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5 Why Analysis

January 2, 2006

Global Supply Management

5-Why Training Agenda

Where does 5-Why Fit within the PRR process

Understanding of 5-Why
Quick 5-Why Exercise as a group Critique Sheet 5- Why Examples Wrap Up/Discussion

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Global Supply Management January 2, 2006

5-WHY Where does it fit within the PRR process?

After a supplier has submitted an initial response and containment plan (Step # 2 in the PRR process), a detailed investigation is necessary to determine what caused the problem. Step # 4 (Supplier determines the root cause) requires a 5-Why analysis to help in identifying the root cause of the problem. Going back to one of the elements within the Purpose of a PRR to facilitate problem resolution, 5-Why is the prescribed tool for determining the root cause of the problem to facilitate problem resolution.

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Global Supply Management January 2, 2006

Is the powerful question own it!!


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Power of Asking Questions

Speed Limit Strictly Enforced

How Fast Are You Going?

How Fast Should You Be Going?

No Reaction

Cause Reaction (Look at speedometer)


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Cause Reaction & Research (Look at speedometer; Search for speed limit sign)
Global Supply Management January 2, 2006

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Power of Asking Questions

Who are the best at asking questions to solve problems?

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Global Supply Management January 2, 2006

Power of Asking Questions

Children!
Why?
because they keep asking objective, open-ended questions until the answer is simple and clear

When working with people to solve a problem, it is not enough to tell them what the solution is. They need to find out and understand the solution for themselves. You help them do this by asking openended , thought provoking questions.
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Global Supply Management January 2, 2006

Close-Ended vs. Open-Ended Questions

Close-Ended:

Structures the response to be answered by one word, often yes or no. Usually gives a predetermined answer.

Example: Did the lack of standardization cause the incorrect setup?

Open-Ended:

Leaves the form of the answer up to the person answering which draws out more thought or research.

Example: How is setup controlled?

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Global Supply Management January 2, 2006

Benefits of Open-Ended Questions

Requires thought Promotes additional research Enhances problem solving skills Does not assume there is one right answer Avoids predetermined answers Stimulates discussion Empowers the person answering
In many circumstances, it is not only the answer itself, but the process by which the answer was determined that is important when asking an Open-Ended question
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Global Supply Management January 2, 2006

More Examples
Example 1: Did the lack of a PM system cause this tool to break? (Close-Ended question, can be answered by a yes or no, gives the person a predetermined answer that PM is to blame) What could have caused the tool to break? (Open-Ended, probing question forces the person to think about all possibilities, not just PM) Example 2: Would improving material flow help reduce lead times? (Good question but its still Close-Ended, focuses the person on material flow as a means to reduce lead time. Is this the best improvement?) What are some options on improving lead time? (Open-Ended, triggering more thought and research on all variables impacting lead time.) Example 3: Is equipment capability causing the variation in your process? (Close-Ended, can be answered by a yes or no, focuses the person on equipment being the source of variation) What could potentially cause variation in your process? (Open-Ended, triggering more thought and research, opens up possibilities of variation with man, material & method, not just machine)
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Global Supply Management January 2, 2006

5 Why
Overview

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Global Supply Management January 2, 2006

5-Why Analysis Three Paths

5-Why:
Specific problem: Why did we have the problem? Problem not detected: Why did the problem reach the Customer? System failure: Why did our system allow it to occur?

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5-Why Analysis
Corrective Action with Responsibility Define Problem Use this path for the specific nonconformance being investigated A Date

Root Causes

WHY?

Therefore

WHY?

Therefore

Use this path to investigate why the problem was not detected.

WHY?

Therefore

WHY?

Therefore

WHY?

Therefore

A
WHY? Therefore

Use this path to investigate the systemic root cause (Quality System Failures)

WHY?

Therefore

C
WHY? Therefore WHY? Therefore

B
Ref. No. (Spill, PR/R) WHY? Therefore

Date of Spill

WHY?

Therefore

Product / Process

Delphi Location

Content Latest Rev Date

WHY?

Therefore

C
Problem Resolution Complete Communicate to Delphi Date: Process Change Break Point Date: Implement System Change Date:

Lessons Learned:

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Global Supply Management January 2, 2006

Root Cause Analysis


Delco fuse box Insert example

What tool do We use for this?

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Brainstorming

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Global Supply Management January 2, 2006

Grasp the Situation

Part I Grasp the Situation


Step 1: Identify the Problem In the first step of the process, you become aware of a problem that may be large, vague, or complicated. You have some information, but do not have detailed facts. Ask: What do I know? Step 2: Clarify the Problem The next step in the process is to clarify the problem. To gain a more clear understanding, ask: What is actually happening? What should be happening? Step 3: Break Down the Problem At this point, break the problem down into smaller, individual elements, if necessary. What else do I know about the problem? Are there other sub-problems?

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Global Supply Management January 2, 2006

Grasp the Situation


Step 4: Locate the Point of Cause (PoC) Now, the focus is on locating the actual point of cause of the problem. You need to track back to see the point of cause first-hand. Ask: Where do I need to go? What do I need to see? Who might have information about the problem? Step 5: Grasp the Tendency of the Problem To grasp the tendency of the problem, ask: Who? Which? When? How often? How much? It is important to ask these questions before asking Why?

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Global Supply Management January 2, 2006

5-Why Analysis

Step 1: Problem Statement


Is the problem statement clear & accurate? Is the analysis on the problem as the customer sees it?

Step 2: Three Paths


Are all three legs filled in? Are there any leaps in logic? Can you ask one, two, or three more Whys? Is there a cause-and-effect relationship in each path? Can the problem be turned on and off? Does the path make sense when read in reverse? Do the whys relate to the actual error? Does the non-conformance path tie to design, operations, dimensional issues, etc.? Does the detection path tie to the customer, control plans, etc.? Does the systemic path tie to management issues or quality system failures?

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Global Supply Management January 2, 2006

5-Why Analysis

Step 3: Corrective Actions


Is there a separate action for each root cause? Is it possible to implement each corrective action? Do corrective actions require Customer approval? If so, how will they be communicated to the Customer? Is there evidence to support verification of corrective actions? Are corrective actions irreversible?If not, do actions address ongoing containment? Is there a plan to standardize lessons learned across products, departments, etc?

Step 4: Lessons Learned


How could the problem have been foreseen? How will information be implemented? On the line or in the plant? At the point of detection? Cross functionally at the Supplier? Other products/plants?

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Global Supply Management January 2, 2006

5-Why Analysis

Step 5: Overall
Are there gaps or holes? Are there things missed or not documented? Do corrective actions address actions the Supplier owns? How many iterations of 5 Why Analysis have there been? Who prepared the 5 Why Analysis? One person? Sales representative ? Clerk? The best answer is a cross functional team that understand the product and process!

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Global Supply Management January 2, 2006

Therefore Test

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5-Why Analysis
Problem
The problem is stated through the eyes of the customer

The first why is the main cause The second why is what causes the main cause Etc.

Etc.

Root Cause

You have root cause if you can demonstrate: cause on, problem on cause off, problem off
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Global Supply Management January 2, 2006

5-Why Example (Non-conformance)

Problem

Cookies taste really bad Cookies are undercooked

Ingredients are wrong


Used goose eggs rather than chicken eggs

Root Cause
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Recipe did not specify bird type

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Global Supply Management January 2, 2006

5-Why Example - PPAP Submittal (Non-conformance)

Problem

PPAP submitted late PPAP package not complete

Validation testing not complete

Test lead time not considered No system to accurately assess lead times of all PPAP elements

Root Cause
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Global Supply Management January 2, 2006

5-Why Example - PPAP Submittal (Detection)

Problem

PPAP submitted late Did not react to the target submittal date Did not know the target submittal date had passed No requirement to follow-up on target submittal dates

Root Cause
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No standard system to manage PPAP submittal timeliness

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Global Supply Management January 2, 2006

5-Why Example - Business Plan (Non-conformance)

Problem

Did not meet the annual business plan goal of a 10% increase in sales Did not thoroughly evaluate market/competition

Did not have adequate resources


Did not anticipate required resources

Root Cause
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Did not develop a plan as to how the goal would be reached

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Global Supply Management January 2, 2006

5-Why Example - Business Plan (Detection)

Problem

Did not meet the annual business plan goal of a 10% increase in sales Did not know the goal was not going to be met Did not evaluate the status of the goal until December Did not have alarms limits identified at strategic intervals (monthly, quarterly, etc.)

Root Cause
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Did not develop a plan to monitor the status of reaching the goal
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Global Supply Management January 2, 2006

Flex Industries Case StudyBackground

Jake Ryan is the Quality Manager at Flex Industries. Flex is a component supplier that manufactures metal stampings and light assembly products. The company has a reputation for supplying high quality parts on a consistent basis. Seldom has there been a customer complaint. Flex has Quality representatives called Customer Support Engineers (CSEs) at every customer assembly plant. The CSEs report any problems to Jake for investigation and follow-up. At 7:00 a.m. this morning, Jake received a call from Janet, CSE at the Winding River Assembly Plant. Janet informed him that the customer had found five defective stabilizing brackets on second shift last night. She checked the remaining inventory and there were no defects in the remaining 326 pieces. The manufacturing sticker on the back of the brackets indicated that they were made by the second shift operator. Normally, the stabilizing bracket is fastened to the regulator motor with three rivets. The five defective brackets had only two rivets in them. The lower set of rivets on all five brackets was missing a rivet. This was the first time that the problem occurred.

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Global Supply Management January 2, 2006

Background

GOOD

BAD

Jake set-up containment procedures at the plant warehouse to sort for discrepant materials. As of this morning, two more defective brackets had been found in the remaining 2019 pieces of inventory at Flex.

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Global Supply Management January 2, 2006

Cause Investigation

Jake went out to the floor to talk with the team leader of the two rivet lines (East and West) and the area quality assurance auditor. He informed Sam (the team leader) of the quality problem and asked him to identify the line which runs the stabilizing bracket assembly. Sam directed Jake to the East line which runs Winding River assembly brackets only. At the East Line, he spoke with Judy (the QA Auditor for the area) and asked to see the quality log sheets. Jake and Judy reviewed the Nov. 11th log sheet and could not find anything out of the ordinary. He asked her to set-up in-house containment procedures to sort for any discrepant material in the finished goods area. Next, Jake tried to locate the second shift operator whose clock number was on the defective parts. Since that operator was gone, Jake spoke with the current machine operator (Ben). He asked Ben about any recent difficulties with the rivet machine. Ben said that he hadnt noticed anything out of the ordinary. Ben also mentioned, however, that there had never been any quality bulletins posted in the two years that this particular part has been running. Jake decided to stay in the area to watch the machine run for a while. After about 15 minutes, he watched Ben dump rivets into the feeder bowl to prepare for the next run.
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Global Supply Management January 2, 2006

Cause Investigation

Shortly after restarting rivet operations, Ben walked over to another riveter and came back with a steel rod. Ben poked around the rivet chute and then continued working. Jake approached Ben and asked him about the steel rod. Ben replied that from time to time the chute gets jammed and he has to clear it out. This happens two or three times during a shift. He didnt mention this in his earlier conversation with Jake because the problem has existed ever since he started working with this machine. The previous operator showed him how to clear the chute. All the rivet machines are like this. Jake called the Machine Repair Department and asked that someone look at the rivet track. A slight gap in the track was found and removed, and Ben continued to work. Two hours later, Jake got a call from Ben saying that the track was still jamming. As far as Jake could see, only rivets were in the bowl. Next, Jake looked into the rivet supplier containers. There was some foreign material in the blue container, but none in the red container. The label on the blue container showed that it was from Ajax Rivet, Inc., and the label on the red container indicated that it was from Franks Fasteners. Obviously, the foreign material was entering the rivet feeder bowl and jamming the track.
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Global Supply Management January 2, 2006

Cause Investigation

Jake called Maintenance and requested that the bowl be cleaned. He also added the cleaning operation to the preventive maintenance schedule on the equipment. He then called both Ajax Rivet, Inc. and Franks Fasteners. He asked about the cleaning procedures on the returnable containers. Franks did a full container purge and clean. Ajax just re-introduced the containers back into their system. When Jake asked why Ajax did not clean their containers, he was told that Ajax was not aware that such a policy was needed. Upon further investigation, Jake learned that Franks Fasteners supplies other major automotive companies. Since these companies require that all returnable containers be cleaned, Franks instituted the purge as part of its practice for all customers. Ajax Rivet, however, depends primarily on Flex as its major customer. No such policy has ever been required of them.

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Global Supply Management January 2, 2006

Cause Investigation
Jake called the Material Control Department and requested that a container maintenance policy be drafted which would apply to all their suppliers. He also asked that a machine modification be developed to sense for the presence of rivets. Hopefully, this would error-roof the process. Key Players

Jake Janet Sam Judy Ben Quality Manager CSE, Winding River Plant Team Leader, East Line QA Auditor, East Line Machine Operator

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Global Supply Management January 2, 2006

Generic Information for 5-Why Example: Regular Cola Soft Drink vs. Diet Cola
The

plant received a PR/R from a customer. (We use 5-Why Analysis to answer every PR/R.) The PR/R states that the customer received Regular Cola in the right container (same for both products) with the Diet Cola label. The order called for Regular Cola. The plant has two identical lines that are capable of running either of our two products. The lines are located immediately beside each other. The only differences in the products are the syrup and the labels. The plant runs both lines 24 hours per day. There are three shifts that run 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. The date code indicates that the defective product was manufactured at 3:03 p.m. Defective product has been contained and sorted.
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Global Supply Management January 2, 2006

Bottling Process Flow for 5-Why

BOTTLES

WATER

SYRUP

B O T T L I N G
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LIDS

INSPECT

LABELS

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Global Supply Management January 2, 2006

Generic Information for 5-Why Real Example: O Ring Seal


The

plant received a PR/R from a customer. (We use 5-Why Analysis to answer every PR/R.) The PR/R states that the customer received Mixed/Foreign Material in Shipment. The supplied part is an O Ring seal for oil filter. A cutting operation produces the part to specified size. As the raw material (cylindrical component) goes through the cutting operation, the irregular end-cuts are removed from the station.
Cutting Station

Matl Flow
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Global Supply Management January 2, 2006

Is this a good or bad Non-Conformance leg?

Missing o-ring on part number K10001J


WHY?

Parts missed the o-ring installation process


WHY?

Parts had to be reworked


WHY?

Why did they have to rework?

Operator did not return parts to the proper process step after rework
WHY?

No standard rework procedures exist This is still a systemic failure & needs to be addressed, but its not the root cause.
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Global Supply Management January 2, 2006

Is this a good or bad Detection leg?

Missing threads on fastener part number LB123


WHY?

Did not detect threads were missing


WHY?

What caused the sensor to get damaged? Sensor to detect thread presence was not working
WHY?

Sensor was damaged


WHY?

No system to assure sensors are working properly This is still a systemic failure & needs to be addressed, but its not the root cause of the lack38 of detection.

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Global Supply Management January 2, 2006

A good 5-Why will answer Yes to the five PDCA questions:


A problem well defined is a problem half solved

Standardize

ACT

Understand the problem

PLAN

5. Has a plan been identified to STANDARDIZE and take all lessons learned across products, processes, plants, functional areas, etc.?

1. Is the problem statement CLEAR and ACCURATE? 2. Has the SYSTEMIC root cause(s) been identified for all legs?

CHECK Follow-up
4. Has a plan been identified to verify the EFFECTIVENESS of all corrective actions?

Execute the Plan

DO

3. Has IRREVERSIBLE CORRECTIVE ACTION(s) been implemented for ALL root causes?

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Is this a good Corrective Action plan?


Plan Fastener P/N 10001 would not assemble Do
WHY?

Corrective Action w/ Responsibility

Date

A
1. Replace worn tool (K. Jones) 2. Begin conducting PM on all dies after every run, minimum 1 x / day, to collect history (L. Burg) 3. Assess & adjust PM intervals for all dies based on history & mfg recommendations (B. Clark) Check 4. Track PM completion % to assure 100% conformance (C. Beckett) Plan
WHY?

6/1/03 6/1/03

Burrs on the thread Do/Act


WHY?

Worn stamping tool


WHY?

Do/Act

7/31/03

Tool exceeded recommended wear life


WHY?

6/1/03

PM interval not adequate

PM failure; No system to strategically set PM intervals

Check 5. Check for burrs on threads for 60 days to verify c/a (M. Mendoeous) A Check 6. Track FTQ at stamping to monitor PM improvement (S. Boland)

6/1/03 7/31/03 6/1/03

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5-Why Critique Sheet

General Guidelines: A.) Dont jump to conclusions!; B.) Be absolutely objective. C.) Dont assume the answer is obvious. D.) If you are not thoroughly familiar with the process yourself, assemble a cross-functional team to complete the analysis. Step 1: Problem Statement Is the analysis being reported on the problem as the Customer sees it? Step 2: Three Paths (Dimensional, Detection, Systemic) -Are there any leaps in logic? -Is this as far as the Whys lead? Can you still ask one, two, three more whys)? -Is there a true cause-and-effect path from beginning to end of each path? Is there statistical data/evidence to prove it? ---Can the problem be turned off and on? -Does the path make sense when read in reverse from cause to cause? (e.g.We did this, so this happened, so this happened, and so on, which resulted in the original problem.) -Do the whys go back to the actual error? -Does the systemic path tie back to management systems/issues? -Does the nonconformance path ties back to issues such as design, operational, tiered supplier management, etc? -Does the detection path ties back to issues such as protect the customer, control plans, etc?

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Global Supply Management January 2, 2006

5-Why Critique Sheet (cont)

Step 3: Corrective Actions -Does each corrective action address the root cause from a path? -Is there a separate corrective action for each root cause? If not, does it make sense that the corrective action applies to more than one root cause? -Is each corrective action possible to implement? -Are there corrective actions that affect the Customer or require customer approval? How will they be communicated to the Customer? -Is there evidence and documentation to support the validity of the corrective actions? -Are the corrective actions irreversible? If not, are there corrective actions in place that address containment? Step 4: Lessons Learned -How could this problem have been foreseen? -How will this information be implemented: a.) on the line or in the plant? b.) at the point of detection? c.) cross-functionally at the Supplier? d.) other product/plants? -Are there lessons learned for the Customer? Step 5: Overall -Do there seem to be big holes where ideas, causes, corrective actions, or lessons learned are being avoided? -Where things are missed or not documented? -Do the corrective actions address the actions the supplier owns? -How many iterations has the supplier gone through so far in preparing this 5-why (It doesnt happen on the first try!) -Who prepared the 5-why?
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Global Supply Management January 2, 2006

5-Why Analysis: Cola Example Path A

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5-Why Analysis: Cola Example Path B

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5-Why Analysis: Cola Example Path C

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5-Why Analysis: ORing Example Path A

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Global Supply Management January 2, 2006

5-Why Analysis: ORing Example Path B

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Global Supply Management January 2, 2006

5-Why Analysis: ORing Example Path C

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Global Supply Management January 2, 2006

Problem Case Audit Standards

5-Why Analysis: Green, Yellow, Red


G: Can follow logic and flow of all 3 legs of 5 why's. The legs all differentiate "What is the problem, why wasn't it detected, and what happened systemically." Y: All 3 legs filled out, some leaps of logic, needs minor corrections to improve. R: 1 or 2 legs missing, Leg 1 repeated as leg 2 or 3, not understanding what the different legs mean--typically missing what the systemic leg is. Poor answers on 2 or more legs.

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Global Supply Management January 2, 2006