WCM Overview QK

WCM Overview
Pengenalan WCM
© BPB Ltd 2009

Problem Solving
Introduction
Perkenalan
PRN_FD_5 PS Quick Kaizen_1-0.ppt

The Problem Solving Approach
• The clearly and precisely problem definition is a key to success in problem solving.
Mendefinisikan masalah dengan jelas dan tepat adalah kunci keberhasilan dalam pemecahan masalah.
• There are 2 types of Problem. Ada 2 tipe masalah.
– Sporadic (Special Causes) - - Sudden, Infrequent, Large deviations. Tiba-tiba, jarang dan deviasi besar.
– Chronic (Common Causes) - - Frequent, Small deviations. Sering dan deviasi kecil
Sporadic losses are indicated by sudden, infrequent, large deviations

and are typically the result of a single cause. As the cause and
effect relationships of sporadic losses are relatively clear.
Kerugian Sporadis ditandai dengan tiba-tiba, jarang, penyimpangan besar dan biasanya hasil dari penyebab
tunggal. Hubungan sebab dan akibat kerugian sporadis relatif jelas.
Chronic losses rarely have a single cause

and tend to be the consequence of
complex cause and effect relationships.
Loss
Sporadic
Losses • Caused by one of a number of causes
Single which vary from one occurrence to
Cause
penyebab another.
tunggal
• Created by the combination of a
number of causes which also vary
from one occurrence to another.
Kerugian kronis jarang memiliki penyebab tunggal dan
Multiple cenderung dampak dari hubungan sebab dan akibat yang
Time
Chronic Causes
sangat kompleks.
• Disebabkan oleh salah satu dari sejumlah penyebab yang
Losses penyebab
banyak bervariasi dari satu kejadian yang lain.
• Diibuat oleh kombinasi dari beberapa penyebab yang juga
bervariasi dari satu kejadian yang lain.
PRN_FD_1 Intro to Problem Solving_1-0.ppt
Pendekatan Problem Solving
• Thought Process of Problem Solving – 4 stages

Proses Pemikiran Problem Solving - 4 tahap
P
R
O
B
L
E
M
C
O
M
P
L
E
X
I
1 2 3 4
T System Root Cause Counter
Y Problem Definition
Understanding Analysis measure
Identifikasi Masalah Pemahaman Proses/System Analisa akar penyebab Tindakan Penanggulangan
• Tools used depend upon the complexity and types of problems.

Penggunaan Tools bergantung kepada tingkat kerumitan dan tipe masalah.
Why 3.1
(Possible Cause 1)
5
2 3
Why 1.1 Why 2.1 Verify Why 4.1

(Possible Cause 1)
(Possible Cause 1) (Possible Cause 1)
Verify Verify Verify

Why 3.2
(Possible Cause 2)
1
Why 1.2
2
Why 2.2
3
Verify
Why 4.2
5
Why 5.1
6
Solution 1 Solution 2 Solution 3
Problem (Possible Cause 2) (Possible Cause 2) (Possible Cause 2) (Possible Cause 1)
Criteria 1
P 5W + 1H Principles & Parts lists &
Verify
Why 1.3
2
(Possible Cause 3)
Verify
Why 2.3
3
(Possible Cause 3)
Why 3.3
4
(Possible Cause 3)
Verify
Verify
5
Verify
Criteria 2
Criteria 3
R failure
Why 4.3
(Possible Cause 1)
Criteria 4
Parameters Verify Verify
Why 3.4
4
Verify
Matrix Analysis
modes 2
(Possible Cause 4)
O Why 1.3
(Possible Cause 4)
Verify
Verify
Why 4.4
5
(Possible Cause 2)
Why 5.2
6
(Possible Cause 1)
B Verify Verify
L 2
Tag
E Why 1.1
(Possible Cause 1)
Verify
Done By:
CORRECTIVE ACTION
Date:
Duration [hrs]:
4) Action plan to remove problem:
Action (Risk Assess First) Who When Done?
M Process
If Modification: 1
Corrective Action Taken:
Risk assessment done
Action
2 Action Plan to
1 2
5W + 1H
Why 1.2 Remove Problem
Maps Problem (Possible Cause 2) (Countermeasure)

3
Mechanism Verify Single

Do any of the following need updating?
Operating Procedures
Safety Procedures
Cleaning Standards
Who Planned Done 4
Planning
Drawings
Lubrication Standards
Inspection Standards 5
C
2 Mechanical Standards
Electrical Standards
5 Why
Software Documentation
Why 1.3 Maintenance Documentation

6
(Possible Cause 3)
What training is required?
O
Verify
M WORKSHOP
DEFECT TAG
OPERATOR
TAG No.
NAME
DATE
STEP 1 2 3 4 5 6 7
I Know ! I Know ! Tag
CORRECTIVE ACTION
P
MACHINE PRIORITY A B C Done By: Date:
Duration [hrs]:
ABNORMALITY CONTAMINATION Corrective Action Taken:

If Modification:
1 Leak 16 Lubrication Risk assessment done
2 Worn 17 Water/Liquid
3 Broken 18 Product
4 Loose 19 Process Waste
5 Missing 20 Gas
L 6
7
Misaligned/deformed
No Standard
21
22
Dirt
Other -Please specify
Tag
8 Blocked
9 Excess Vibration HARD TO ACCESS TO….
10 Excess Noise 23 Clean
11 Excess Temperature 24 Inspect Do any of the following need updating?
Who Planned Done
12 Malfunction 25 Lubricate Operating Procedures
13 Redundant Equipment 26 Replace
E
Safety Procedures
14 Corrosion 27 Tighten Cleaning Standards
15 Other -Please specify 28 Other -Please specify Lubrication Standards
Inspection Standards
Mechanical Standards
Problem Description Electrical Standards

Maintenance Documentation
X Defect Tags v 2.4
I 2 3
1 4
T
Y System Root Cause Counter
Problem Definition

Defining a problem – “Simple Problems”

Mendefinisikan Masalah – “Masalah yg sederhana”
P
R Simple problems can be easily seen, explained and described
“Masalah yang sederana” dapat dengan mudah dilihat, dijelaskan dan di uraikan.
O
B
L
E See
Lihat..
it,
M
Say it,
C Katakan..
O Write
Tulis..
it!
M
P
L
E
X
I
T
Y Craftsman Operator
1
Problem Definition
Identifikasi Masalah
Defining a problem – “More Complex Problems”

Mendefinisikan Masalah – “Masalah yang lebih kompleks
P More complex problems require a structured approach to gather the

R
O
data and define the problem.
Masalah yang lebih kompleks membutuhkan pendekatan yang terstruktur untuk mengumpulkan data dan mendefinisikan masalah.
B
L
E
M
Using a 5W + 1H data collection technique
Menggunakan teknik pengumpulan data 5W + 1H
C
O
M 5W data & 1H
P physical facts
L for the event WHAT WHEN WHERE WHO WHICH
E
X
I
T
Y
HOW
1
Problem Definition
7
Defining a problem using structured questions; 5W+1H

Mendefinisikan masalah menggunakan pertanyaan yang terstruktur ; 5W + 1H
What product, machine, size is the problem related to?

WHAT Produk, mesin dan ukuran apa yang berkaitan dengan masalah?
P
R Is the problem linked to a specific event?
E.g. during continuous running, at changeover, start up,
O shut down, after handover, after a break etc…
B
WHEN
Apakah masalah terkait dengan suatu peristiwa tertentu? Mis. selama mesin
L berjalan terus menerus, pada changeover, start up, shutdown, setelah serah
terima, setelah istirahat dll ..
E
M Where on the machine, product, component etc..
WHERE is the problem occurring?
C Dimana pada mesin, produk, komponen dll.? Masalahnya yang terjadi?
O
M 5W data & 1H Is the problem linked to a shift, team or person?
physical facts Here we identify a lack of capability, not who to blame!
P WHO Apakah masalahnya terkait dengan shift, tim atau orang?? Di sini kita
L for the event mengidentifikasi kurangnya kemampuan, bukan siapa yang harus disalahkan!
E
X Which direction is the problem going? Is it getting
better or worse, are there any related trends?
I WHICH Bagaimana trend masalah yg terjadi? Apakah semakin Lebih baik
T atau lebih buruk, apakah ada tren yang berhubungan?
Y
How do you see the physical change of machine
1 and /or product compared to its optimal condition?
HOW Bagaimana kita melihat perubahan fisik dari mesin dan/atau produk
Problem Definition dibandingkan dengan kondisi yang optimal?
8
Defining a problem – “More Complex Problems”

Mendefinisikan Masalah – “Masalah yang lebih kompleks
P
R
O
B
More complex problems require an
5W data & 1H
L
physical facts even more structured and rigorous
E
M collection approach to gather & investigate
C
the data to define the problem.
Masalah yang lebih kompleks membutuhkan pendekatan yang lebih
O
5W data & 1H terstruktur dan ketat untuk mengumpulkan & menyelidiki data untuk
M mendefinisikan masalah.
P physical facts
L for the event
E
X
I
T
Y
1
Problem Definition
Identifikasi Masalah (02) The Problem Solving Approach_Solving

Problems & Making Decisions Course_1- 9
1_May 2012
5W data Defining a problem – “Very Complex

stratification
& 1H physical
Problems” Mendefinisikan Masalah – “Masalah yang sangat kompleks
facts
P
R
The most complex Masalah yang sangat kompleks membutuhkan
pendekatan yang lebih terstruktur dan ketat
O problems require an untuk mengumpulkan dan menyelidiki data
B 5W data & 1H untuk mendefinisikan masalah
L
physical facts
even more structured
E
M collection and rigorous approach 120
100
What - Product
What
Hours
80
to gather & investigate

60
40
20
C Product Product Product Product
the data to define the

Type A Type B Type C Type D
O When
M 5W data & 1H 60
When – does it occur
problem.
50
Hours
40
P physical facts 30
20
for the event

10
L Product
Changeover
Shift
Change
Continuous
Running
Start-up
E 60
Where
Where – does it occur
X
Using a 5W + 1H
50
Hours
40
I 30
Menggunakan
20
T stratification teknik stratifikasi

10
Wet end
transfer
Mixer Dryer Takeoff
Y 5W + 1H untuk
technique to mengisolasi
24
20
Who – is it related to
Who
Hours
1
16
fenomena
isolate the
12
Problem Definition
8
tertentu 4
‘B’ Shift ‘C’ Shift ‘A’ Shift ‘D’ Shift
specific phenomena.
5W data
stratification
& 1H physical
facts
P
R
O
B 5W data & 1H
L
physical facts
E
M collection
C
O
M
5W data & 1H
P physical facts
L for the event
E
X
I
2 3 4
T System Root Cause Counter-
Y Understanding Analysis Measures
1 Pemahaman Proses/System Analisa akar penyebab Tindakan Penanggulangan
Problem Definition
11
System Understanding – “Simple” Systems

Pemahaman System – sistem “sederhana”
P On many occasions the system is understood by the

R
O
problem solver. Pada banyak kesempatan system dipahami oleh problem solver.
B
L
E It is not necessary to use any additional techniques
M other than “common sense”. Hal ini tidak perlu untuk menggunakan teknik
tambahan selain "akal sehat".
C
O I Know !
Intuition - immediate knowing of
M something without the conscious use of
P
L reasoning; based on skills, knowledge
E
X and experience.
Intuisi - segera mengetahui sesuatu tanpa menggunakan penalaran sadar;
I berdasarkan keterampilan, pengetahuan dan pengalaman.
T
Y
2
This approach should be applied first in solving
System Pendekatan ini harus diterapkan pertama dalam memecahkan
Understanding every problem! setiap masalah!
Pemahaman Proses/System
12
System Understanding – “More Complex” Systems

Pemahaman System – sistem “Lebih Kompleks”
P Reference to support materials and current knowledge is

R
O
required to clarify understanding on how the machine or
B process works. Referensi untuk bahan dukungan dan pengetahuan saat ini diperlukan untuk
memperjelas pemahaman tentang bagaimana mesin atau proses bekerja.
L
E
M
Process For Machines: Mechanism Drawings
C Maps
O
Mechanism
Drawings Machine Draw what you see
M Drawings
P
& how it works
Gambar lah apa yang anda lihat dan
L cara kerjanya.
E I Know !
X
I
T
Y
Process
2 For Processes: Maps
Process Mapping
System
Understanding
13
System Understanding – “Most Complex” Systems

Pemahaman System – sistem “Sangat Kompleks”
P Sometimes the system is not fully understood and

R
O
Principles &
Parameters
Parts lists &
failure
modes
therefore detailed understanding is require
B Kadang-kadang sistem itidak sepenuhnya dipahami dan karena itu
dibutuhkan pemahaman yang lebih detil.
L
E
M Rigorous techniques of system analysis are
C Mechanism
Process
Maps required Dibutuhkan teknik analisa system yang ketat/kuat.
O Drawings
M
P
L
E I Know !
X
I Principles &
T Parameters
Y
Parts lists &
2 System failure
Understanding modes
14
5W data
stratification
& 1H physical
facts
Parts lists &

Principles & failure
P 5W data & 1H Parameters modes
R physical facts
O
collection
B
L
E
M Process
5W data & 1H Maps
Mechanism
C physical facts Drawings
O for the event

M
P
L
E I Know !
X
I
1 3 4
T Root Cause Counter
Analysis measure
2 System Analisa akar penyebab Tindakan Penanggulangan
Understanding 15
Root Cause Analysis

Analisa akar penyebab
3 stages in the analysis process

P 3 tahapan dalam proses analisa
R
O
B Identifying possible causes Identifikasi peluang penyebab
L
E
M
Verifying real cause/s Verifikasi penyebab sebenarnya
C Establish root cause Menentapkan akar penyebab

O
M
P
L At the lowest level, the root cause may be obvious.
Pada level yang terendah, akar penyebab mungkin kelihatan jelas
E
X As the problem and system become more complex the
I
T techniques become more sophisticated.
Y Ketika masalah dan system menjadi lebih kompleks teknik yang digunakan akan semakin mutakhir.
3 Root Cause
Analysis
16
Root Cause Analysis - simple obvious cause

Analisa akar penyebab – Penyebab yang jelas dan sederhana
P At the simplest level, the cause may be obvious.

R Pada level yang tsederhana, akar penyebab mungkin kelihatan jelas
O
B
L
E
M Just Do It….
C
O
M
P
L
E I Know !
X
I
T
Y
3 Root Cause
Analysis
Root Cause Analysis – where several possible causes exist

Analisa akar penyebab – Penyebab terdiri dari beberapa (lebih dari satu)
For simple problems with more than one possible cause

P
R
“1 Why analysis” may be used
Untuk masalah yang sederhana dengan lebih dari satu penyebab mungkin dapat menggunakan
O analisa“1 why”
B
2
L
E Why 1.1
2 Possible Causes
Kemungkinan penyebab Why 1.1
(Possible Cause 1)
(Possible Cause 1)
M
+ Verification
Verify
2 Action Plan to
1
Verifikasi
Problem (Possible Cause 2) (Countermeasure)
C Verify Verify
O Why 1.3
2
M (Possible Cause 3)
2
Verify
1 Action Plan to Remove
P Problem
L Why 1.2 Root Cause
I Know ! (Possible Cause 2)
(Countermeasure)
E
X
I Verify
T
Y 2
3 Why 1.3
Root Cause (Possible Cause 3)
Analysis
Verify
18
Root Cause Analysis – where the root cause may not be

found at the “1 Why analysis” level
P
R
O To establish the root cause for the “single 1 why” problems
B
L
“5 why analysis” may be required
E Why 1.1
2
(Possible Cause 1)
M Verify
Problem
Why 1.2
2
(Possible Cause 2)
Action Plan to
Remove Problem
(Countermeasure)
Root cause analysis on a verified 1Why cause
C
Single cause
Verify
Single
O Why 1.3
2
5 Why
Verify
P
L Problem Why 1 Why 2 Why 3
E
I Know ! (Possible Cause 1) (Possible Cause 2) (Possible Cause 3) etc.
X
I
T Verify Verify Verify
Y
3 Root Cause
Analysis
19
Root Cause Analysis – verification

Analisa Akar Penyebab - Verifikasi
Verify each
P possible
R cause
O Verifikasi setiap
B kemungkinan penyebab
L
E Why 1.1
2
(Possible Cause 1)
M
1
Verify
2 Action Plan to
We always verify if a possible cause is a real cause or
not, before moving on
C
Selalu verifikasi jika kemungkinan penyebab adalah penyebab yang sebenarnya
Verify
Single
O
atau pun bukan sebelum melanjutkan ke langkah berikutnya
2
Why 1.3
5 Why
Various techniques can be employed

Verify
P
L
I Know ! including testing and experimentation at
E the highest level
X
I
T
Y Each real cause requires a countermeasure
Setiap penyebab yang sebenarnya membutuhkan tindakan penanggulangan
3 Root Cause
Analysis
20
Root Cause Analysis – where multiple causes exist

Analisa Akar Penyebab - Dimana ada banyak penyebab
4
Why 3.1
(Possible Cause 1)
5
2 3

(Possible Cause 1)

Why 3.2
For more complex problems with multiple causes,

(Possible Cause 2)
2 3 5 6
1
Why 1.2 Why 2.2 Verify
Why 4.2 Why 5.1
P
4
Verify Verify Verify Verify
Why 3.3
(Possible Cause 3)
the “5 Why Advanced” analysis technique is used.

2 3
R Why 1.3
(Possible Cause 3)
Verify
Why 2.3
(Possible Cause 3)
Verify
Verify
4
Why 4.3
5
(Possible Cause 1)
Why 3.4 Verify
O
2
(Possible Cause 4)
Untuk masalah yang lebih kompleks dan

Why 1.3
5 6
(Possible Cause 4)
Verify
Why 4.4 Why 5.2
Verify
B Verify Verify
dengan banyak penyebab membutuhkan 4
L teknik analisa 5 Why tingkat lanjut. Why 3.1

(Possible Cause 1)
E Why 1.1
(Possible Cause 1)
2
2 3
5
M Verify Why 1.1 Why 2.1 Verify Why 4.1

(Possible Cause 1)
2 Action Plan to
1
Problem (Possible Cause 2) (Countermeasure) 4
C Verify
Verify Verify
Why 3.2
Verify
Single (Possible Cause 2)
O Why 1.3
2
2 3
1 5 6
5 Why
Verify Problem Why 4.2 Why 5.1
P (Possible Cause 2) (Possible Cause 2) (Possible Cause 2) (Possible Cause 1)
L 4
I Know ! Verify Verify Verify Verify
E Why 3.3
2 3 (Possible Cause 3)
X Why 1.3 Why 2.3 5
I (Possible Cause 3) (Possible Cause 3)
Verify
Why 4.3
T Verify Verify
(Possible Cause 1)
4
Y Verify
Why 3.4
2
(Possible Cause 4)
3 Root Cause Why 1.3

(Possible Cause 4)
5 6
Verify
Why 4.4 Why 5.2
Analysis Verify
Verify Verify
5W data
stratification
& 1H physical
facts
4
Why 3.1
(Possible Cause 1)
5
2 3

(Possible Cause 1)

Why 3.2
(Possible Cause 2)
2 3 5 6
1
Problem Why 4.2 Why 5.1
(Possible Cause 2) (Possible Cause 2) (Possible Cause 2) (Possible Cause 1)
P 5W data & 1H Verify
Why 1.3
2
Verify
Why 2.3
3
Why 3.3
4
(Possible Cause 3)
Verify
5
Verify
Parts lists &

Verify
R physical facts
Why 4.3
Principles &
(Possible Cause 1)
failure Verify Verify

4
Parameters modes
2
Why 3.4
(Possible Cause 4)
Verify
O collection
Why 1.3
(Possible Cause 4)
Verify
Verify
Why 4.4
5
(Possible Cause 2)
Why 5.2
6
(Possible Cause 1)
B Verify Verify
L 2
Why 1.1
E (Possible Cause 1)
Verify
M 5W data & 1H Process

Maps 1 2 Action Plan to
Mechanism
physical facts Drawings Verify
C Single
O for the event Why 1.3

(Possible Cause 3)
2
5 Why
M I Know ! Verify
P
L I Know !
E
X
I
1 2 4
T System Counter
Understanding 3 measure
Root Cause
Identifikasi Masalah Pemahaman Proses/System Analysis Tindakan Penanggulangan
22
Hierarchy of Proposed Solutions
Hirarki Usulan Solusi
4
Elimination by Design
Eleminasi dengan Design
Level of Solution Effectiveness
Countermeasure
Penanggulangan
3 Mistake Proofing
Pembuktian Kesalahan
Tingkat Efektifitas Solusi
2 Standardisation
Standardisasi
1b
Containment Containment
Penahanan/ Control
Penahanan
1a
Administration
Administrasi
Hierarchy of Proposed Solutions
Level Activity Description
 Remove the root cause by design/ Menghilangkan akar masalah dengan design
4 Elimination by Design
Eleminasi dengan Design
 Remove the step by design/ Menghilangkan langkah proses dengan design
 Remove need for activity/ Menghilangkan kebutuhannya dari aktifitas proses
 Install one of the 3 levels of mistake proofing device/ Instal satu dari 3 tingkatan alat pembuktian kesalahan.
- Stop Hentikan
3 Mistake Proofing - Control Kendalikan Defect at Source
Pembuktian Kesalahan
- Warn Peringatan
 Define/revise the Maintenance Plan based on time Tentukan / merevisi Rencana Pemeliharaan
berdasarkan waktu (Inspeksi dan perubahan berkala)
(inspection and periodical changes)
2 Standardisation 
Tim mengembangkan OPL dan
Team develops OPL’s and trains all employees, (procedures updated) melatih semua karyawan
Standardisasi  Update Standard work routine, (develop an Improvement sheet) Perbaharui Standard Kerja yang rutin
 Implement visual controls Melaksanakan Visual Kontrol
 Implement inspection routines Melaksanakan Pemeriksaan Rutin
1b Containment  Fix the breakdown and increase monitoring on the equipment. Memperbaiki kerusakan dan meningkatkan
pemantauan pada peralatan
Penahanan
 Put the rejects into a separate bin so that you can clearly see them. Masukkan reject ke tempat yang terpisah
sehingga dapat terlihat dengan jelas
 Set up a daily performance monitoring and review process to ensure that things are kept on track
Mengatur pemantauan kinerja harian dan peninjauan proses untuk memastikan sesuatu pada jalurnya
 Clean up the spill and repair the damage. Bersihkan tumpahan dan perbaiki kerusakan
 Retrain operators Melatih operator

 Add Check list Tambah Check List
1a Administration  Replace the broken part Penggantian part yg rusak
 Write a new procedure Buat Prosedur baru
Administrasi  Investigate further Investigasi lebih dalam lagi
 Put up a warning sign Buat tanda peringatan
Countermeasure
Tindakan Penanggulangan vs Penahanan
vs Containment
Countermeasure – an action that will
P permanently eliminate the root cause of the
R
O
problem. suatu tindakan yang secara permanen akan menghilangkan akar
penyebab masalah
B
L For example Pokayoke (mistake proofing). A true
E
M
Pokayoke does not rely on human memory or
action, and will give a warning or stop the process
C when a defect/problem is found.
O Misalnya Pokayoke (pembuktian kesalahan). “Pokayoke” sejati tidak bergantung pada
M memori manusia atau tindakan, dan akan memberikan peringatan atau menghentikan
P proses ketika cacat / masalah yang ditemukan.
Containment – an action that only controls

L
E
X
I
the root cause but does not eliminate it.
suatu tindakan yang hanya mengendalikan akar penyebab tetapi tidak menghilangkannya
T Counter
Y
measure Note; SOPs and people training are only
Tindakan Penanggulangan
containment actions if they rely on human memory
or action. SOP dan pelatihan orang hanya tindakan penahanan jika mereka bergantung
pada memori manusia atau tindakan
25
Countermeasures
Tindakan Penanggulangan - Hirarki
- Hierarchy
Criteria 1
Criteria 2
Alternative solutions that are
P
Criteria 3
Criteria 4 Matrix assessed to optimise the final
R
O
Analysis countermeasure
Alternatif solusi yang dinilai untuk mengoptimalkan penanggulangan
B 4) Action plan to remove problem:
akhir
L 1
E 2
M Action Basic countermeasure with

4
Planning
6
C
O
sustaining actions
Penanggulangan dasar dengan mempertahankan tindakan
M
P
L Just Do It
E Basic countermeasure
X Penanggulangan dasar
I
T Counter
Y
measure
26
5W data
stratification
& 1H physical
facts
4
Why 3.1
(Possible Cause 1)
5
2 3

(Possible Cause 1)

Why 3.2
(Possible Cause 2)
1
Why 1.2
2
Why 2.2
3
Verify
Why 4.2
5
Why 5.1
6
Criteria 1
P 5W data & 1H Principles & Parts lists &
Verify
Why 1.3
2
(Possible Cause 3)
Verify
Why 2.3
3
(Possible Cause 3)
Why 3.3
4
(Possible Cause 3)
Verify
Verify
5
Verify
Criteria 2
Criteria 3
R physical facts failure
Why 4.3
(Possible Cause 1)
Criteria 4
Why 3.4
4
Verify
modes 2
(Possible Cause 4)
O collection
Why 1.3
(Possible Cause 4)
Verify
Verify
Why 4.4
5
(Possible Cause 2)
Why 5.2
6
(Possible Cause 1)
B Verify Verify
Matrix Analysis
L
2
1
E Why 1.1
(Possible Cause 1)
Verify
2
M Process
5W data & 1H Maps
1
Problem
Why 1.2
(Possible Cause 2)
2 Action Plan to
Remove Problem
(Countermeasure)
4
Mechanism
physical facts Drawings
Verify
2
Single 6
C
7
for the event

Why 1.3
(Possible Cause 3) 5 Why Action
O
Verify
Planning
M I Know ! I Know !
P
L
E
X
Just Do It
I
1 2 3 Root Cause
T System
Understanding Analysis 4
Counter
Identifikasi Masalah Pemahaman Proses/System Analisa akar penyebab measure
DEFECT TAG TAG No.
OPERATOR NAME
DATE
WORKSHOP STEP 1 2 3 4 5 6 7
MACHINE PRIORITY A B C
ABNORMALITY CONTAMINATION
1 Leak 16 Lubrication
3 Broken 18 Product
• Tags
5 Missing 20 Gas
6 Misaligned/deformed 21 Dirt
7 No Standard 22 Other -Please specify
8 Blocked
11 Excess Temperature 24 Inspect
12 Malfunction 25 Lubricate
14 Corrosion 27 Tighten
15 Other -Please specify 28 Other -Please specify
Problem Description Area: Equipment: Lead By: Assisted By: Date Started:
QK No:
Quick Kaizen Sheet
1) Problem sketch & description: (80% sketch & 20% words) 2) List the possible causes of the problem:
2
Defect Tags v 2.4
5) Date Complete: 3
7
4) Action plan to remove problem: 3) Verify which possible cause is a real cause:
• Quick Kaizen
Action (Risk Assess First) Who When Done? What to Check How to Check Findings Cause?
1 1 Y □ N□
2 2 Y □ N□
3 3 Y □ N□
4 4 Y □ N□
5 5 Y □ N□
6 6 Y □ N□
7 7 Y □ N□
EWO - Enhanced Work Order - Worksheet 1

Problem Definition EWO Number:
Workshop and Process Step: Issued By: Issued Date:
Cause Code:
• Enhanced Work Order

Equipment Name & No: Damage Code:
Downtime workshop Waiting

Start date and time: [m2]: WET SCRAP
(e.g. boardline): time:
Downtime machine only: End date and time: EWO

Total time
for repair:
[m2]: DRY SCRAP GROSS
- Enhanced Work Order - Worksheet
(before sorting)
2
Problem machine, Additional data Maintenance Breakdown
Total and Loss Analysis [m2]: DRY SCRAP NET
EWO Number:
Problem Description
no downtime (e.g. scrap): (e.g. CMMS ref.) downtime: (after resorting)
Workshop and Process Step: Issued By: Issue Date:
Problem description: Drawing/photograph of the problem (Use reverse of page if necessary):
Further possible causes: Verification of root causes (how & result) (OK = not a root cause) (NOK = the root cause):
Insufficient
5 5 OK/NOK
Further Root Cause Analysis

Deterioration Increased stress
strength
EWO - Enhanced Work Order - Worksheet 3

6 People
6 Development Classification OK/NOK
- Root Cause Analysis EWO Number:
Workshop and Process Step: Issued By: Issue Date:

Previous EWO
Has the problem occurred before? No If Yes, date
Task Routine Regular Non Routine Experience of the No. Months' Years'
New Task New Job Less than a week Less than a month
Frequency (daily) (wkly/mthly / Occasional Person inFailure
doing tojob Failure to service service
5W & 1H analysis: 7 7 OK/NOK
Define The Problem

Link from downtime and breakdown to people: maintain restore, External
What: Who: basic Failure to observe eliminate
People Design
Influence
conditions: operating deterioration: Defective Part
Development Weakness
Contaminatio conditions Worn out Weather Raw
Which n, Lubrication, Elect, Worn Material Utilities
When: 8 8 OK/NOK Skill Based out Mech Mistakes/Lapses Deviations
(trend): Loose
Ability Conscious /Deliberate/Wrong Failure to follow rules, procedures or
Links
Capability judgement , instructions - can be unintentional or
Where: Permanent Countermeasures (actions required to eliminate the root cause of the loss): How: Who: When planned: When actual: Qualification Unconscious/Unintentional/Lapse of deliberate
Permament Countermeasures
memory
No: Impact of Error on Key performance Indicator(s)/Cost: Drawing/Detail of Countermeasure (Use reverse of page if necessary):
Possible root causes (1 why): Verification of possible root causes (how and result) (OK = not a root cause) (NOK = the root cause):
Root Cause Analysis
1 1 OK/NOK
No: OK/NOK
2 2
Possible Causes (taken from those within the 7 Verification of each possible cause (how & result): SKILLS TOOLS PROCEDURES ENVIRONMENT CARE PERSONAL
ATTITUDE BEHAVIOUR
1 2 categories3 opposite): (OK = not a root cause) (NOK = the root cause): KNOWLEDGE EQUIPMENT SYSTEMS CONDITIONS ATTENTION CONDITIONS
3 3 OK/NOK
Lack of skill, Incorrect tools, Procedure too Over confident, Work environment, Carelessness, Medical conditions,
Lack of knowledge, Tools not suitable, difficult/complex, Bad habit due to Access issues, Absent mindedness, Personal issues,
No: 1 OK/NOK OK/NOK
4 4 Lack of Equipment poorly No procedure, lack past experience or Weather Excessive Stress/ Family issues,
competence, maintained, of standard. custom and Conditions, Pressure, Health problems.
Immediate countermeasures - those actions taken to get the equipment back up and running.
Is an "On The Job Risk Assessment" required before starting the repair? No validation
Yes of No not Procedure incorrect
Equipment practice, Lighting, Noise. Misunderstanding,
Countermeasures
2 OK/NOK training, working correctly, or out of date, Not aware of Misjudgement,

Part(s) used to carry out the immediate cuntermeasures: No verification of Equipment poorly New changes not consequences, Taking shortcuts,
Root Cause Analysis

Sustaining Actions (actions that will ensure the permanent countermeasures become part of our standards): Who: When planned: When actual:
training, designed, incorporated. Disagree with Negligence.
Lack of supervision, PPE. standards,
3 OK/NOK NotStandard
aware of Procedure not
Review AM Standards: AM
required standards, followed.
Sustaining Actions
Unclear
responsibilities. OPL for operating
Create and communicate OPL, and4update skills matrix: OK/NOK conditions
Skillmatrix
FOLLOW UP: Yes No PM Calendar/Skill

PRIORITY: Matrix: High Medium Low RESPONSIBLE:
Review 5 OK/NOK PM Calendar
Go to People
Classify People Development to determine root cause Development
6 OK/NOK Classification
Review Design Report to Relevant

Feedback Improvement to Manufacturer
Actions: and EEM Pillar: Who: When planned: When actual:
Standard Department
Review training plan/gaps on skill matrix.

Train Train Train
Review training material
All actions complete: Date completed:
Communicate knowledge/information/standards.
Communicate Communicate Communicate Communicate
Sustaining Actions
OPL/OPL Matrix.
Provide one to one feedback on results/impact of

Coach/Feedback Coach/Feedback
behaviour.
Provide clear and frank one to one

Supervise
direction/supervision.
Consider redesigning to simplify/eliminate/error Write Procedure

Redesign Redesign Redesign
proof. Poke Yoke. Redesign
Provide professional guidance/help. Contact HR Professional

Department. Counselling
Horizontal Expansion
• Standard & Major Kaizen

All actions complete: Date completed:

TAGS
Why 3.1
(Possible Cause 1)
5
2 3

(Possible Cause 1)

Why 3.2
(Possible Cause 2)
1
Why 1.2
2
Why 2.2
3
Verify
Why 4.2
5
Why 5.1
6
Criteria 1
Verify
Why 1.3
2
(Possible Cause 3)
Verify
Why 2.3
3
(Possible Cause 3)
Why 3.3
4
(Possible Cause 3)
Verify
Verify
5
Verify
Criteria 2
Criteria 3
R failure
Why 4.3
(Possible Cause 1)
Criteria 4
Why 3.4
4
Verify
Matrix Analysis
modes 2
(Possible Cause 4)
O Why 1.3
(Possible Cause 4)
Verify
Verify
Why 4.4
5
(Possible Cause 2)
Why 5.2
6
(Possible Cause 1)
B Verify Verify
L 2
Tag
E Why 1.1
(Possible Cause 1)
Verify
Done By:
CORRECTIVE ACTION
Date:
Duration [hrs]:
M Process
If Modification: 1
Action
2 Action Plan to
1 2
5W + 1H

3

Safety Procedures
Cleaning Standards
Who Planned Done 4
Planning
Drawings
2
C
5 Why
6
(Possible Cause 3)
O
Verify
M WORKSHOP
DEFECT TAG
OPERATOR
TAG No.
NAME
DATE
STEP 1 2 3 4 5 6 7
CORRECTIVE ACTION
P
Duration [hrs]:

If Modification:
3 Broken 18 Product
5 Missing 20 Gas
L 6
7
Misaligned/deformed
No Standard
21 Dirt
22 Other -Please specify
Tag
8 Blocked
Malfunction Who Planned Done
12 25 Lubricate
E
Safety Procedures

X Defect Tags v 2.4
I
1 2 3 4
T
Problem Definition
Quick Kaizen
Why 3.1
(Possible Cause 1)
5
2 3

(Possible Cause 1)

Why 3.2
(Possible Cause 2)
1
Why 1.2
2
Why 2.2
3
Verify
Why 4.2
5
Why 5.1
6
Criteria 1
Verify
Why 1.3
2
(Possible Cause 3)
Verify
Why 2.3
3
(Possible Cause 3)
Why 3.3
4
(Possible Cause 3)
Verify
Verify
5
Verify
Criteria 2
Criteria 3
R failure
Why 4.3
(Possible Cause 1)
Criteria 4
Why 3.4
4
Verify
Matrix Analysis
modes 2
(Possible Cause 4)
O Why 1.3
(Possible Cause 4)
Verify
Verify
Why 4.4
5
(Possible Cause 2)
Why 5.2
6
(Possible Cause 1)
B Verify Verify
L 2
Single
Tag
E Why 1.1
(Possible Cause 1)
Verify
5 Why Done By:
CORRECTIVE ACTION
Date:
Duration [hrs]:
M Process
If Modification: 1
Action
2 Action Plan to
1 2
5W + 1H

3
Mechanism Verify
Safety Procedures
Cleaning Standards
Who Planned Done 4
Planning
Drawings
2
C
6
(Possible Cause 3)
O
Verify
M WORKSHOP
DEFECT TAG
OPERATOR
TAG No.
NAME
DATE
STEP 1 2 3 4 5 6 7
CORRECTIVE ACTION
P
Duration [hrs]:

If Modification:
3 Broken 18 Product
5 Missing 20 Gas
L 6
7
Misaligned/deformed
No Standard
21 Dirt
Tag
8 Blocked
12 25 Lubricate
E
Safety Procedures

X Defect Tags v 2.4
I
T 1 2 3 4
Y Root Cause Counter
System
Problem Definition
Enhanced Work Order
Why 3.1
(Possible Cause 1)
5
2 3

(Possible Cause 1)

Why 3.2
(Possible Cause 2)
1
Why 1.2
2
Why 2.2
3
Verify
Why 4.2
5
Why 5.1
6
Criteria 1
Verify
Why 1.3
2
(Possible Cause 3)
Verify
Why 2.3
3
(Possible Cause 3)
Why 3.3
4
(Possible Cause 3)
Verify
Verify
5
Verify
Criteria 2
Criteria 3
R failure
Why 4.3
(Possible Cause 1)
Criteria 4
Why 3.4
4
Verify
Matrix Analysis
modes 2
(Possible Cause 4)
O Why 1.3
(Possible Cause 4)
Verify
Verify
Why 4.4
5
(Possible Cause 2)
Why 5.2
6
(Possible Cause 1)
B Verify Verify
L 2
Tag
E Why 1.1
(Possible Cause 1)
Verify
Done By:
CORRECTIVE ACTION
Date:
Duration [hrs]:
M Process
If Modification: 1
Action
2 Action Plan to
1 2
5W + 1H

3

Safety Procedures
Cleaning Standards
Who Planned Done 4
Planning
Drawings
2
C
5 Why
6
(Possible Cause 3)
O
Verify
M WORKSHOP
DEFECT TAG
OPERATOR
TAG No.
NAME
DATE
STEP 1 2 3 4 5 6 7
CORRECTIVE ACTION
P
Duration [hrs]:

If Modification:
3 Broken 18 Product
5 Missing 20 Gas
L 6
7
Misaligned/deformed
No Standard
21 Dirt
Tag
8 Blocked
12 25 Lubricate
E
Safety Procedures

X Defect Tags v 2.4
I
T 1 2 3 4
System
Problem Definition
Analisa akar penyebab Tindakan Penanggulangan
Identifikasi Masalah Pemahaman Proses/System
Standard Kaizen
4
Why 3.1
(Possible Cause 1)
5
2 3

(Possible Cause 1)

Why 3.2
(Possible Cause 2)
1
Why 1.2
2
Why 2.2
3
Verify
Why 4.2
5
Why 5.1
6
Criteria 1
Verify
Why 1.3
2
(Possible Cause 3)
Verify
Why 2.3
3
(Possible Cause 3)
Why 3.3
4
(Possible Cause 3)
Verify
Verify
5
Verify
Criteria 2
Criteria 3
R failure
Why 4.3
(Possible Cause 1)
Criteria 4
Why 3.4
4
Verify
Matrix Analysis
modes 2
(Possible Cause 4)
O Why 1.3
(Possible Cause 4)
Verify
Verify
Why 4.4
5
(Possible Cause 2)
Why 5.2
6
(Possible Cause 1)
B Verify Verify
L 2
Tag
E Why 1.1
(Possible Cause 1)
Verify
Done By:
CORRECTIVE ACTION
Date:
Duration [hrs]:
M Process
If Modification: 1
Action
2 Action Plan to
1 2
5W + 1H

3

Safety Procedures
Cleaning Standards
Who Planned Done 4
Planning
Drawings
2
C
5 Why
6
(Possible Cause 3)
O
Verify
M WORKSHOP
DEFECT TAG
OPERATOR
TAG No.
NAME
DATE
STEP 1 2 3 4 5 6 7
CORRECTIVE ACTION
P
Duration [hrs]:

If Modification:
3 Broken 18 Product
5 Missing 20 Gas
L 6
7
Misaligned/deformed
No Standard
21 Dirt
Tag
8 Blocked
Malfunction Lubricate Who Planned Done
12 25
E
Safety Procedures

X Defect Tags v 2.4
I
T 1 2 3 4
System
Problem Definition
Major Kaizen
4
Why 3.1
(Possible Cause 1)
5
2 3

(Possible Cause 1)

Why 3.2
(Possible Cause 2)
1
Why 1.2
2
Why 2.2
3
Verify
Why 4.2
5
Why 5.1
6
Criteria 1
Verify
Why 1.3
2
(Possible Cause 3)
Verify
Why 2.3
3
(Possible Cause 3)
Why 3.3
4
(Possible Cause 3)
Verify
Verify
5
Verify
Criteria 2
Criteria 3
R failure
Why 4.3
(Possible Cause 1)
Criteria 4
Why 3.4
4
Verify
Matrix Analysis
modes 2
(Possible Cause 4)
O Why 1.3
(Possible Cause 4)
Verify
Verify
Why 4.4
5
(Possible Cause 2)
Why 5.2
6
(Possible Cause 1)
B Verify Verify
L 2
Tag
E Why 1.1
(Possible Cause 1)
Verify
Done By:
CORRECTIVE ACTION
Date:
Duration [hrs]:
M Process
If Modification: 1
Action
2 Action Plan to
1 2
5W + 1H

3

Safety Procedures
Cleaning Standards
Who Planned Done 4
Planning
Drawings
2
C
5 Why
6
(Possible Cause 3)
O
Verify
M WORKSHOP
DEFECT TAG
OPERATOR
TAG No.
NAME
DATE
STEP 1 2 3 4 5 6 7
CORRECTIVE ACTION
P
Duration [hrs]:

If Modification:
3 Broken 18 Product
5 Missing 20 Gas
L 6
7
Misaligned/deformed
No Standard
21
22
Dirt
Other -Please specify
Tag
8 Blocked
12 25 Lubricate
E
Safety Procedures

X Defect Tags v 2.4
I
T 1 2 3 4
Y
System Root Cause Counter
Problem Definition
The principles of Problem Solving
Prinsip Problem Solving
Go to The workplace, the place where event actually

GEMBA Actual Place the spot happens 1G
Tempat yang sebenarnya Pergi ke Tempat kerja, tempat di mana peristiwa yang sebenarnya
Problem Definition
tempat terjadi
Examine The 'phenomenon' (what actually happened,
GEMBUTSU Actual Things the what you can actually observe with your own 3G
object eyes, without any preconceived ideas about it)
Hal yang sebenarnya Memeriksa Apa yang sebenarnya terjadi, apa yang sebenarnya Anda
Objek dapat mengamati dengan mata Anda sendiri, tanpa
prasangka-prasangka tentang hal itu
Check The actual equipment, materials, products

GENJITSU Actual Facts facts & and other physical objects actually
figures involved in an event 5G
Fakta yang sebenarnya Memeriksa Peralatan yang sebenarnya, bahan, produk dan benda-
Fakta & Angka benda fisik lainnya yang terlibat pada suatu kejadian
Principles (physical and or chemical)
Refer to
Understanding
GENRI Principles the The principles of how the machine should
theory work in optimum condition
System
Prinsip / dasar Lihat Teori Prinsip (fisik dan atau kimia) Prinsip-prinsip bagaimana
mesin harus bekerja dalam kondisi optimal
Standards & Refer to Standards & Parameters (physical values)

GENSOKU the The absolute conditions that should exist to
Parameters standards support the achievement of the principle
Standard & Parameter Lihat Standard Standar & Parameter (nilai fisik)
Kondisi mutlak yang harus ada untuk mendukung pencapaian prinsip
(01) Introduction To Problem 34
Solving_Solving Problems & Making
Decisions Course_1-1_May 2012
Problem Solving
Quick Kaizen

When to use Quick Kaizen
Kapan digunakan Quick Kaizen
Quick Kaizens are the most widely used problem solving

technique and are generally the first tool used for repetitive or
sporadic problems.
Quick Kaizens adalah teknik pemecahan masalah yang paling banyak digunakan dan
umumnya alat pertama yang digunakan untuk masalah berulang atau sporadis.
Utilize the knowledge and experience already within the

organization in a structured approach.
Memanfaatkan pengetahuan dan pengalaman yang sudah ada dalam organisasi dalam pendekatan
yang terstruktur.
To understand the problem, go to spot (go gemba) is

recommended.
Untuk memahami masalah, disarankan pergi ke tempat (pergi gemba).
Ideal for use at: Idealnya di gunakan pada saat :

● Morning Meetings – Multi discipline
Meeting Pagi – antar departemen
● Incident investigations for Safety , Quality , Environment
Investigasi Insiden untuk safety, Quality dan lingkungan
● During commissioning of new plant or process
Selama Komisioning pabrik ataupun proses baru
● Diagnostic training
Training Diagnostic
Quick Kaizen
Experienced based – linked logic from
Berdasarkan pengalaman - terkait logika dari masalah terhadap tindakan
P problem to action.
R
O Assumes machine knowledge
Pengertian pengetahuan mesin
B
L There is more than one possible cause Craftsman Operator
E Lebih dari satu kemungkinan penyebab
M
C Why 1.1
2
(Possible Cause 1)
Tag
O DEFECT TAG
OPERATOR
WORKSHOP
DEFECT TAGMACHINE TAG No.
TAG No.
NAME
DATE
STEP 1 2 3 4 5 6 7
Verify
Done By:
CORRECTIVE ACTION
Date:
M
PRIORITY A B C
OPERATOR NAME Duration [hrs]:
DATE If Modification:
ABNORMALITY CONTAMINATION Corrective Action Taken: 1
WORKSHOP STEP 1 2 3 4 5 6 7 2 Action Plan to Risk assessment done
1
I Know !
DEFECT TAG TAG No.1 Leak 16 Lubrication
MACHINE A 17
NAME 2 Worn PRIORITY B Water/Liquid
C
OPERATOR Remove Problem
Action
3 Broken 18 Product
DATE 4 Loose 19 Process Waste Why 1.2 2
WORKSHOP ABNORMALITY CONTAMINATION 20 Gas
STEP 15 2Missing
3 4 5 6 7 Problem (Possible Cause 2) (Countermeasure)
P
1 Leak 16 Lubrication
MACHINE 2 Worn PRIORITY A 17 BWater/Liquid
C
7 No Standard 22 Other -Please specify
3 Broken 18 Product
8 Blocked
3
4 Loose 9 Excess
Process Waste
19 Vibration HARD TO ACCESS TO….
Planning
ABNORMALITY 5 Missing CONTAMINATION 20 Gas
1 Leak 10 Excess Noise
16 Lubrication 23 Clean Do any of the following need updating?
2 Worn 11 Excess Temperature
17 Water/Liquid 24 Inspect Who Planned Done 4
7 No Standard 22 Other -Please specifyLubricate
3 Broken 8 Blocked
12 Malfunction
18 Product 25 Verify Operating Procedures
Safety Procedures
4 Loose 19 Process Redundant Equipment 26 Replace
13Waste
HARD TO ACCESS TO….
9 Excess Vibration14 Corrosion Cleaning Standards
L
5 Missing 20 Gas 27 Tighten Lubrication Standards
6 Misaligned/deformed 21 Dirt 15 Other -Please specify 28 Other -Please specify Inspection Standards 5
7 No Standard 22 Other -Please specify Mechanical Standards
12 Malfunction 25 Lubricate Electrical Standards
8 Blocked
Tags
13 Redundant Equipment 26 Replace Problem Description 2 Software Documentation
9 Excess Vibration HARD TO ACCESS
14 Corrosion 27TO….
Tighten Maintenance Documentation
10 Excess Noise 15 Other 23 -Please
Clean specify 28 Other -Please specify
6
12 Malfunction 25 Lubricate Why 1.3 What training is required?
E
13 Redundant Equipment 26 Replace Problem Description 7
14 Corrosion 27 Tighten (Possible Cause 3)
15 Other -Please specify 28 Other -Please specify
Problem Description
Defect Tags v 2.4
Verify
X
Defect Tags v 2.4
1
Defect Tags v 2.4
2 3 4
I
T System Root Cause Counter

Quick Kaizen
4
Why 3.1
(Possible Cause 1)
5
2 3

(Possible Cause 1)

Why 3.2
(Possible Cause 2)
1
Why 1.2
2
Why 2.2
3
Verify
Why 4.2
5
Why 5.1
6
Criteria 1
Verify
Why 1.3
2
(Possible Cause 3)
Verify
Why 2.3
3
(Possible Cause 3)
Why 3.3
4
(Possible Cause 3)
Verify
Verify
5
Verify
Criteria 2
Criteria 3
R failure
Why 4.3
(Possible Cause 1)
Criteria 4
Why 3.4
4
Verify
Matrix Analysis
modes 2
(Possible Cause 4)
O Why 1.3
(Possible Cause 4)
Verify
Verify
Why 4.4
5
(Possible Cause 2)
Why 5.2
6
(Possible Cause 1)
B Verify Verify
L 2
Single
Tag
E Why 1.1
(Possible Cause 1)
Verify
5 Why Done By:
CORRECTIVE ACTION
Date:
Duration [hrs]:
M Process
If Modification: 1
Action
2 Action Plan to
1 2
5W + 1H

3
Mechanism Verify
Safety Procedures
Cleaning Standards
Who Planned Done 4
Planning
Drawings
C
2 Mechanical Standards
6
(Possible Cause 3)
O
Verify
M WORKSHOP
DEFECT TAG
OPERATOR
TAG No.
NAME
DATE
STEP 1 2 3 4 5 6 7
CORRECTIVE ACTION
P
Duration [hrs]:

If Modification:
3 Broken 18 Product
5 Missing 20 Gas
L 6 Misaligned/deformed
No Standard
21 Dirt
Tag
7
8 Blocked
Who Planned Done
12 Malfunction 25 Lubricate
E
Safety Procedures

X Defect Tags v 2.4
I
1 2 3 4
T
Problem Definition

Quick Kaizen Problem

Definition
Experience based - understand Root Cause
Analysis
system to analyze the root cause
P Counter
R measure
O berdasarkan pengalaman – Pemahaman system untuk menganalisa akar
B penyebab.
L
E 1) Problem sketch & description: (80% sketch & 20% words)
List the possible causes of the problem:
Verify which possible cause is a real cause: 4) Action plan to remove problem:
What to Check How to Check Findings Cause? Action (Risk Assess First) Who When Done?
M 1
1 Y □ N□ 1
2
2 □ N□ Counter
Problem List Possible Verification of
Y 2
3
C 5) Date Complete:
3 □ N□ 3
Measure Action
Y
4
□ N□
O Definition Root Cause Root Cause
4 Y 4
M
5 5 Y □ N□ 5
Plan
6 6 Y □ N□ 6
P 7 7 Y □ N□ 7
L
E I Know !
X
I
T
1 2 3 4
Y
System Root Cause Counter
Problem Definition

Problem
Quick Kaizen Definition
Root Cause
Analysis
Counter
P Risk Assess every Countermeasures measure
R Penilaian Resiko setiap penanggulangan
O
B Assessed By: Date:
Risk Assessment Sheet:
L Step 1 - Hazards Step 2 - Impact
Note - This risk assessment is to be used where possible
additional hazards are created by the proposed modification.
Step 3 - Assessment Step 4 - Countermeasures
E
What are the additional hazards? Who / what might be harmed and how? Evaluate impact and likelihood of occurrence Take action to eliminate / reduce the risk
4) Action plan to remove problem: Spot hazards by: Think mainly about groups of people that could be Evaluate the impact if an accident occurs, plus the likelihood that an Think what measures are already in place to reduce the likelihood of harm or make any
• walking around the area harmed, then think about the process, product and accident occurs. Use the scales shown below; Impact rating should be harm less serious. Can they be used or enhanced to deal with this additional hazard?
• thinking about proposed modifications machine. based on the most likely outcome (not the worst case). Likelihood You need to make sure you have reduced any risks "so far as is reasonably practical".
M
• asking fellow employees Remember: rating should assume that any existing control measures are in place. Compare what you are doing with good practice and if there is a difference list what needs
• discussing with your safety representative • Normal running, abnormal conditions (operator Multiply the two values to get an overall risk score. Prioritise hazards to be done.
1 • checking manufacturers instructions intervention), maintenance activity with the highest risk score to be dealt with first. While completing the action were any further hazards found?
2
Counter Action /
Don't forget long term risks
• people may not be in the work place all the time
• visitors and contractors
Say how the hazard could cause harm

IR - Impact Rating
Fatality = 4
LR - Likelihood
Rating
Risk Prioritisation
= IR x LR
On completion of the action carry out another risk assessment.
Measure Action
Lost Time / Med Once / day = 4 3 or above = immediate
C
Hazard
Number Treatment = 3 Once / week = 3 action
3 First Aid = 2 Once / Month = 2 2 = management decision Action by Done
i.e. 1.1, What further action is necessary? Action by when
Minor Incident = 1 Once / year = 1 1 = no action whom (Re-assess)
1.2 etc
O 4
Plan
5
M 6
P 7
L
E
X
I
4 Counter
T
Y measure

“How to Do” Quick Kaizen
Bagaimana melaksanakan “Quick Kaizen”
Define the Problem

Definisikan Masalah
1) Problem sketch & description: (80% sketch & 20% words)

Gambarkan Masalah & jelaskan (80% Gambar & 20% Kalimat)
Draw a sketch of the problem
Gambarkan sketsa dari masalah
Explain the relevant detail of the sketch

in as few words as possible
Jelasskan dengan detail yang relevan dari sketsa? Dalam kata-kata sesedikit
mungkin
Briefly explain the impact of the problem to
show the importance of solving it
Jelaskan secara singkat dampak dari masalah ? Tunjukkan pentingnya dari
penyelsaiannya.
Problem Definition
List the possible causes (1 Why analysis)

Daftarkan kemungkinan penyebab (analisa 1 why)
2) List the possible causes of the problem:
1
Create a list of why you believe the problem occurred. –
2 Think logically and practically – this is not a brainstorm!!
Buat daftar mengapa Anda yakin bahwa masalah terjadi. - Pikirkan secara
logis dan praktis - ini bukan brainstorming
3 Consider Machine : Materials : Method : “Man”

Pertimbangkan Mesin, Material, Metode dan orang
4 Note: There may be more than 7, so don’t be

restricted by the sheet
5 Mungking ada lebih dari 7, jangan dibatasi oleh sheet
7
3
Root Cause
Analysis
Verify which is the real cause / s
3) Verify which possible cause is a real cause:

What to Check How to Check Findings Cause?
1 Y □ N□
For each2 possible cause, For each check item, be clear on
the method for checking.
Y □ N□
identify what specifically is to
Eg. Reference to a procedure.
be checked.
List the3 check items in Specific Tools or measurement Y□ □
Highlight whether
you have found a
N
sequence related to the techniques
real cause
possible4 causes in (2)
Untuk setiap kemungkinan penyebab,
Untuk setiap item cek, harus jelas pada metode
pemeriksaan ? Misalnya. Referensi untuk
□ □
Sorot apakah YYes orNNo
Anda telah
Identifikasikan apa yang secara khusus prosedur. Alat tertentu atau teknik pengukuran menemukan
harus diperiksa.
5
Daftarkan item cek di urutan terkait
penyebab
sebenarnya
Y □ N□
dengan penyebab yang mungkin dalam (2)
6
Describe briefly the
Y □ N□
outcome of the check.
3
7
(the condition found) Y □ N□
Jelaskan dengan singkat hasil dari
Root Cause pengecheckan
Analysis PRN_FD_5 PS Quick Kaizen_1-0.ppt
Countermeasures against real cause

Penanggulangan terhadap penyebab sebenarnya
4) Action plan to remove problem: 5) Date Complete:
1 Identify and list the actions that will remove

the real cause.
2 Identify and list the actions that need to be taken to ensure
the identified real cause does not return.
3
Where countermeasures are modifications, risk assess to
ensure another problem does not appear.
4
(see risk assessment)
Identify who & by when the actions are to be completed
Track the actions until completion then sign off
5
1. Mengidentifikasi dan daftar tindakan yang akan menghilangkan Penyebab sebenarnya.
2. Mengidentifikasi dan daftar tindakan yang perlu diambil untuk memastikan penyebab
sebenarnya tidak akan kembali lagi
6 3. Dimana penanggulangan di modifikasi, penilaian risiko untuk memastikan masalah lain
tidak muncul. ? (lihat penilaian risiko)
4. Identifikasi siapa & kapan tindakan harus diselesaikan
7 5. Melacak tindakan sampai selesai kemudian menandatangani
4 Counter
measure PRN_FD_5 PS Quick Kaizen_1-0.ppt
“How to Do” Quick Kaizen Reverse
Risk Assessment of Countermeasures

Assessed By: Date:
Risk Assessment Sheet: Note - This risk assessment is to be used where possible
additional hazards are created by the proposed modification.
Step 1 - Hazards Step 2 - Impact Step 3 - Assessment Step 4 - Countermeasures
What are the additional hazards? Who / what might be harmed and how? Evaluate impact and likelihood of occurrence Take action to eliminate / reduce the risk
Spot hazards by: Think mainly about groups of people that could be Evaluate the impact if an accident occurs, plus the likelihood that an Think what measures are already in place to reduce the likelihood of harm or make any
• walking around the area harmed, then think about the process, product and accident occurs. Use the scales shown below; Impact rating should be harm less serious. Can they be used or enhanced to deal with this additional hazard?
• thinking about proposed modifications machine. based on the most likely outcome (not the worst case). Likelihood You need to make sure you have reduced any risks "so far as is reasonably practical".
• asking fellow employees Remember: rating should assume that any existing control measures are in place. Compare what you are doing with good practice and if there is a difference list what needs
• discussing with your safety representative • Normal running, abnormal conditions (operator Multiply the two values to get an overall risk score. Prioritise hazards to be done.
• checking manufacturers instructions intervention), maintenance activity with the highest risk score to be dealt with first. While completing the action were any further hazards found?
• people may not be in the work place all the time On completion of the action carry out another risk assessment.
Don't forget long term risks • visitors and contractors
IR - Impact Rating LR - Likelihood Risk Prioritisation
Action / Say how the hazard could cause harm Fatality = 4 Rating = IR x LR
Hazard Lost Time / Med Once / day = 4 3 or above = immediate
Number Treatment = 3 Once / week = 3 action
First Aid = 2 Once / Month = 2 2 = management decision Action by Done
i.e. 1.1, What further action is necessary? Action by when
Minor Incident = 1 Once / year = 1 1 = no action whom (Re-assess)
1.2 etc
Step 1 - Hazard
Identify if there are
any specific Step 3 - Assessment
additional hazards Evaluate the impact and
Step 4 – Additional
related to the likelihood of occurrence Countermeasures
countermeasures. Step 2 - Impact Identify further
Identify who or what Risk = Impact x Likelihood countermeasures to reduce
Mengidentifikasikan might be harmed as a
bahaya apakah ada risk and re assess post
result of putting the Mengevaluasi dampak dan
completion.
bahaya tambahan khusus kemungkinan terjadinya
yang terkait dengan
countermeasure in
Mengidentifikasi dampak Mengidentifikasi penanggulangan
penanggulangan lebih lanjut untuk mengurangi risiko
siapa atau apa yang
mungkin dirugikan sebagai dan kembali menilai pasca
akibat dari menempatkan penyelesaian.
penanggulangan di
4 Counter
measure PRN_FD_5 PS Quick Kaizen_1-0.ppt
Quick Kaizen Example
Contoh Quick Kaizen
Quick Kaizen Sheet QK No: Area: Equipment: Lead By: Assisted By: Date Started:
Which Pillar? QK/18/003 Take Off - Agus Waluyo Asep AU 14-Mar-18
HS E CS FI AM PM EEM TPQC PD CR
Tanggal 07-08/03/2018, Hasil routine analysis dan setelah dilakukan resampling
untuk finish produk plasterboard ditemukan dibeberapa waktu hasil Flexural strength 1 Hasil analisa rehydration efficiency
out off specification
2 Hasil analisa TRS
3 Kualitas paper
4 Kualitas Stucco
5 Bubble size
4) Action plan to remove problem: 5) Date Complete: 3) Verify which possible cause is a real cause:
Action (Risk Assessement Required - see page 2) Who When Done? What to Check How to Check Findings Cause?
1 1 Hasil analisa rehydration efficiency

Melakukan analisa rehydration efficiency
pada tanggal tersebut
Hasil analisa rehydration efficiency
sekitar 97% □ N
Y
Kualitas stucco cenderung under kalsinasi dikarenakan penggunaan gypsum baru
2 dengan purity lebih rendah 93-94% dan kondisi gypsum basah sehingga diperlukan
Gypsum Rock Fidding System Managemen
Faozan 2-Apr-18 2 Hasil analisa TRS
Melakukan analisa TRS pada tanggal
tersebut
Hasil analisa TRS 66-67% dan
normal condition 65-70% □ N
Y
Ivory paper grammage = 174.1%,
3 3 Kualitas Paper
Melakukan crosscheck paper yang
digunakan pada waktu tersebut
Spec= 170 ± 3% dan Cob test 20.1
g/m2, Spec= 20-30 g/m2
□ N
Y
Hasil analisa Stucco cenderung
4 4 Kualitas Stucco
Melakukan crosscheck hasil analisa stucco under kalsinasi sehingga residual
yang digunakan pada waktu tersebut tinggi mengakibatkan board strength
turun
Y  N□
5 5 Bubble size
Melakukan analisa bubble size di area wet Bubble size 300-400 micron normal
end condition □ N
Y
6 6 Y □ N□
7 7 Y □ N□
Contoh Quick Kaizen
Quick Kaizen Sheet QK No: Area: Equipment: Lead By: Assisted By: Date Started:
Which Pillar? QK/18/006 Take Off - Agus Waluyo Asep AU 29-Jun-18
HS E CS FI AM PM EEM TPQC PD CR
25 June 2018, telah ditemukan boards oleh CV. HOANG QUAN & CV. NHAT
DUYEN AHN (Vietnam) dengan kondisi empty edge sebanyak 58 lembar 1 SOP tidak dilakukan sesuai prosedur
Classic Board SE 9.0 x 1210 x 2415 mm_29/05/2018 2 Edge destroyer tidak digunakan
3 Edge destroyer tidak berfungsi
4 Impact edge destroyer tidak terlihat di stacker
5 DAM Slurry tidak stabil
4) Action plan to remove problem: 5) Date Complete: 29-Jun-18 3) Verify which possible cause is a real cause:
Action (Risk Assessement Required - see page 2) Who When Done? What to Check How to Check Findings Cause?
Setiap stack dilakukan visual
1 1 SOP Monitor of Dry Stack Appearance

Memastikan SOP sudah dilakukan sesuai check untuk edge tetapi pada
prosedur atau tidak waktu tersebut tidak terlihat dan
teraba
□ N
Y
2 2 Penggunaan edge destroyer memastikan penggunaan edge destroyer Menggunakan edge destroyer
□ N
Y
 N□
Edge destroyer tidak berfungsi
Melakukan cleaning dan memperbaiki posisi edge destroyer supaya lebih banyak memastikan edge destroyer berfungsi
3 bersentuhan dengan edge board
Eng.Team 29-Jun-18 Done 3 Fungsi edge destroyer
dengan baik
dengan normal, macet dan hanya
Y
sedikit menyentuh edge board
4 4 Impact edge destroyer di stacker

Melihat visual edge setiap board
distacker
visual terlihat OK dan tidak teraba
□ N
Y
5 Membuat program auto wet reject di WinCC, apabila % volume DAM Slurry < 20 Icen 27-Jun-18 Done 5 DAM Slurry di area Mixer
Melihat aktual DAM Slurry di Mixer dan DAM Slurry kadang-kadang low
WinCC dan < 20 Y  N□
6 6 Y □ N□
7 7 Y □ N□
Contoh Quick Kaizen
QK No: Area: Equipment: Lead By: Assisted By: Date Started:

Quick Kaizen Sheet HO-007 MOULDING PLASTER GRELBIN JB MB / JAB / JMD 27/11/2006
KILN ENTRANCE 1 JOINT POORLY INSTALLED

MATERIAL LOSS ON THE
SCREW CONVEYOR FEEDING SCREW
2 JOINT WORN OUT
GRELBIN #0 (INDIRECT FIRED CONVEYOR
ROTARY KILN) JOINT 3 CRACK IN SCREWW CONVEYOR BODY

MATERIAL
LOSS 4 SCREW CONVEYOR MISALIGMENT
AMOUNT OF MATERIAL = 10€ /
DAY 5
360 WORKING DAYS / YEAR
6
TOTAL LOSS = 9000€ / YEAR
7
4) Action plan to remove problem: 5) Date Complete: 3) Verify which possible cause is a real cause:
Action (Risk Assess First) Who When Done? What to Check How to Check Findings Cause?
1
ALIGN SCREW CONVEYOR
(IMMEDIATE COUNTERMEASURE)
MB 29/11/2006  1 JOINT POSITION
STOP & LOCK CHECK
JOINT POSITION
JOINT POSITION
OK Y □ N□

2
INCLUDE SCREW CONVEYOR
ALIGNMENT ON PM CALENDAR
JAB 01/12/2006  2 JOINT CONDITION
STOP & LOCK CHECK
JOINT CONDITION
JOINT
CONDITION OK Y □ N□

3
CREATE & COMMUNICATE SMP ON
SCREW CONVEYOR ALIGNMENT
JAB 07/12/2006  3
CRACK IN SCREW
CONVEYOR BODY
STOP & LOCK LOOK FOR
CRACK IN BODY
NO CRACKS IN
BODY Y □ N□

SCREW
4
CREATE & COMMUNICATE OPL ON
CAUSE AND COUNTERMEASURE
JMD 07/12/2006  4
SCREW CONVEYOR
ALIGNMENT
STOP & LOCK CHECK SCREW
CONVEYOR IS CENTRED
CONVEYOR NOT
CENTRED
Y □
 N□
5 5 Y □ N□
6 6 Y □ N□
7 7 Y □ N□
Contoh Penilaian Resiko
Risk Assessment of Countermeasures
SIMULATION 1
SIMULASI
• Work in pairs to analyse the problem

Kerjakan berpasangan untuk menganalisa masalah

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© BPB Ltd 2009

PRN_FD_5 PS Quick Kaizen_1-0.ppt

• There are 2 types of Problem. Ada 2 tipe masalah.

Sporadic losses are indicated by sudden, infrequent, large deviations

Chronic losses rarely have a single cause

• Thought Process of Problem Solving – 4 stages

• Tools used depend upon the complexity and types of problems.

Why 1.1 Why 2.1 Verify Why 4.1

Verify Verify Verify

Maps Problem (Possible Cause 2) (Countermeasure)

Mechanism Verify Single

Why 1.3 Maintenance Documentation

ABNORMALITY CONTAMINATION Corrective Action Taken:

Problem Description Electrical Standards

What training is required?

X Defect Tags v 2.4

PRN_FD_1 Intro to Problem Solving_1-0.ppt

Defining a problem – “Simple Problems”

Defining a problem – “More Complex Problems”

P More complex problems require a structured approach to gather the

Defining a problem using structured questions; 5W+1H

What product, machine, size is the problem related to?

Defining a problem – “More Complex Problems”

Identifikasi Masalah (02) The Problem Solving Approach_Solving

5W data Defining a problem – “Very Complex

to gather & investigate

C Product Product Product Product

the data to define the

for the event

T stratification teknik stratifikasi

‘B’ Shift ‘C’ Shift ‘A’ Shift ‘D’ Shift

System Understanding – “Simple” Systems

P On many occasions the system is understood by the

System Understanding – “More Complex” Systems

P Reference to support materials and current knowledge is

System Understanding – “Most Complex” Systems

P Sometimes the system is not fully understood and

Parts lists &

C physical facts Drawings

O for the event

Root Cause Analysis

3 stages in the analysis process

C Establish root cause Menentapkan akar penyebab

Root Cause Analysis - simple obvious cause

P At the simplest level, the cause may be obvious.

Root Cause Analysis – where several possible causes exist

For simple problems with more than one possible cause

Root Cause Analysis – where the root cause may not be

Root Cause Analysis – verification

Various techniques can be employed

Root Cause Analysis – where multiple causes exist

Why 1.1 Why 2.1 Verify Why 4.1

Verify Verify Verify

For more complex problems with multiple causes,

the “5 Why Advanced” analysis technique is used.

Why 3.4 Verify

Untuk masalah yang lebih kompleks dan

dengan banyak penyebab membutuhkan 4

L teknik analisa 5 Why tingkat lanjut. Why 3.1

M Verify Why 1.1 Why 2.1 Verify Why 4.1

3 Root Cause Why 1.3

Why 1.1 Why 2.1 Verify Why 4.1