s another schedule we’ll miss • State of the Union Address is 1/28 and President Reagan intends to speak with Christa McAuliffe in orbit • The spacecraft is qualified to 40° • We’ve approved the waivers 24 times before • The second O-Ring will seal • There might not even be a temperature problem – data inconclusive • There is an element of risk in every launch Conclusion : Let’s test them.

Go / No Go Decision on Low Temp Launch Morton Thiokol • They are the customer and they are resisting • Contract renewal is tomorrow : It’s Rockwell or us (40. maybe engineering is being too cautious • The data is inconclusive Conclusion : Go .000 people depend on these jobs) • We’ve gotten away with this before.

What Was the True Root Cause? Was it the design of the SRB ? Was it the O Rings? Was it the temp at launch ? Was i h d i i W it the decision process of MMT ? f Was it the nature of Morton Thiokol’s CEO or NASA’s leadership ? .

“Root Cause” Analysis Root Cause Don’t Neglect the Human factor “Human beings cause problems” It’s not always • Systems • Designs • Culture Bob Nelms – Failsafe Networks Life : A seemingly endless series of situations to which we must respond .

they will! . If you ask them to.It is rare to find individuals who can see their own role in things that go wrong.

Event FTA P E t Process If we follow the steps… Let the data drive our search… We ill W will get to the root of the problem t t th t f th bl Phenomenon WHY Event Phenomenon Event WHY WHY Why Why y Root Cause Stay with the Physical Causes as long as we can. then go to Human Cause .

photographs and (i e statements records) Genbutsu Genba Capture the product and evidence (containment) Situation analysis Lot traceability Temporary countermeasure Release / restart of process . statements.e.D&M Event FTA P E t Process 1 Define Problem 2 Develop Timeline 3 Conduct Fault Tree Analysis 4 Implement Countermeasures 5 Confirm C fi Results and Change Standards Event 1 Define Problem D fi P bl Preserve the scene. if appropriate Gather data (i.

D&M Event FTA P E t Process 1 Define Problem 2 Develop Timeline 3 Conduct Fault Tree Analysis 4 Implement Countermeasures 5 Confirm Results and Change Standards Event 2 Develop Timeline Investigate and discern facts Interviews / statements I t i t t t Understand the process and what happened Analyze data and current state Chronology of events ( Ch l f (sequence) ) Process map / timeline / event analysis Compare process to standard .

A Event FTA P E t Process 1 Define Problem 2 Develop Timeline 3 Conduct Fault Tree Analysis 4 Implement Countermeasures 5 Confirm Results and Change Standards Event 3 Conduct Fault Tree Analysis Structured brainstorming of possible causes Identification of major phenomena Cause analysis y Identification of root cause Develop countermeasures .

I Event FTA P E t Process 1 Define Problem 2 Develop Timeline 3 Conduct Fault Tree Analysis 4 Implement Countermeasures 5 Confirm Results and Change Standards Event 4 Implement Countermeasures Develop “Should” process and implement D l “Sh ld” di l t Short and long term countermeasures Countermeasure causes Kaizen (improve) process Conduct necessary training Develop control plans and/or standards if standards. appropriate .

C Event FTA P E t Process 1 Define Problem 2 Develop Timeline 3 Conduct Fault Tree Analysis 4 Implement Countermeasures 5 Confirm Results and Change Standards Event 5 Confirm Results and Change Standards See cou e easu es through countermeasures oug Monitor “Should” process Develop/change standards. as necessary Control and standardize Standardize and institutionalize Evaluate results Track progress via audits .

Timeline : What Happened Timeline helps us to avoid jumping to conclusions and is integral to identification of proper phenomena .

use the “5-Why” approach to dig into the root cause (s) . .The Fault Tree : Why It Happened Once the proper phenomena have been identified.

15. Basic D B i Description of Triggering Event i ti fT i i E t Summary of Data Gathering Approach Process High Level (Actual Schematic) Stabilization Overview Physical Evidence People Evidence Paper Evidence Summary Sequence of Events Should vs. restart? 5. As Is Process (Compare vs. 11. How do I know it is contained? 3. 6. Standard) Cause and Effect (Optional) Summary of Gaps Identified Physical Causes Helps modify Human Causes behavior Fault Tree Countermeasures Understand their Thoughts Thought Process (Balance of Consequences) Hidden Organizational & Personal Causes Develop Timeline What did I find out? Conduct Fault Tree Analysis What caused it? Who caused it? What are the root causes? What are you willing to do? What were the circumstances? Who Wh did what wrong? h t ? How did you & your culture contribute? . 7. 1 What do I know? 2. How do I know it is OK to 4. 13. 17. 10. 14. 9. 16. 18.Event FTA Roadmap Template Define Problem Develop Timeline Conduct Fault Tree Analysis Key Tool Implement Countermeasures Confirm Results and Change Standards Define Problem 1. 12. 8.

Event FTA Template Date: February 2009 .

Who (did it happen to)? What (was the undesired Where (did it happen)? When (did it happen)? How do you know it is contained (esp. Employee used V2887 rubber. product)? How did you know it was OK to restart (stabilization)? Your Name: Completion Date: Des Moines Cold Feed Extruder Area (Agricultural Tire) 18 tires treaded with the wrong tread compound. Keep it simple.Insert basic description of TRIGGERING EVENT here. Held all tires treaded on this shift. 178 8:10am 1-6-2009 Used PICS data to track down tires treaded on B2B3 on 1-6-2009. Use the word “Anonymous” if the person’s identity must be protected. Cut rubber samples from each tire and took them to the lab to have the stock tested. Manager 1-8-2009 actual/potential consequence)? . but spec rubber is V2807 B2B3 Dept. All tires that passed the MRC lab retest were released from hold.

t too 6 s ocate all tires. p Assess: Verified what tires were involved.A few BULLETS. to locate a t es complications. Stab e ue Stabilize: Due to co p cat o s. g pp Stop: Once warm up sample was found to test bad. Re-Start: Until all suspect tires were verified to have been placed on hold. Production resumed after 16 hours. Isolate: All tires were frozen in PICS and placed in storage with hold tags on them. curing was shut down. it took 16 hrs. referring to containment and collection of data Containment p p p . production in curing stopped.should relate to WHAT on page 2) Why were tires treaded with wrong stock? . in GENERAL terms. Evidence Plan (What do I need to know?) People: Physical: Paper: See photo’s on next page for outline What is the Problem? (what q ( question will y you answer in this FTA -.

Collection of data and evidence e idence .

Keep it simple.Insert labeled schematics identifying the issue so the reader can understand the remainder of this document. Incorrect stock delivered to CFE Operator loaded stock at 8:10 am 18 tires p processed Sample p warm up ticket filled out Driver gave sample and ticket to supervisor Sample to lab at 2:10 pm Warm up sample failed & retest failed Curing shut down . Can be hand drawn.

Insert schematic. drawing. Keep it simple yet informative. etc. Effective Containment and Stabilization is critical. indicating containment and stabilization. Review with others to confirm your thinking. . data table.

Insert labeled photos and sketches of PHYSICAL EVIDENCE here. Make sure ALL items referred-to in other portions of this document are included. Keep it simple. .

. p p Make sure ALL items referred-to in other p portions of this document are included.Insert labeled photos and sketches of PHYSICAL EVIDENCE here. Keep it simple.

Insert labeled photos and sketches of PHYSICAL EVIDENCE here. Make sure ALL items referred-to in other portions of this document are included. Keep it simple. .

How did this happen? Operator: I don’t know. if it is a small skid no. p j . every time I scan a skid I check the ticket and try to find a stamp on the load. Manager: Do you think you can always tell the difference between the right rubber and wrong rubber? Operator: Y O t Yes. but l t t fi d th t Manager: We have 4 different standards that say we scan and verify loads vs. All 4 of these standards could have prevented this from happening. yes no Manager: You do know you are suppose to scan every load in correct? Operator: Yes.WHO said WHAT Always interview with someone else present to have dual confirmation of who said what. Manager: We had an issue on 1-6-2009 with tires that were treaded with the wrong rubber. But I can tell the difference between the rubbers. Why didn’t you follow them? Operator: I just didn’t scan. spec for tires. b t I always try to find the stamp. Manager: Why didn’t you scan this load into the extruder? Operator: I always try to. Develop interview guidelines. Manager: Do you always scan the rubber into the cfe? Operator: Not always if it is a large skid yes. It was a small skid and a fast tire.

WHAT said WHAT The follow standards give operator instructions : Standard Standard Standard Standard 178-26 178-23 178-17 763-20 loading rubber at cfe’s p g cfe rubber sampling green tire to spec rubber ID warm up sampling .

WHAT said WHAT The follow standards were not followed by operator : Standard Standard Standard Standard 178-26 178-23 178-17 763-20 loading rubber at cfe’s cfe rubber sampling green tire to spec rubber ID warm up sampling .

CONTACTED PE TO FREEZE THESE TIRES IN PICS DID PRODUCTION TURNOVER WITH ON COMING SHIFT ALL TIRES WERE PLACED BY THE 1 & 2 BOOTH WITH HOLD TAGS PLACED ON THE RACKS WITH THE HELP OF CURING. CUL PULLED PICS INFO FOR EACH TIRE AND CUT SAMPLES OFF EACH TIRE. CUL CALLED CURING TO HAVE ALL hdct PRESSES SHUT DOWN ON QUALITY. PULLED PICS INFO NUMBER OF TIRES WERE PLACED ON HOLD. IN GENERAL TERMS. MILA TOOK SAMPLES TO THE LAB. LAB REQUESTED ANOTHER SAMPLE FROM AROUND THE SAME TIME FRAME. 450PM 510PM 515PM 530PM 545PM 135 OFFICE 645PM 815PM 850PM 1230AM 1245AM . referring to the schematic Event Timeline Form Who/What loaded w rong rubber into cf e e.Approximately 10 bullets. MEETING WITH NORVEL. TIME 810am Component Machine Comments: didn’t scan rubber into extruder 811am treaded 18 tires ussing v2887 rubber instead of v2807 rubber 850am Took rubber sample and information off v2887 ticket 851am cf e rubber sample w as taken to the lab 2pm LAB CALLED DOWN TO TELL TELL TIREROOM WARM UP SAMPLE FAILED OFF OF B2B3. CUL CUT A SAMPLE OFF OF A TIRE IN FRONT OF THE PRESS DELIVERED SAMPLE TO THE LAB AND WAITED FOR THE SAMPLE TO BE TESTED 415PM B2B3 430PM 445PM More detailed than previous high level map p g p SAMPLE FAILED TEST CUL CAME BACK DOWN TO THE AREA AND FOUND WHAT GREEN TIRES WERE PRODUCED WITH THE HELP OF PICS. DID TIMELINE ON ISSUES IN MAIN CONFERENCE ROOM.

Keep it simple. Highlight items in the “As Is” process that did not meet standard requirements.Insert labeled schematics so the reader can understand what should have happened vs. what did happen. .

Insert labeled schematics so the reader can understand what should have happened vs. Reg.987. Originator Machine Name Item/Step: Manager Date: Shift 3 Improve Countermeasues to close the gap between standard and actual. including supervisors. and after each break. No. Keep it simple. Dept. Improvement implemented Standard restored Start Expose the Problem 1 Is there a standard NO Y ES Investigate gap betw een actual/ideal and standards.00 by not standards we have in place.All tags and impression must match marquee rubber not scanned in and stock not verified.Verify stock code of rubber and scan ticket when loading new rubber skid.employee didn’t follow standard Delivered 3 h D li d hours l t . tags and impression V2887 2 Difference No verification or scanning . Spec = V2807.D li bb li Deliver warm-up samples to the lab every 2 hours. Standards Based Improvement Summary Highlight items in the “As Is” process that did not meet standard requirements. Delivered 5 hrs after sample taken. after lunch 2:00 pm. what did I t th d d t d h t h ld h h d h t happen.warm-up samples sample taken at 8:51 and and delivered at must be delivered at start of shift. 763-20 warm up sampling . Re-educate dept. Work Std ….employee didn’t follow standard sample not taken to lab after morning of lunch breaks . Expose problems Is there a gap betw een standard and actual? Y ES NO 2 M ake new standard 4 3 Phomonom cost plant $10. 178-23 f 178 23 cfe rubber sampling . (Visual explaination of improvement) Before Improvement After Improveme Identify w ith (X) how issue w as exposed Quality Safety Bekido VOR Review Expose w ork that can't be done to std f rom problem detection inf ormation Be aware of problems. M/C Std ….employee didn’t follow standard 5 Control Educate to follow standards (Contents and method of education: What controls are in place to Foll Action A ti Education to be done by HR for not following standards.employee did ’t late l didn’t follow standard No match . FM-900-003 . Process Std ? Standard Actual Work 178-26 loading rubber at cfe's . identify is sues (Quantify size of problem) Is there a dfference between actual/ideal and standard? Measure/Analyze Did you compare with …. on requirement for delivering samples to lab. 178-17 green tire to spec rubber id . Impro vement o r Resto re Educate to standard 5 4 Revise o r make new std to reflect impro vement 5 Educate to standard 4 End Improve 1 Define Example of Improvement.

rubber scan information etc… Curing presses were down 18 hrs awaiting confirmation of containment. . No system to prevent this from happening. Gaps-All Poor turnover/communication Lack of knowledge to lot trace on all shifts Unable to access lot trace information i. actual schematics Gaps-Tire Room Samples taken at 7:15am and 8:10am.e. Delivered to lab at 2:00pm. CFE run records.IN GENERAL TERMS. Scanned same rubber load ticket twice. Why did it take until 1:00 to confirm all tires were contained contained. Gaps-MRC Lab Sample delivered to the lab at 2:00pm. Tire room notification of failed sample at 5:00pm. Gaps-Curing Room Tire was scanned ahead of time at the press. As a result another tire was laid in the press without needing to scan. PICS system does not allow backing out tire. Scanned multiple tires at the same time. We didn t follow standard 8:10am 2:00pm didn’t standard. referring to should vs.

Write in past tense. Why did tires get treaded with wrong stock? Wrong stock was delivered to CFE CFE. Rubber not scanned at start of new load. Use sentences/paragraphs. Warm up sample delivered to lab 5 hours late.HOW did the incident occur (What were the PHYSICS of the incident)? BE SPECIFIC. Wrong stock was not identified by operator. .

Machine. Use “5Why” to get to root. . Material. The 5 Why approach and branching drives th name FTA di the FTA.Complete FTA: Address Man. Phenomena (unusual actions) identified helps with cause analysis. and Method.

Utilize SDP process for control. realistic. Address immediate. time-sensitive) action items. detection. attainable. measurable. and prevention needs: from FTA. Keep it simple and realistic.Establish SMART (specific. .

every time I scan a skid I check the ticket and try to find a stamp on the load. But I can tell the difference between the rubbers. but I always try to find the stamp. . Human Cause #1 B2B3 operator didn’t follow standards Manager: We had an issue on 1-6-2009 with tires that were treaded with the wrong rubber. if it is a small skid no.For each Human Cause. Why didn’t you follow them? p j Operator: I just didn’t scan. Manager: You do know you are suppose to scan every load in correct? Operator: Yes. Manager: Do you think you can always tell the difference between the right rubber and wrong rubber? Operator: Yes. It was a small skid and a fast tire. All 4 of these standards could have prevented this from happening. How did this happen? Operator: I don’t know. Manager: Do you always scan the rubber into the cfe? Operator: Not always if it is a large skid yes. The Triggering Situation is the “point in time” when the inappropriate decision was made that led to the Human Cause. Manager: Why didn’t you scan this load into the extruder? Operator: I always t t O t l try to. Manager: We have 4 different standards that say we scan and verify loads vs. Fill-in ONE copy of this page for each of the identified HUMAN CAUSES. spec for tires. describe the Triggering Situation. Describe the circumstances at this point in time.

Capture the ACTUAL WORDS that MIGHT have been running through the persons mind.Inappropriate As Desired .Determine the thought process of the person who behaved inappropriately. Bullet-style.Appropriate • Identifying codes similar • Machine allowed to run without scan • Re-scan of previously scanned ticket d i k • Operator doesn’t always scan small skids • Failure to deliver MRC sample for 5 hours • CFE lot trace times on racks of tires the same • Make codes different • Machine recognizes skid change and requires new scan • Machine recognizes previously scanned ticket d i k • Machine forced scan regardless of size • Delivery to lab every two hours • Tires scanned in order of g placed back on treading when p rack . Complete Balance of Consequences. As Is .

Must be generic.. not specific to only this one incident.. Bullet-style..push for production • I( (name).. and present tense. i. Think about what you are willing to change – add to FTA if possible.assume everyone knows what I know • I (name).don’t think it is important to scan a small skid p . Preface all responses with the words “We” and “I”.do not do enough ) d td h audits • I (name).e.do not explain why it is important to follow standards • I (name).. possible What is it about the way we ARE that is evident in the above thoughts? Organizational Causes • We allow similar stock codes to be used • We have inadequate compound segregation • We allow machine to run without scan • We have no system to detect or alert a failure to deliver sample g p • We give supervisors more tasks than they can complete in a 12 hour shift • We do not define clear consequences for not following standards • We do not enforce scanning Personal Causes • I (name).

and reinforcement Emphasis on “Define & Measure” and development of timeline Proper identification of phenomena and follow through on “5-Why” analysis Don’t neglect the human factor Weave the process into our culture and work to modify behavior . critique.Training. and development of expectations Definition of appropriate triggers and level of activity necessary Management review. coaching.

Thank you for joining us 69 Copyright 2010 MoreSteam.moresteam.com .com www.

com/master-black-belt.com .com/presentations/webcast-fault-tree-analysis.com www.moresteam. slides and other materials: http://www.M L G ld Vi P id t M k ti MoreSteam. Debra Detwiler.com St lgoldman@moresteam. Master Black Belt – Bridgestone Americas detwilerdebbie@bfusa.cfm Master Black Belt Program: http://www.moresteam.moresteam.Resource Links and Contacts Questions? Comments? We’d love to hear from you.com Additional Resources: Archived presentation.com Larry Goldman.cfm 70 Copyright 2010 MoreSteam. Vice President Marketing .

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