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Key Points Regarding
5 Why & Drill Deep and Wide
Problem Solving and Communication
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Heribert Nuhn
QMS
Qualitäts-Management-Systeme
Germany
D-56587 Strassenhaus
Deutschland
Tel.: ++ 49 2634 9560 71
Fax.: ++ 49 2634 9560 72
Mobil: + 49 171 315 7768
eMail: [email protected]
8D
5y
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FMEA
RGA/ A
ISO/ TS
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PROBLEM SOLVING TOOLS (8D)
The 8D-Process
____________________________________________________________________________________________________________________________________________
D0. Become Aware of the Problem:
- '5W 2H'
- 'Stair Stepping'
- Five criteria for the application of Problem Solving
D2. Describe the Problem:
- Pareto analysis
- Descriptive statistics: tables and charts (especially: data over time)
- Diagrams: flow charts, cause and effect diagrams, etc.
- Problem Definition and Problem Profile
D4. Define and Verify the Root Cause(s):
- Cause and effect diagrams
- Analytical statistics, DoE
- Comparative Analysis
- Logical testing
- Verify, Validate, Prove
- Escape Point
Version 05.2006
PROBLEM SOLVING TOOLS (GM)
Flow Chart
Fishbone Diagram
Pareto Chart
Problem
Histogram
5 Why’s
Run Chart
Problem
D.4
&
D.7
Scatter Plot
Version 05.2006
Why
Why
Why
Why
Why
Control Chart
DRILL
DEEP
&
WIDE
Pictograph
Recurrence Prevention Model
Spills
Emerging Emerging
Launch Issues Current Issues
Functional Plant Issues/
Build Issues Production
Supplier Process Issues
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Recurrence Prevention Model
• Build the Base using 8D-Method
• identify metric and threshold
• define and verify Root Cause
• Drill Deep Analysis: 3 x 5 Why
• predict, prevent and protect
Problem on part
Why did the planning process
not predict the defect?
P1
W hy?
P2
Why?
Why did the manufacturing
process not prevent the
defect?
P3
W hy?
W hy?
W hy?
M4
Why?
Mn
Prevent
Corrective Action
Prevent Root Cause
Q2
Why?
Predict
Corrective Action
M3
Q1
W hy?
Pn
Predict Root Cause
M2
Why?
Why did the quality process
not protect GM from the
defect?
P4
Why?
M1
Q3
W hy?
Q4
Why?
Qn
Protect
Corrective Action
Protect Root Cause
• Drill Wide and Read Across
• identify key issues
• identify same products, processes
• implement Lessons Learned
Version 05.2006
Issues
Other Products
Drill Deep Analysis
Predict
Check/Act
Planning Process:
Planning process informational content
informational content
in FMEAs and
in FMEAs and CPs
Controlplans
Protect
Quality Process:
process containment
detection &&
responsiveness
Prevent
Manufacturing
Manufacturingprocess
Process: standardized
work
and
standardized
work
error
andproofing
error
proofing
Do
Version 05.2006
Plan
Drill Deep Analysis
What is the intent of the Drill Deep Analysis?
A better understanding on 3 levels:
• Why did the planning process not
predict the defect?
• Why did the manufacturing process not
prevent the defect?
• Why did the quality process not
protect customer from the defect?
Version 05.2006
Drill Deep Analysis
Defect on Part
Why did the
planning process
not predict the defect?
Drill Deep Visual
P1
Why?
P2
Why?
Why did the
manufacturing process
not prevent the
defect?
P3
Why?
Why?
Pn
Predict Root Cause
M2
Why?
M3
Why?
M4
Why?
Q1
Why?
Mn
Prevent
Corrective Action
Prevent Root Cause
Q2
Why?
Q3
Why?
Q4
Why?
Qn
Protect Root Cause
Version 05.2006
Predict
Corrective Action
M1
Why?
Why did the quality process
not protect the customer
from the defect?
P4
Protect
Corrective Action
Drill Deep Analysis
G
R
A
S
P
T
H
E
5-Whys-Funnel
S
I
T
U
A
T
I
O
N
PROBLEM IDENTIFIED
(Large,
Vague,
Complicated)
Where in the process
is the problem occurring?
Problem Clarified
Area of Cause Located
Point of Cause
(PoC)
“Go See” the problem
Why? 1
C
A
U
S
E
I
N
V
E
S
T
I
G
A
T
I
O
N
Cause
Cause
Why? 3
Five Whys?
Investigation of Root Cause
Cause
Why? 4
Cause
Why? 5
Why did we not
foresee the problem?
Root Cause
Systemic Issues
Lessons Learned
Version 05.2006
Basic Cause/ Effect Investigation
Why? 2
Why did it happen
in manufacturing?
Why did
our “system” fail?
Root Cause
Quality Planning:
Root Cause
Manufacturing:
Root Cause
QMS:
Predict
Prevent
Protect
Drill Deep Analysis - Worksheet
Drill Deep Worksheet
Phone:
Name:
Revision Date:
Supplier contact:
GM SQE:
Supplier Duns:
Supplier Name and Location:
Issue Title:
ID Type:
PRR
PRTS
CDP
Other
ID Number:
Failure Mode:
Effects of Failure Mode:
Cause of Failure Mode:
5 Whys
M1
Why did the manufacturing process
not prevent this failure mode?
M2
****************
****************
**
****************
****************
**Manuf acturing process ****************prevention &
****************
standardized work
**
****************
****************
**
Prevent
**
**
**
**
**
**
M5
M-RC
Q2
**
**
**
**
**
**
Q3
Q4
Q5
Q-RC
P1
Why did the planning process not
predict this failure mode?
P2
****************
****************
**
****************
****************
** Planning process inf ormat ional cont ent
****************
in FMEAs and CPs
****************
**
****************
****************
**
Due Date
M4
Q1
Prot ect
Owner
M3
Why did the quality process not
protect GM from this failure mode?
****************
****************
**
****************
****************
** Qualit y process **************** det ect ion &
****************cont ainment
**
****************
****************
**
Corrective Action
**
**
**
**
**
**
P3
Predict
P4
P5
P-RC
K1
What are the key findings based on
this quality issue?
K2
****************
****************
**
****************
****************
**
****************
****************
**
Version 05.2006
K3
K4
K5
**
**
**
**
**
**
Root Causes - Grouped
Predict
Planning Process
Prevent
Manufacturing Process
Protect
Quality Process
Key Findings
FMEA - corrective actions
ineffective
Work Instruction
not followed
Measurement/ CP
Poor validation - design
FM EA - correct ive act ions inef f ect ive
FM EA - correct ive act ions inef f ect ive
FM EA - correct ive act ions inef f ect ive
FM EA - correct ive act ions inef f ect ive
FM EA - correct ive act ions inef f ect ive
FM EA - correct ive act ions inef f ect ive
Assembly - dropped screw
Assembly - dropped screw
Assembly - dropped screw
Assembly - JI not f ollowed
Assembly - JI not f ollowed
Assembly - JI not f ollowed
Assembly - m issing part s
Assembly - not connect ed
Assembly - not connect ed
Assem bly - part backwards, JI not f ollowed
Assembly - part dropped and mishandled
Assem bly - t ape in wrong posit ion
Assem bly - wrong part , mat erial handling locat ion wrong
No checks in CP
No cont rols
No cont rols - lat ent , caused in vehicle
No inspect ion
Poor cont rols
Poor m easurement
Poor design
Poor design validat ion
Poor validat ion - design
Poor validat ion - design
Poor validat ion - design
Poor validat ion - design
Poor validat ion - design
FMEA - detection too low
FM EA - det ect ion t oo low
FM EA - det ect ion t oo low
FM EA - det ect ion t oo low
FM EA - det ect ion t oo low
FM EA - det ect ion t oo low
FM EA - det ect ion t oo low
FM EA - det ect ion t oo low
FM EA - det ect ion t oo low
FMEA - not included
FMEA - not
FMEA - not
FMEA - not
FMEA - not
FMEA - not
FMEA - not
FMEA - not
FMEA - not
FMEA - not
FMEA - not
included
included
included
included
included
included
included
included
included
included
FMEA - not
FMEA - not
FMEA - not
FMEA - not
FMEA - not
included
included
included
included
included
Material Handling
M at erial Handling - dam age due t o rack design
M at erial Handling - nonconf orming product m ishandled
Poor M at erial Handling
Poor M at erial Handling
Mat erial Handling process not f ollowed
Packaging
Packaging
Packaging
Packaging
Packaging
FMEA - not included
Procedures
FMEA - not included
Procedure - m ishandling
FMEA - not included
Procedure - repair
FMEA-not included
FMEA - not included
Procedure - repair
Procedure not f ollowed
Procedure not f ollowed
Repair procedure not f ollowed
FMEA - occurrence too low
FM EA - occurrence t oo low
FM EA - occurrence t oo low
FM EA - occurrence t oo low
Version 05.2006
Machine Set Up/ PM
Excessive solder, no PM
Incorrect set up of t est er
Insuf f icient solder due t o poor wash
Machine cycle int erupt ed
No detection
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion
No det ect ion met hod
No det ect ion, no visual cont rols
No det ect ion
No detection - occurs after pack
No det ect ion - occurs af t er pack
No det ect ion - occurs af t er pack
No det ect ion - occurs af t er pack
Visual inspection
Visual inspect ion
Visual inspect ion
Visual inspect ion
Visual inspect ion
Systemic Issues Read Across
Predict
Prevent
Planning / Documentation
0
5
10
FMEA - not included
FMEA - detection too
low
FMEA - corrective
actions inef fective
FMEA - occurrence too
low
15
Protect
Manufacturing System
20
25
0
Work
Instruction
not follow ed
5
10
Key Findings
Quality System
15
0
No detection
Procedures
Measurement/CP
Material
Handling
Visual
inspection
Machine Set
Up/ PM
No detection occurs after
pack
5
10
Key Findings
15
20
0
25
Poor validation - design
Packaging
The TOP Bar of each Pareto represents the Systemic Issues
which will require an initial Read Across
Version 05.2006
2
4
6
8
Systemic Issues Read Across
Predict
Prevent
Protect
Key Findings
Systemic
Issue
Version 05.2006
Corrective ActionsChampion
Due Date
Plant 5
Issue
Not Completed
Plant 4
Action Plan
Plant 3
N/A
Original Product Line and Location
Plant with Similar Product/ Process
Not Applicable
Complete and 3rd party / Verified
Complete & Supplier Verified Only
Plant 2
Location
Plant 1
O
X
Supplier Name
Systemic Issues Read Across
Supplier Name
XYZ Corporation
Location
Springfield, ZX
O
X
N/A
Define the Corrective Actions for each Systemic Issue
Original Product Line and Location
Plant with Similar Product/ Process
Not Applicable
Complete and 3rd party / Verified
Complete & Supplier Verified Only
Read Across to Each Plant
Due Date
Plant 5
Champion
Plant 2
Corrective Actions
Issue
Plant 1
Not Completed
TheDepartmental
highest frequency
root2/30/04
cause O x x
Review,
Doe
On-line workshop
from each Pareto chart is transferred here.
Include the Key Finding
Predict
Failure Mode Not Included
Prevent
Work Instructions not Followed
Cross training matrix
Doe
2/30/04
O
x
x
No Error Detection
Develop plan to add
error detection to new
N/Cs
Doe
2/30/04
O
x
x
Protect
Assign a Champion and record a due date
Key Findings
Systemic
Issue
Version 05.2006
Poor Validation/Design
Peer Reviews and
Standardizes Validation
Plan
Doe
2/30/04
O
x
x
Drill Deep and Wide
Summary
• Drill Deep Analysis is not used to understand
what failed but why the system failed.
• Technical root cause should be known before
the Drill Deep Worksheet is completed.
• 3 x 5 Whys <--> Drill Deep Analysis is
required for every PRR (according GP-5)
Version 05.2006