Problem Solving

Corrective Action
Problem Solving
1
Trainer: Carol Kurtz
American Society for Quality (ASQ)

 Certified Quality Engineer
 Certified Quality Auditor
 Certified Quality Manager
 Certified Mechanical Inspector
20+ years of Quality & Manufacturing
Experience
2
Course Objectives
 Understand 8D Corrective Action &

Problem Process
 Identify and Use Tools for Each 8D
Process Step
 Understand Vocabulary & Principles
 Compare to Other Fact Based Problem
Solving Methods
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Corrective Action
 Action to eliminate the cause of a

detected nonconformity.
 Action to protect the customer from
receiving or using nonconforming
product.
 Corrective action is taken to prevent
recurrence.
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Problem Solving
 Problem Solving: Typically involves a

methodology of clarifying the description
of the problem, analyzing causes,
identifying alternatives, assessing each
alternative, choosing one, implementing
it, and evaluating whether the problem
was solved or not.
 8D, PDCA, DMAIC (du-may-ic)
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Corrective Action Origins
 The origins of the 8-D system
actually goes back many
years.
 The US Government first
‘standardized’ the system in
Mil-Std-1520 “Corrective
Action and Disposition
System for Nonconforming
Material”
 Mil-Std-1520 - First released:
1974
 Last Revision was C of 1986
 Cancelled in 1995
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What is 8D?
 8D means Eight Disciplines

 It is a methodology used for solving
problems
 8D also refers to the form that is used to
document the problem and resolution
 Also called 8-D Report
 Corrective Action Report
 EW8D Report – East-West-8D
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Why 8D?
 8D is a structured approach to solving
problems
 Fact Based
 Data Collection & Analysis
 Tests progress and results
 Verify & Validate
 Documented
 History – An information database
 Anticipate future problems
 Prevent recurrence
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8D Corrective Action
D4:
D5: Choose &
D0: Recognize the Identify Potential
Verify Corrective
Problem Causes
Actions
D6: Implement &

D1: Establish the Select Likely
Validate
Team Causes
Corrective Actions
D2: Describe the D7: Prevent

No Root Cause?
Problem Recurrence
Yes
D3: Determine and

Implement Identify Possible D8: Congratulate
Containment Corrective Actions the Team
Actions
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Six Sigma DMAIC
D1: Team Approach
D0: Recognize Problem
Define D2: Describe Problem
D3: Containment
Measure
Analyze D4: Define & Verify Root Causes
Improve D5: Select & Validate Corrective Actions

D6: Implement Corrective Actions
Control D7: Prevent Recurrence
D8: Congratulate Team
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Plan Do Check Act - PDCA
D1: Team Approach
Plan: D0: Recognize Problem
Identify the Problem D2: Describe Problem
Analyze The Problem D3: Containment
Do:
Develop Solutions
Implement Solutions
D4: Define & Verify Root Causes
D5: Select & Validate Corrective Actions
Check: D6: Implement Corrective Actions
Evaluate Results
Achieve Desired Results?
Act:
Standardize Solution D7: Prevent Recurrence
D8: Congratulate Team
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Some Vocabulary
 Problem  Effect
 Symptom  Cause
 Concern  Special Cause
 Root Problem  Common Cause
 Failure Mode  Root Cause
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Verification & Validation
Verification and Validation are often not
well understood. Verification and
Validation work together as a sort of
‘before’ (Verification) and ‘after’
(Validation) proof.
Verification provides ‘insurance’ at a point in
time that the action will do what it is intended
to do without causing another problem.
Predictive.
Validation provides measurable ‘evidence’
over time that the action worked properly.
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Verification & Validation
Step Process Purpose

That the containment action will stop the symptom from
D3 Verification
reaching the customer.
That the containment action has satisfactorily stopped
Validation the symptom from reaching the customer according to
the same indicator that made it apparent.
D4 Verification That the real Root Cause is identified.
D5 Verification That the corrective action will eliminate the problem.
That the corrective action has eliminated the problem
D6 Validation
according to the same indicator that made it apparent.
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Structure of a Problem
 Determining the structure of a problem

assists in the selection of the correct
tools to use.
 It may give clues to the nature of the root
causes.
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Structure of a Problem
Gradual change, deteriorating performance over time:

Established
Performance
Time
Sudden change, catastrophic change from standard:

Established
Performance
Time
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Structure of a Problem (continued)
Start-up, gap between expected and actual performance:

Expected
Performance
Time
Actual
Performance
Recurring change, comes and goes with unknown causes:

Established
Performance
Time
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Structure of a Problem (continued)
Positive change:
Established
Performance
Time
Sometimes we experience positive changes

that need to be investigated so that processes
and products may be improved.
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Classifying Problems
 Correctly categorizing and classifying a

problem precedes any problem solving
effort.
 Ensures proper methods and tools are
selected.
 If not done, wasted time and effort may
occur and wrong solutions may be
implemented.
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Classifying Problems – Type I
 Plant Floor Problems
 Rapid response is needed
 Usually have discernable root causes
 Usually require less data collection and analysis
 Usually can be solved by local experts
 Usually gradual or sudden problem structures
 Special causes
 Specific problem requiring Problem Analysis
 8D methodology applies
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Classifying Problems – Type II
 Technical Problems
 Permanent corrective actions are needed
 Usually have difficult to discern root causes
 Usually require more data collection and analysis
 Usually require some technical expertise to solve
 May be any problem structure
 Special Causes
 Specific problem requiring Problem Analysis
 8D methodology applies
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Classifying Problems – Type III
 Process Improvement
 Major systemic fixes needed
 Multiple causes and effects
 May require data collection and analysis
 May need “systems thinking” to solve
 Usually requires process owner’s involvement
 Common cause problem
 Structures include startup and positive. Others may apply.
 Broad problems requiring a Situation Analysis
 Quality Improvement Projects, Continual Improvement
Projects or other methodologies apply.
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Problem Solving Tools
 Trend Chart  Situation Analysis
 Control Chart  Flowchart
 Pareto Chart  Failure Analysis
 Brainstorm  Database
 Checksheet  Decision Analysis
 Histogram  Action Plan
 Nominal Group  Root Cause Analysis
Technique  Cause & Effect Diagram
 Five Why’s  Scatter Diagram
 Computer Aided  Design of Experiments
Engineering  Poka Yoke
 APQP  Preventive Action Matrix
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Problem Solving Tools
Tool Purpose 8D Step
Indicator to track magnitude of D1 D2 D3 D4 D5 D6
Trend Chart
symptoms D7 D8
Quantifier to prioritize and
Pareto Chart D2 D8
subdivide the problems
Indicator to monitor and
Paynter Chart D2 D3 D6 D8
validate the problems
Method to move from symptom
Repeated Why D2
to problem description
Process to find root cause
Information Database using Is/Is Not, Differences, D2 D4 D5 D6
Changes
Method to choose best action
Decision Making D3 D5
from among alternatives
Record of assignments, D1 D2 D3 D4 D5 D6
Action Plan
responsibilities and timing D7 D8
Report of problem solving
D1 D2 D3 D4 D5 D6
EW8D process for management
D7 D8
review
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Problem Solving Tools Quiz
Trend Charts
Pareto
Analysis
RAC-
Root Cause
Analysis
? Problem
Solving
Tools
?
RAC-
Pareto
Root Cause
Analysis
Analysis
?
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D0: Recognize the Symptoms
 Detect the problem!

 Nonconforming Product
 Out of Control Conditions on Charts
 Rework
 Trend Charts
 What others?
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Here? Supplier
In
Tran
Or Here? sit Or Here? Or Here?
Company
Receiving / Inventory /
In-Process
Inventory Shipping
In
Or Here? Tran
Or Here? sit Or Here?
Or Here? Customer
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Trend Chart
A line graph plotting data over time.
 Use to observe behavior over time
 Provides a baseline and visual examination of
trends
 No statistical analysis
 Look for trends and patterns
 Ask “Why?”
 Good for operations/processes where data for
control charts is not available
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Trend Chart
Average Hours Worked Per Employee (3rd shift)
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41
40
39
38
37
36
35
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Change shift starting times
New entrance opened.
Task group established.
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 Nonconforming Product
 Out of Control Conditions on Charts
 Rework
 Trend Charts
 What others?
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Control Chart
A line graph of a quality characteristic
that has been measured over time
 Based on sample averages or individual
samples
 Includes statistically determined Control
Limits.
 Requires certain assumptions and
interpretation
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Interpreting Control Charts
Control Charts provide information as to whether a process is being influenced by
Chance causes or Special causes. A process is said to be in Statistical Control
when all Special causes of variation have been removed and only Common
causes remain. This is evidenced on a Control Chart by the absence of points
beyond the Control Limits and by the absence of Non-Random Patterns or Trends
within the Control Limits. A process in Statistical Control indicates that production is
representative of the best the process can achieve with the materials, tools and
equipment provided. Further process improvement can only be made by reducing
variation due to Common causes, which generally means management taking action
to improve the system.
Upper Control Limit
Average
Lower Control Limit
A. Most points are near the center line.

B. A few points are near the control limit.
C. No points (or only a ‘rare’ point) are beyond the Control Limits.
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When Special causes of variation are affecting a process and making it unstable
and unreliable, the process is said to be Out Of Control. Special causes of variation
can be identified and eliminated thus improving the capability of the process and
quality of the product. Generally, Special causes can be eliminated by action from
someone directly connected with the process.
The following are some of the more common Out of Control patterns:
Change To
Machine Made
Tool Broke
Tool Wear?
Upper Control Limit
Average
Lower Control Limit
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Points Outside of Limits
Upper Control Limit
Average
Lower Control Limit
Trends
A run of 7 intervals up or down is a sign of an out of control trend.
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Run of 7 ABOVE the Line
A Run of 7 successive points above or below the center line is an out of control
condition.
Run of 7 BELOW the line
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Systematic Variables
Predictable, Repeatable Patterns

Cycles
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Freaks
Sudden, Unpredictable
Instability
Large Fluctuations, Erratic Up and Down Movements
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Mixtures
Unusual Number of Points Near Control Limits (Different Machines?)
Sudden Shift in Level
Typically Indicates a Change in the System or Process
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Stratification
Constant, Small Fluctuations Near the Center of the Chart
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Control Chart Analysis Reaction
There is a wide range of non-random patterns that require action. When

the presence of a special cause is suspected, the following actions should
be taken (subject to local instructions).
1. CHECK
Check that all calculations and plots have been accurately completed,
including those for control limits and means. When using variable charts,
check that the pair (x bar, and R bar) are consistent. When satisfied that
the data is accurate, act immediately.
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2. INVESTIGATE
Investigate the process operation to determine the cause.
Use tools such as:
Brainstorming
Cause and Effect
Pareto Analysis
Your investigation should cover issues such as:
The method and tools for measurement
The staff involved (to identify any training needs
Time series, such as staff changes on particular days of the week
Changes in material
Machine wear and maintenance
Mixed samples from different people or machines
Incorrect data, mistakenly or otherwise
Changes in the environment (humidity etc.)
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3.ACT
Decide on appropriate action and implement it.
Identify on the control chart
The cause of the problem
The action taken
As far as possible,eliminate the possibility of the special cause happening
again.
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4. CONTINUE MONITORING
Plotting should continue against the existing limits
The effects of the process intervention should become visible. If not, it should
be investigated.
Where control chart analysis highlights an improvement in performance, the
effect should be researched in order that:
Its operation can become integral to the process
Its application can be applied to other processes where appropriate
Control limits should be recalculated when out of control periods for which
special causes have been found have been eliminated from the process.
The control limits are recalculated excluding the data plotted for the out of
control period. A suitable sample size is also necessary.
On completion of the recalculation, you will need to check that all plots lie
within the new limits
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Other Indicators
 Customer Concerns & Issues
 Warranty Data
 Quality Reports
 Product Quality Planning
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D1: Establish the Team
 Establish a small group of people with

the knowledge, time, authority and skill
to solve the problem and implement
corrective actions. The group selects a
team leader.
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The 8D Team Members
 Cross Functional or Multi-Disciplinary
 Process Owner
 Technical Expert
 Others involved in the containment,
analysis, correction and prevention of
the problem
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Team Roles
Several roles need to be established for the team. These roles are: Leader,
Champion, Record Keeper (Recorder), Participants and (if needed)
Facilitator.
Leader
Group member who ensures the group performs its duties and
responsibilities. Spokesperson, calls meetings, establishes meeting
time/duration and sets/directs agenda. Day-to-day authority, responsible for
overall coordination and assists the team in setting goals and objectives.
Record Keeper Participants

Writes and publishes minutes. Respect each others ideas.
Keep an open mind.
Champion Be receptive to consensus decision
Guide, direct, motivate, train, making.
coach, advocate to upper Understand assignments and accept
management. them willingly.
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Problem Solver Characteristics
 Persistent
 Intuitive (supported by mechanical aptitude)
 Logic & discipline
 Common sense
 Ability to balance priorities
 Ownership
 Inquisitive and willing
 Creative and open minded
 Needs proof & facts
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Effective Team Characteristics
 Leadership
 Clearly define goals
 Clearly defined responsibilities
 Trust & Respect
 Authority
 Positive Atmosphere
 Good two way communication
 Effective action plan with timing
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Management Responsibility
 Provide time and resouces
 Provide mentoring
 Understand need for change
 Recognize accomplishments & team
process
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Brainstorming
 Generate a great number of possible
solutions to a problem
 Use to avoid conventional or in-the-box
thinking
 Overcome mental blocks, inspire
creativity
 Take advantage of team synergy
 Ideas from different perspectives
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Team Check List
Team Check List Yes No
Has a champion accepted responsibility for monitoring the measurables?
Have measurables been developed to the extent possible?

Have special gaps been identified? Has the common cause versus
special cause relationship been identified?
Has the team leader been identified?
Does the team leader represent the necessary cross-functional
expertise?
Has team information been communicated internally and externally?
Has the team agreed upon the goals, objectives, and process for this
problem solving effort?
Is a facilitator needed to help keep process on track and gain consensus?
Does the team have regular meetings?

Does the team keep minutes and assignments in an action plan?
Does the team work well together in following the process and
objectives?
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D2: Problem Description
 Describe the problem in measurable

terms. Specify the internal or external
customer problem by describing it in
specific terms.
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Problem Statement
 Problem statement =
Object + concern + quantification
 Example:
 20% of Tuesday’s first shift production of
end cap #3245A have a ¼” to ¾” crack at
the lower left corner of the strain relief hole.
 Remember: A well defined problem is
half solved!
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Five Why’s
A technique for stepping through successive layers of
symptoms to find the root problem statement.
 Go to the point of occurrence of the problem (gemba)
 Begin asking “Why?”
 Using a flowchart, track back from symptom to
symptom until you find:
 The root cause
 A level where permanent corrective action can be
implemented
 A point where “Why?” can no longer be answered
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Flowchart
Start or input at the beginning of
A picture of a
a process
process using Action Step

Document associated
with a step such as a
form or report
symbols and arrows

to represent Action Step
sequence of the
steps. Yes Question or Decision? No
Action Step Action Step
Completed process
56
Situation Analysis
 Tool used to break broad problems into
smaller prioritized pieces to attack one at
a time.
 Many problem solving efforts start with
large, messy, poorly defined, unforcused
issues.
 This method is detailed in the book The
New Rational Manager by Kepner &
Tregoe
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Pareto Analysis
A Pareto chart offers the following benefits:
 Focuses on the problems or causes of
problems that have the greatest impact
 Displays the relative significance of
problems or problem causes in a simple,
quick-to-interpret, visual format
 Can be used repeatedly to produce
continuous improvements
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Pareto Analysis
Ball Lifting Percent Cum Percent
Frequency
Cause (%) (%)
Bonder Set-up
19 38% 38%
Issues
Unetched Glass
on Bond 11 22% 60%
Pad
Foreign Contam
on Bond 9 18% 78%
Pad
Excessive Probe
3 6% 84%
Damage
Silicon Dust on
2 4% 88%
Bond Pad
Corrosion 1 2% 90%
Bond Pad Peel-off 1 2% 92%
Cratering 1 2% 94%
Resin Bleed-out 1 2% 96%
Others 2 4% 100%
Total 50 100% -
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Paynter Chart
 This chart is combination of Trend and
Pareto charts.
 Provides information on actions taken
and shows effects.
 Can be modified for Returns, Scrap,
Rework, etc.
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Paynter Chart
Number of 3rd shift workers affected
Problems: July Aug Sept Oct Nov Dec Total
Traffic jam on Hiway 90 84 4 3 0 90
Buses Late 30 30 9 8 30 30
% Late Employees Third Shift # Late Employees Not Enough Parking 17 16 17 8 0 17
100 60 Bad Weather 9 10 20 21 9 9
Road Construction 4 0 0 0 21 4
90 54 150 140 50 40 60 150
80 48 = Containment Action: Change Shift Starting Time

= Corrective Action: Open second gate,
70 42 change shift starting times back to 'normal'.
= Corrective Action: Task Group established.
60 36
50 30
Average Hours Worked Per Employee (3rd shift)
40 24 45
44
30 18 43
42
20 12 41
40
10 6 39
38
0 0 37
1 2 3 36
Buses Late Bad Weather Not Enough Parking 35
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Change shift starting times
New entrance opened.
Task group established.
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Information Database
 A tool for organizing all data about a
problem into four categories: What,
Where, When, Extent.
 Used for Problem Analysis
 Detailed in The New Rational Manager
by Kepner/Tregoe
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Information Database
Is Is Not
What: What is the object you are having a problem with? What could be happening but is not?
What is the problem concern? What could be the problem concern, but is not?
Where do you see the concern on the object? Be specific Where on the object is the problem NOT seen? Does the
Where:
in terms of inside to outside, end to end, etc. problem cover the entire object?
Where (geographically) can you take me to show me the Where else could you have observed the defective object,
problem? Where did you first see it? but did not?
When in time did you first notice the problem? Be as When in time could it have first been observed, buy was
When:
specific as you can about the day and time. not?
At what step in the process, life or operating cycle do you Where else in the process, life or operating cycle might
first see the problem? you have observed the problem, but did not?
Since you first saw it, what have you seen? Be specific
What other times could you have observed it but did not?
about minutes, hours, days, months. Can you plot trends?
How Big: How much of each object has the defect? How many objects could be defective, but aren't?
What is the trend? Has it leveled off? Has it gone away? Is What other trends could have been observed, but were
it getting worse? not?
How many objects have the defect? How many objects could have had the defect, but didn't?
How many defects do you see on each object? How many defects per object could be there, but are not?
How big is the defect in terms of people, time, $ and/or
How big could the defect be, but is not?
other resources?
What percent is the defect in relation to the problem?
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Checksheet
 Checksheets are simple and effective
method of gathering information
on the job.
 Ensures consistency of data collected.
 Simplifies data collection and analysis.
 Highlights trends.
 Spots problems.
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Checksheet
Part Number 621532-B
Part Defect Checksheet
Date 12-16-04
Defect 1st Shift 2nd Shift 3rd Shift Totals

Nicks
22 14 5 41
Missing holes
1 0 0 1
Missing screws
8 4 0 12
Totals
31 18 5 54
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Histogram
 Chart using bars of varying height to
show frequency distribution of some
characteristic.
 Use for problem recognition, problem
definition, data analysis, and validation
of corrective actions.
 Visually evaluate spread, centering,
capability.
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Histogram
23mm OD Histogram
P/N 543612 on Machine 6
6
5
Frequency
4
3
Frequency
2
1
0
19 21 23 25 27 or
e
M
Outside Diameter
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D3: Containment
 Define and implement those intermediate

actions that will protect the customer
from the problem until permanent
corrective action is implemented.
 Verify with data the effectiveness of
these actions.
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D3: Containment
Contain Symptom Flow
Immediate Containment Choose
with Current
Information and Verify Before
Problem Description Implement
Stop Defect at Each Certify parts and Confirm

Point in the Process Customer Dissatisfaction
Back to the Source No Longer Exists
Determine
Escape Point
Should an existing ‘check’ (control)
have caught the defect?
Validate that Action

Taken is Fully Effective
Validate After Implementation
69
D3: Containment
Objectives
 The objective of this step is to isolate the effects of the problem
by implementing containment actions.
 Once a problem has been described, immediate actions are to be
taken to isolate the problem from the customer. In many cases
the customer must be notified of the problem.
 These actions are typically ‘Band-aid’ fixes.
 Common containment actions include:
 100% sorting of components
 Items inspected before shipment
 Parts purchased from a supplier rather than manufactured in-
house
 Tooling changed more frequently
 Single source
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D3: Containment
Containment Action Checksheet
Containment Action Checksheet Yes No
Has immediate containment action been taken to protect the customer?
Has the concern been stopped at each point in the process back to the source?
Have you verified that the action taken is FULLY effective?
Have you certified that parts no longer have the symptom?
Have you specially identified the 'certified' parts?
Have you validated the containment action?
Is data being collected in a form that will validate the effectiveness of the containment
action?
Has baseline data been collected for comparison?
Are responsibilities clear for all actions?
Have you ensured that implementation of the containment action will not create other
problems?
Have you coordinated the action plan with the customer?
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D4: Determine Root Causes
 Identify potential causes which could

explain why the problem occurred.
 Test each potential cause against the
problem description and data.
 Identify alternative corrective actions to
eliminate root cause.
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 Root Cause of Event (Occur or Occurrence)
 What system allowed for the event to occur?
 Root Cause of Escape

 What system allowed for the event to escape
without detection?
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Root Cause Analysis – 5 Why’s
 The 5 why's refers to the practice of
asking, five times, why a failure has
occurred in order to get to the root
cause/causes of the problem.
 There can be more than one cause to a
problem as well.
 This root cause analysis is often done by
a team with knowledge the problem
process or item.
74
Root Cause Analysis
 Process of analyzing “is” & “is not” pairs
of information for differences and
changes that lead to root cause
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Root Cause Analysis
Is Is Not
What:
Object Heavy traffic
Defect Late Employees
Where:
Seen on object I-70 Expressway
Seen geographically East bound I-70 near Main Street
When:
First seen July 7, 1996
When else seen Ever since
When seen in process (life cycle) Afternoon
How Big:
How many objects have the defect? Third shift (4:00PM)
How many defects per object? Once per day
What is the trend? Increasing --> SPECIAL CAUSE!
Enhanced Problem Description -->
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Cause & Effect Diagram
 Shows the relationship of causes and sub-causes to
an identified effect or problem. Clearly identify the
problem or effect to be diagrammed in the box at the
right
 Draw the fishbone structure
 Identify the major categories, factors, the causes
related to the effect.
 Brainstorm, or note the causes of the problem that fall
within each of the major categories.
 Each branch may have sub-branches, or sub-sub-
branches
 As ideas are generated determine which branch of the
"bone" they should be placed
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Cause & Effect Diagram
Man Machine Measurement
Effect
Method Materials
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Scatter Diagram
 Scatter diagrams are used to study possible
relationships between two variables. Although these
diagrams cannot prove that one variable causes the
other, they do indicate the existence of a relationship,
as well as the strength of that relationship.
 A scatter diagram is composed of a horizontal axis
containing the measured values of one variable and a
vertical axis representing the measurements of the
other variable.
 The purpose of the scatter diagram is to display what
happens to one variables when another variable is
changed. The diagram is used to test a theory that the
two variables are related. The type of relationship that
exits is indicated by the slope of the diagram.
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Scatter Diagram
Strongly correlated
80
Scatter Diagram
Moderately correlated
81
Scatter Diagram
No Correlation
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Design of Experiments - DOE
 Shanin’s Red X Component Search
 Taguchi’s Methods
 Classical Design of Experiments
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D5: Select & Verify CA
 After root causes and possible corrective

actions have been identified, select the
corrective actions that will permanently
correct the problem.
 Decision analysis may be needed if the
choice is not obvious.
 Verify that the selected corrective
actions will resolve the problem.
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Poka Yoke
Poka Yoke Devices
 Are Built within the Process
 In General Have Low Cost
 Have the Capacity for 100%
Inspection
Remember SQC is performed outside the
process which adds cost and allows defects
to escape the system.
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Poka Yoke
Interference Fit
Poka Yoke
Orientation
Poka Yoke
86
Poka Yoke
Spring loaded
Floppy disks
have many 1 1 shutter
poka-yokes built
in. One example 6 4 6 4 6 mechanism - Do
you remember
is you cannot the old 5.25 inch
insert the disk floppies from the
into the drive early to mid-
completely if the 1980’s? Failsafe
disk is upside disk surface
down. This is 3 5 2 5 protection [#4].
because of the
corner notch Slide Tab to
[#1]. protect against
erasure.
720k disks have Mechanism
no hole [#2] senses [#5].
while HD disks
have hole ‘Precision’ alignment. Disk alignment holes and notches [#6] ensure the disk is
(mechanism properly aligned and also provides a ‘focus’ area for manufacturing.
senses)[#3].
87
Poka Yoke
Computer Files Computer Floppy
Drives
Microsoft: File type
identified by file Microsoft: Disk must
name suffix. If one be inserted and ejected
does not add the by hand. It is possible to
correct suffix, the Warning lights alert the
eject a disk while it is driver of potential
program the file is
being written to. problems. These
from will not
New lawn mowers are recognize it. devices employ a
required to have a Macintosh Poka Yoke warning method
safety bar on the Macintosh Poka (1984): Disk drive grabs instead of a control
handle that must be Yoke (1984): File disk as it is being method.
pulled back in order to type and creator inserted and draws it in
start the engine. If you application are and seats it. Disk
let go of the safety bar, identified and cannot be manually
the mower blade stops embedded in the first ejected. You must drag
in 3 seconds or less. part of every file. File the ‘desktop’ icon for the
This is an adaptation of name plays NO part disk to the ‘Trash’. The
the "dead man switch" in recognition by the drive then ejects the
from railroad originating program. disk as long as there
locomotives.
are no disk operations
taking place.
88
Corrective Action Check List
Corrective Action & Verify Check List Yes No

Has corrective action been established?
Does it meet the required givens?

Have different alternatives been examined as possible corrective actions?
Have Poke-Yoke techniques been considered?
Has each alternative been screened?
Have the risks involved with the corrective action been considered?
Was the corrective action verified?
Was the corrective action proven to eliminate the root cause?
89
D6: Implement & Validate CA
 Implementation can proceed when best
corrective action has been selected &
verified.
 An effective implementation plan
reduces problems.
 Validation is obtained by tracking
performance over time after
implementation to ensure the corrections
are permanent.
90
D6: Implement & Validate CA
Implementation Check List
Implement CA & Validate Over Time Yes No
Has the implementation plan been constructed to reflect Product
Development Process events and engineering change process?
Do the corrective actions make sense in relation to the cycle plan for the
products?
Have both Design and Process FMEAs been reviewed and revised as
required?
Have significant / safety / critical characteristics been reviewed and identified
for variable data analysis?
Do control plans include a reaction plan?
Is simultaneous engineering used to develop process sheets and
implement manufacturing change?
Is the Paynter Chart in place for validating data?
91
D7: Prevent System Recurrence
 Implement the corrective actions in other

potentially affected areas.
 Ensure the systems that allowed the
problem to occur and escape have been
corrected.
 The problem is now Type III requiring a
larger scale continual improvement
project of some type.
92
D7: Prevent System Recurrence
Prevent System Problems Check List
Prevent System Problems Check List Yes No
Have the system prevention practices, procedures & specification standards
that allowed the problem to occur and escape been identified?
Has a champion for system prevention practices been identified?
Does the team have the cross-functional expertise to implement the solution?
Has a person been identified who is responsible for implementing the system
preventive action?
Does the system preventive action address a large scale process in a
business, manufacturing or engineering system?
Does the system preventive action match root cause (occur & escape) of the
system failure?
Does the team utilize error proofing and successive checks on a proactive
on-going basis to eliminate the occurrence and escape of all defects?
Has a pieces over time (Paynter Chart) been used to indicate that the system
preventive actions are working?
Has the System Preventive Action been linked to the Product Development
phase?
93
D8: Congratulate the Team
 Recognize the collective efforts of your

team. Publicize your achievement. Share
your knowledge and learning.
94
D8: Congratulate the Team
Congratulate The Team Checksheet
Congratulate The Team Checksheet Yes No

Have documented actions and lessons learned been linked to Product
Development Process for future generations of products?
Has appropriate recognition for the team been determined?
Has application for patents & awards been considered?
Has team been reassessed?
Has the team analyzed data for next largest opportunity?
95
References
 http://elsmar.com/
 http://www.isixsigma.com/spotlight/default.asp
 http://www.isixsigma.com/dictionary/glossary.asp
 http://www.asq.org/learn-about-quality/
 Prince Corp, Corrective Action Manual
 The New Rational Manager, Kepner & Tregoe
 http://deming.eng.clemson.edu/pub/tutorials/
 http://www.qualityspctools.com/menu.html
 Ford Team Oriented Problem Solving
 http://www.cjkurtz.com/qualitytools.htm
96

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Corrective Action

American Society for Quality (ASQ)

 Understand 8D Corrective Action &

 Action to eliminate the cause of a

 Problem Solving: Typically involves a

 8D means Eight Disciplines

 EW8D Report – East-West-8D

D6: Implement &

D2: Describe the D7: Prevent

D3: Determine and

Analyze D4: Define & Verify Root Causes

Improve D5: Select & Validate Corrective Actions

Control D7: Prevent Recurrence

D8: Congratulate Team

D8: Congratulate Team

Step Process Purpose

 Determining the structure of a problem

Gradual change, deteriorating performance over time:

Sudden change, catastrophic change from standard:

Start-up, gap between expected and actual performance:

Recurring change, comes and goes with unknown causes:

Sometimes we experience positive changes

 Correctly categorizing and classifying a

 Detect the problem!

Upper Control Limit

Lower Control Limit

A. Most points are near the center line.

Upper Control Limit

Lower Control Limit

Upper Control Limit

Lower Control Limit

A run of 7 intervals up or down is a sign of an out of control trend.

Run of 7 BELOW the line

Predictable, Repeatable Patterns

Large Fluctuations, Erratic Up and Down Movements

Unusual Number of Points Near Control Limits (Different Machines?)

Sudden Shift in Level

Typically Indicates a Change in the System or Process

Constant, Small Fluctuations Near the Center of the Chart

There is a wide range of non-random patterns that require action. When

 Establish a small group of people with

Record Keeper Participants

Have measurables been developed to the extent possible?

Is a facilitator needed to help keep process on track and gain consensus?

Does the team have regular meetings?

 Describe the problem in measurable

process using Action Step

symbols and arrows

Action Step Action Step

Bond Pad Peel-off 1 2% 92%

Resin Bleed-out 1 2% 96%

80 48 = Containment Action: Change Shift Starting Time

Defect 1st Shift 2nd Shift 3rd Shift Totals

 Define and implement those intermediate

Stop Defect at Each Certify parts and Confirm

Validate that Action

 Identify potential causes which could

 Root Cause of Escape

Man Machine Measurement

 After root causes and possible corrective

Corrective Action & Verify Check List Yes No

Does it meet the required givens?

 Implement the corrective actions in other

 Recognize the collective efforts of your