8d Problemsolvingmethod 130828060105 Phpapp02

8D-Problem solving
method
Dr.ing. tefan KOVACS
Contents
Goal of this course

Historic of 8D
Glossary
What is 8D ?
Global 8D
8D-X factory procedure
The main steps of 8D
GOAL OF THIS COURSE

The students should be able to use
8D in their current activity, based on
the guidelines of the X factory
procedure or independently if
needed.
The students should retain some
operative methods like 5W, 5W2H,
Fishbone, etc.
History of 8D
The development of a Team Oriented Problem
Solving strategy, based on the use of statistical
methods of data analysis, was done at Ford Motor
Company. The executives of the Powertrain
Organization (transmissions, chassis, engines)
wanted a methodology where teams (design
engineering, manufacturing engineering, and
production) could work on recurring problems. In
1986, the assignment was given to develop a
manual and a subsequent course that would
achieve a new approach to solving tough
engineering design and manufacturing problems.
History of 8D
The manual for this methodology was documented
and defined in "Team Oriented Problem
Solving"(TOPS), first published in 1987. The manual
and subsequent course material was piloted at World
Headquarters in Dearborn, Michigan. Many changes
and revisions were made based on feedback from the
pilot sessions. This has been Ford's approach to
problem solving ever since. It was never based on any
military standard or other existing problem solving
methodology. The material is extensive and the 8D
titles are merely the chapter headings for each step in
the process. Ford also refers to their current variant as
G8D (Global 8D)
History of 8D-Military usage

The US Government first standardized a process during the
Second World War as Military Standard 1520 'Corrective Action
and Disposition System for Nonconforming Material' .This
military standard focused on nonconforming material and the
disposition of the material.
The 8D Problem Solving Process is used to identify, correct and
eliminate recurring problems. The methodology is useful in
product and process improvement. It establishes a permanent
corrective action based on statistical analysis of the problem. It
focuses on the origin of the problem by determining Root
Causes.
This 'Determine a Root Cause' step is a part of the military
usage of the 8D's but was not a reference in the development of
the 8D problem solving methodology and is not referenced or
included in the TOPS manual or course.
Glossary
Action plan-This is a formal record of assignments,
responsibilities and timing.
Advanced product quality planning-A cross functional
approach that enables communication and feedback to flow
throughout the organization for improved quality and productivity.
APQP focuses on linking Prevent Recurrence with:
Defined product development process (event, timing, quality
of event)
G-Y-R (Green, Yellow, Red) program control process (macro
view of critical path).
Design Quality Review (DQR) or micro view of working
documents.
Engineering change management (Verification and
Validation)
Analytical Tools
Glossary
Common cause-Process inputs and conditions
that regularly contribute to the variability of
process outputs. Because Common Causes are
regular contributors, the Process or System
Variability is defined in terms of them.
Containment action-Verified action that
immediately stops the Symptom from reaching
the customer.
Corrective action-Action that permanently
eliminates the Root Cause of a problem.
Selected in D5 and implemented in D6.
Glossary
Champion-Someone who has authority but
does not participate directly in the teams
problem solving activities. A supporter and
persuader of the teams actions.
Common cause-Process inputs and
conditions that regularly contribute to the
variability of process outputs. Because
Common Causes are regular contributors,
the Process or System Variability is
defined in terms of them
Glossary
Decision making-Process used to select the best Corrective
Action. Assess impact and risks.
Design Quality Reviews-A process that measures the
Product Development Process. Examines information across
the cross-functional Product Development Team in terms of:
The ability of the design to meet customer needs and wants.
Comparison with Best-In-Class (BIC)
Ability to meet Affordable Targets (AFT)
Level of robustness of both the process and the product.
Things-Gone-Wrong / Things-Gone-Right in process
(including Team functioning).
Defining Quality of the Event for the engineering process.
Design Verification Plan & Report
Glossary
Empowerement-A proactive
process, to delegate, authorize, or
enable the Team members to have
Ownership and to be responsible for
changing the rules.
Escape-Primary question in problem
solving which explains how the
problem reached the customer.
Glossary
Information database-A tool for Root
Cause Analysis that organizes all known
data about a problem into four categories:
What, Where, When and How Big
by using Is / Is Not comparisons in D2. The
database is analyzed for Differences and
Changes leading to Root Cause in D4.
Corrective actions are evaluated using
Decision Making and Verification in d%.
Actions are implemented in D6
Glossary
Management review-Jointly agreed to by
Management and Team for periodic review of
progress to objectives. This is the teams
opportunity to obtain management assistance
where required.
Management decision making-The technique
chosen by Ford to achieve structural changes to
meet customer satisfaction. This approach consists
of theory, methods and philosophy for extracting
information from data, converting data into
information that enables us to improve the quality
of managerial decisions.
Glossary
Pareto chart-Type of bar chart used in problem
description to quantify concerns / defects in
descending order of importance. It works on the
principle that 20% of the problems are responsible
for 80% of the occurrences.
Paynter chart-Chart that identifies multiple
problem descriptions and provides validation of
containment and corrective actions over time. The
chart consists of two-dimensional tracking of a
specific number of problems along the Y axis and
occurrences of failures in weeks or months along
the X axis.
Glossary
Poka-Yoke-Error Proofing - Techniques use
simple and inexpensive devices to prevent
errors about to occur or detect errors and
defects that have occurred.
Policy deployment-System focus
providing direction and alignment focusing
on process Whats and Hows to develop
different measures at different
organizational levels to achieve common
policy and/or goal
Glossary
Problem Description Analysis-Process to organize and gather
appropriate information about the Symptom into a Problem
Description through the use of Repeated WHY's and the
Information database.
Problem Improvement Methodology-Structured approach to
ensure that our processes better met customer needs and wants
over time, in an efficient manner, with a minimum of waste and
error. The stages are:
Identify the opportunity
Define the scope
Analyze the current process
Envision future processes
Pilot and Verify the proposed changes
Implement changes
Continually improve
Glossary
Process measurables- Indicators identified and monitored on an ongoing
basis that result in consistent product quality and greater customer
satisfaction.
Product development process-A group of events and processes that
includes:
System design specification
Quality function deployment
Technology reviews
Risk assessment
Quality road map
Serviceability
Design and process verification plan and report
Design and process FMEA (Failure Modes Effects Analysis0
Critical, safety and significant characteristics
Control plans and flow charts
Process capability
Initial sample review
Process review
Glossary
Quality Function Deployment-A
planning tool used by multidisciplinary teams for translating
customer needs and expectations
into appropriate system and
component requirements. The output
of QFD process is the identification of
system and component significant
characteristics as well as key process
and production characteristics.
Glossary
Quality Operating System-Manufacturing
plant - A data driven management process
designed by Ford to get to the Root Cause of
problems by employing the Prevent
Recurrence methodology. A system format
which includes and Executive Summary of key
plant measurables, a Preventive Focus on
performance of products during product
development, a Customer focus group of
measurables reflecting Voice of the Customer,
and in internal Focus of process measurables.
Glossary
Recognize gaps-Process of finding the distance
between what should be happening and what is
actually happening. Examples of gaps are Best-InClass versus current performance, Customer
Expectations versus what customer receives, Plan
versus actual.
Repeated WHYs-Method for improved Problem
Description that moves from the problem Symptom
to the Problem Description by asking WHY to obtain
better definition of object, concern and
quantification. This question is asked repeatedly
until a level is reached which can be acted upon.
Glossary
Special cause-Process inputs and conditions which
SPORADICALLY contribute to the variability of process
outputs. The variability due to one or more Special
Causes can be identified by the use of control charts.
The process or system variability is defined without
them.
System design specification-A tool which utilizes
QFD methodology to identify the need to add or revise
engineering and test specifications to correspond to all
specific customer requirements. The output of SDS is
revised system and component engineering
requirements and testing specifications (DVP&R).
Glossary
V-Loop- Process of Verifying Containment and
Corrective Actions before implementation and
Validating the actions over time after
implementation. This process is performed by using
the same indicator that demonstrated the problem.
Validate-Proof developed AFTER implementation
and over time. The action taken must do what is
intended by providing before and after data
comparison, and must not introduce a new
problem. Proof must be developed by using the
same indicator that demonstrated the problem and
should be tracked on the Paynter chart.
What is 8 D ?
8D is a problem-solving methodology
for product and process
improvement. It is structured into
eight disciplines, emphasizing
team synergy. The team as whole
is better and smarter than the
quality sum of the individuals. Each
discipline is supported by a checklist
of assessment questions, such as
"what is wrong with what", "what,
What is 8D ? General
schema
What is 8D ?
It could be used to identify, correct
and eliminate the recurrence of
quality problems.
Actually, we could speak about 8(9)
steps, described in detail in this
course.
8D and typical operation

flowchart
Global 8D
In the late 1990s, Ford developed a
revised version of the 8D process,
that they call "Global 8D" (G8D)
which is the current global standard
for Ford and many other companies
in the automotive supply chain. The
major revisions to the process are as
follows:
Global 8D
Addition of a 0D (D-Zero) step as a gateway to
the process. At D0, the team documents the
symptoms that initiated the effort along with any
Emergency Response Actions (ERAs) that were
taken before formal initiation of the G8D. D0 also
incorporates standard assessing questions meant
to determine whether a full G8D is required. The
assessing questions are meant to ensure that in a
world of limited problem-solving resources, the
efforts required for a full team-based problemsolving effort are limited to those problems that
warrant these resources.
Global 8D
Addition of Escape Point to D4 through D6. The idea
here is to consider not only theRoot causeof a
problem, but equally importantly, what went wrong
with the control system in allowing this problem to
escape. Global 8D requires the team to identify and
verify this Escape Point (defined as the earliest
control point in the control system following the
Root Cause that should have detected the problem
but failed to do so) at D4. Then, through D5 and
D6, the process requires the team to choose, verify,
implement, and validate Permanent Corrective
Actions to address the Escape Point.
When is an 8D recquired ?
Often, a 8-D is a customer response at a problem.
Feedback from the customer shows concern with a
product or service.
Ideally, a measurable will indicate when a 8-D
should start. When an undesirable trend in a
process develops ,corrective action can be taken to
reduce the cause of the variation before a
symptom occurs in the process and escapes to the
customer.
A decision must be made regarding if the symptom
could be fixed or requires further analysis. If so, a
8-D team must assembled.
Case study
Should a customer ask for solving of
the problem ? Perhaps it is a minor
problem (which could became
serious) and he is not thinking to
report it.
Should the enterprise applying 8D be
avare of every problem, no matter
how small it is ?
Please, give some examples of
major, medium and minor problems

1.1 This procedure establishes the process used
at X factory Romania for the analysis of existing
or potential problems in order to identify their
root causes, to establish and implement the
corrections and corrective / preventive actions,
verification and review the effectiveness of the
implemented actions. Also this procedure
describes the way to record in SAP system the
identified causes, the corrections and the
corrective/preventive actions initiated to
eliminate nonconformities and their causes.

1.2 The procedure applies to X factory
Romanias Business Units and
Departments for the nonconformities
detected at internal audits (according to
CRP-822), at the control of
nonconforming products (according to
CRP-83), at solutioning of customers
claims / FPRs, at suppliers performance
evaluation, or for potential
nonconformities

References:
- X factory Romanias Quality Manual, code: CR-MQ;
- ISO 9000, Quality Management Systems. Basic
principles and terminology;
- ISO 9001, Quality Management Systems.
Requirements;
- DP-001014, Corrective/Preventive Actions;
- DP-006001, Suppliers performance
measurements;
- CRP-822, Internal audits;
- CRP-83, Control of nonconforming product;

3.1 Corrective action (ISO 9000) action to
eliminate the cause of a nonconformity,
defect or other undesirable situation.
Note 1: There can be more than one cause
for nonconformity.
Note 2: Corrective action is taken to prevent
recurrence whereas preventive action is
taken to prevent occurrence.
Note 3: There is a distinction between
correction and corrective action.

3.2 Preventive action (ISO 9000)
action to eliminate the cause of a
potential nonconformity or other
undesirable potential situation.
Note 1: There can be more than one
cause for a potential nonconformity.
Note 2: Preventive action is taken to
prevent occurrence whereas corrective
action is taken to prevent recurrence.

3.4 Root Cause Cause of a
problem/nonconformity that goes
beyond the obvious, visible aspect of
the problem/ nonconformity and seeks
to identify the base reason for the
problem/nonconformity. This is the
cause or causes, which if eliminated,
will prevent the problem/nonconformity
from reoccurring in the future.

5.1 Identification and recording of the
nonconformities and their causes
5.1.1 The nonconformities can be detected on:
- receiving, manufacturing flow, and final inspection;
- internal and external quality audits;
- feedback from customers (complaints, suggestions,
etc.);
- projects for improvement;
- current reviews performed in Production Centers/
Departments;
- evaluation of suppliers performance;
- audits performed by suppliers.

5.2 Internal corrective and
preventive actions
To establish and implement the
corrective and preventive actions, the
8D principles described below shall be
used.

D0 CPAR initiation:
When a problem is identified, the Quality/Quality
Assurance Engineer analyses the opportunity for
corrective/ preventive actions. When it is determined that
formal corrective/preventative action is warranted, a CPAR
is initiated in SAP R/3 (in accordance with Annex 6.1).
CPAR shall be issued in the following situations:
- Nonconformities found in internal/external audits (customers / ISO /
API);
- Repeatable nonconformities (more than 3 times in a month);
- Repair and rework with values more than 5.000 USD;
- Intracompany (FPR / NCR) or direct customers complaints;
- Nonconformities which leads to late delivery (more than 15 days);
- Scrap whose root cause is "operator error".

D1 Building the team for 8D
analysis of the problem
The assigned Manager has the
responsibility to initiate the 8D
process and in this respect,he shall
establish and organize an 8D team.

D1 Building the team for 8D
analysis of the problem
The 8D team members can be (as
applicable) the following persons: Process
Engineers,Production Supervisors, Quality
Engineer/Supervisor, Quality Assurance
Engineer,Design Engineer, Programmers,
Welding Engineer, Purchasing Referent,
Planner, Operators. The 8D team leader is
the assigned Manager.

D1 Building the team for 8D analysis of
the problem
This team has the following tasks:
- 8D process preparing (information,
data,documents, product samples, etc).
- attending the cause analysis meetings when
necessary.
- analyzing and identification of the root causes.
- establishing and proposing of corrective/preventive
actions and implementing due dates.
- applying of the proposed solutions.
8D-Cameron procedure
D2 Precise definition of the
problem
The 8D team makes an initial
analysis of the problem, and if it is
necessary, reformulates the
nonconformity description (in CPAR
too).
The method 5W2H shall be used
(Who?;What?; Why?; Where?; When?;
How much?;How often?)

D3 Establishing of immediate
measures (corrections, etc.) to
eliminate the problem / nonconformity
or to eliminate /minimize the effects.
The 8D team analyses the necessity
of immediate actions, i.e. hold on
anufacturing,nonconform products
isolation, other customers
notification, etc.

D4 The problem / nonconformity
analysis to identify the root cause The 8D
team analyses the problem /nonconformity
to identify the rootcause/causes.
Specific methods like Analysis 5 Why? Or
Fish bone - Ishikawa diagram (cause
effect diagram)shall be used.
The 8D team leader fills the TASK 001
Root Cause Analysis in CPAR and this task
shall be closed.

D5 Establishing of corrective
/preventive actions and their
implementation to eliminate the
cause/ causes

D5 Establishing of corrective /preventive
actions and their implementation to eliminate
the cause/ causes
- The 8D team 8D, after identification of
causes, establishes the actions to eliminate
them. A responsible person and a due date
shall be assigned to each action.
- The preventive actions are established in
order to avoid potential
nonconformities,accidents or damages, or to
improve the processes or products.

/preventive actions and their
implementation to eliminate the cause/
causes
-The sources of nonconformities
(Nonconformity reports for products, Reports
for complaints, etc) are also recorded in the
corrective/ preventive actions reports to
ensure identification of the documents which
were the basis for initiating those actions.

D5 Establishing of corrective /preventive
actions and their implementation to eliminate the
cause/ causes
Some example of types of corrective or
preventive actions (without limiting thereto) can
be:
- modify the manufacturing specification or the
manufacturing process;
- prepare new technologies or instructions for nondocumented sub-processes;
- modify/supplement the procedures or instructions to
clarify specific aspects;

/preventive actions and their implementation
to eliminate the cause/ causes
Some example of types of corrective or
preventive actions (without limiting thereto)
can be:
- train the personnel in charge (also after
preparing a new procedure or instruction or after
modifying the existing ones);
- endowment with new technologies or
tools/devices/ measuring instruments, etc.

D6 Verification of
implementation and
effectiveness of
corrective/preventive actions
The status, implementation results
and effectiveness of the taken
actions are recorded in the
Corrective/ Preventive Actions Report
by the initiating person.

D7 Preventive actions.
Identify if is the case to extend the
corrective actions also to other
similar products/processes or if are
necessary also other long term
actions (modify procedures,
processes,etc.)

D8 CPAR closing up (according to
Annex 6.5).
If all actions have been implemented
at the due date and this action have
been considered effective, the
appointed person for the task 005
Follow Up shall close the CPAR.
0D
What is done ?Prepare for the 8D

Collect the Symptoms
Symptoms Checklist
Emergency Response Action
0D
Identify the problem.
Is there a singular problem or a
repeating problem ? Would it be
above or belov ALARP ?
It deserves to be studied ?
It could lead towards problems that
would manifest in loss, incidents and
accidents ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
0D-Case study
Any problem, here ?
1D
Use Team Approach
Establish a small group of people
with the knowledge, time, authority
and skill to solve the problem and
implement corrective actions. The
group must select a team leader.
1D
When a problem cannot be solved quickly by an individual, it is necessary to
form a Team. The team will engage in the investigation and resolution of the
problem. Many factors are critical to establish a group and to ensure that the
group can work effectively together. Using a team approach is not just a step in
the problem solving process, but an overriding framework for decision making.
It is necessary to reevaluate team membership continually.
Model for Effective Teamwork:

Structure
Goals
Roles
Procedures
Interpersonal Relationships
1D
1D
Common causes are the myriad of ever-present factors (e.g., process
inputs or conditions) that contribute in varying degrees to relatively
small, apparently random shifts in outcomes day after day, week after
week, month after month. The collective effect of all common causes is
often referred to as system variation because it defines the amount of
variation inherent in the system.
Special causes are factors that sporadically induce variation over and
above that inherent in the system. Frequently, special cause variation
appears as an extreme point or some specific, identifiable pattern in
data. Special causes are often referred to as assignable causes because
the variation they produce can be tracked down and assigned to an
identifiable source. (In contrast, it is usually difficult, if not impossible, to
link common cause variation to any particular source.) Special Cause
variation results from events which are occurring outside the process. For
example, a relatively major change in temperature or humidity could
cause significant variation (points outside control limits) in the process.
1D
Brainstorming- how to:
The following rules are important to brainstorming successfully:
A leader should take control of the session, initially defining the
problem to be solved with any criteria that must be met, and then
keeping the session on course. He or she should encourage an
enthusiastic, uncritical attitude among brainstormers and
encourage participation by all members of the team. The session
should be announced as lasting a fixed length of time, and the
leader should ensure that no train of thought is followed for too
long. The leader should try to keep the brainstorming on subject,
and should try to steer it towards the development of some
practical solutions.
Participants in the brainstorming process should come from as
wide a range of disciplines with as broad a range of experience as
possible. This brings many more creative ideas to the session.
1D
Brainstorming-how to:
Brainstormers should be encouraged to have fun brainstorming,
coming up with as many ideas as possible, from solidly practical ones
to wildly impractical ones in an environment where creativity is
welcomed.
Ideas must not be criticised or evaluated during the brainstorming
session. Criticism introduces an element of risk for a group member in
putting forward an idea. This stifles creativity and cripples the free
running nature of a good brainstorming session.
Brainstormers should not only come up with new ideas in a
brainstorming session, but should also 'spark off' from associations
with other people's ideas and develop other peoples ideas.
A record should be kept of the session either as notes or a tape
recording. This should be studied subsequently for evaluation. It can
also be helpful to jot down ideas on a board which can be seen by all
brainstormers.
1D
Individual vs. Group Brainstorming
Brainstorming can either be carried out by individuals or groups:
Individual brainstorming tends to produce a wider range of ideas than
group brainstorming, but tends not to develop the ideas as effectively,
perhaps as individuals on their own run up against problems they cannot
solve. Individuals are free to explore ideas in their own time without any
fear of criticism, and without being dominated by other group members.
Group brainstorming develops ideas more deeply and effectively, as
when difficulties in the development of an idea by one person are reached,
another person's creativity and experience can be used to break them
down. Group brainstorming tends to produce fewer ideas (as time is spent
developing ideas in depth) and can lead to the suppression of creative but
quiet people by loud and uncreative ones.
Individual and group brainstorming can be mixed, perhaps by defining a
problem, and then letting team members initially come up with a wide
range of possibly shallow solutions. These solutions could then be
enhanced and developed by group brainstorming.
1D
Define Scope Of Team
Select team members and functions
Define roles and responsibilities
Identify external customer needs,
expectations and requirements
Identify internal customer needs,
expectations and requirements
Complete preliminary studies
Identify costs, timing and constraints
Identify documentation process and method
Develop investigation plan
1D
Team Organization
Cross-functional
Design Engineering (Typically the leader)

Quality Assurance
Purchasing
Manufacturing Engineering
Material Control
Sales/Marketing
Etc.
Participation appropriate for phase being conducted

Resources - Team defines Needs
*Should* involve customer or subcontractor

participation (not always feasible)
1D
Roles In A Team
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-Writes and publishes minutes.
Participants:
Respect each others ideas.
Keep an open mind.
Be receptive to consensus decision making.
Understand assignments and accept them willingly.
Champion-Guide, direct, motivate, train, coach, advocate to upper
management.
1D
Inputs To Team
Field service reports
Problems and issues reported from Internal customers
Internal evaluations using surrogate customers
Road trips (e.g.: Struts)
Management comments and/or direction
Government requirements and/or regulations
Contract review
Input from higher system level or past QFD projects
Media commentary and analysis
Customer letters and suggestions
Things gone Right/Wrong reports
Dealer comments
Fleet operator comments
1D
Basic Team Rules
Team must develop their own ground rules
Once developed, everyone must live by them
Ground Rules are an aid to self-management
Team can modify or enhance the rules as they continue to meet
Determine if there should be a meeting

Decide who should attend
Provide advance notices
Maintain meeting minutes or records
Establish ground rules
Provide and Follow an agenda
Evaluate meetings
Allow NO interruptions
1D
What s important ?
Form a Team
Core Team Structure
Team Preparation
1D-Case study
What criteria would you choose in selecting a
team that should solve the problema of a tank
that was produced in X factory, tested in X
factory but when arrived at the beneficiary, it was
looking like in the figure ?
1D-Case Study
Who should be the leader of the
team ? Is this man a good leader ?
2D
Describe the Problem
Describe the problem in measurable
terms. Specify the internal or
external customer problem by
describing it in specific terms.
Specify the internal / external
customer problem by identifying in
quantifiable terms the Who, What,
When, Where, Why, How, How Many
(5W2H) for the problem.
2D
Problem definition is the basis of problem
solving. The definition is used during
brainstorming sessions to identify root
causes in step 2 and main (potential)
causes in step 4. Potential causes are those
most likely causes that appear on the
surface to be the source of the problem. A
potential cause may be the root cause but
must be supported by evidence.
2D
Part of the problem solving process is to identify the root
cause of the problem and understand why it existed in
the first place. Only then can a permanent solution be
chosen and implemented. to make certain the problem
will never surface again. The root cause is the reason
the problem exists. When it is corrected or removed
from the system, the problem will disappear. It is
important to improve our understanding of today's
technology to make possible the planning required to
achieve quality and productivity breakthroughs for
tomorrow and into the future.
2D
Customer Complaints
Many problems arise from customer complaints. An
internal customer complaint could involve one
department complaining that they cannot use the
output of another department. An external customer
complaint could involve a customer complaining to
a dealer that a transmission shifts funny.
Frequently the wrong problem is solved and the
customer complaint is not addressed. It is very
important that the customer complaint be clearly
understood. The only method to ensure this is to
have direct customer contact.
2D
Customer Complaints
For internal customers, it is advisable to have
representatives from the complaining organization
as part of the problem solving team. In many cases
this approach is the only way a problem can truly
be solved.
External customer complaints typically require
direct interviews to understand why the customer
is not satisfied. It is not unusual for a customer
complaint to be misrepresented by a company
reporting system that classifies problems in
prearranged standard categories.
2D
Operational Definition of the Problem
It is important that the problem be described in terms that have the
same meaning to everyone. This is best achieved through an
operational definition.
An operational definition consists of verifiable criteria that
have the same meaning to the production workers, manager,
customer, engineer, buyer, technician, team members, etc.,
and are used for past, present and future comparisons and
analysis.
Sometimes problems are mistakenly described in terms of symptoms:
Machine is down due to electrical problem. No backup machine or alternative
available.
The scrap rate has increased from from 3% to 22%.
Customer warranty claims on engine component is 12%.
Failure of durability tests of a transmission component at 50,000 miles will
delay launch.
2D
Symptoms vs. Causes
It is not uncommon for problems to be reported as symptoms.
More examples are: noise, won t work, no power, machine down,
broken tool, head froze up, contaminated, rough surface,
porosity, shortage of parts, rattles, quality problem, worn out,
line stopped, not to specification, labour problem, management
problem, too much variation, etc.
The problem solving team must use a systematic approach to
define the real problem in as much detail as possible. A
definition of the problem can best be developed using
approaches that organize the facts to get a comparative
analysis. These approaches do this by asking what is against
what is not. Then they draw distinctions from this comparison,
testing these against the problem definition and forming a
statement or description of the problem which must be resolved.
2D
Problem Solving
Systematic approaches to problem solving:
Business as a System (Business as a Process)
Analytical problem solving
Process flow
Problem analysis methodologies:
5W2H
Stratification
Comparative analysis
Similarity analysis
2D-5W2H Analysis
It is sometimes difficult to define the problem and sort out
real differences. The first, most important step, however, it
to determine that the customer complaint is fully
understood.
5W2H :
Who? Identity customers complaining
What? Identity the problem adequately and accurately
When? Timing - When did the problem start?
Where? Location - Where is it occurring?
Why? Identify known explanations
How? In what mode or situation did the problem occur?
How Many? Magnitude - Quantify the problem
To reduce the risk of making wrong decisions, consideration

and analysis of potential problems in advance will provide
contingency actions to maintain control and protect the
customer.
2D-5W-2H Analysis
Who? - Identity individuals associated with the problem. Characterize
customers who are complaining. Which operators are having difficulty?
What? - Describe the problem adequately. Does the severity of the
problem vary? Are operational definitions clear (e.g. defects)? Is the
measurement system repeatable and accurate?
When? - Identify the time the problem started and its prevalence in
earlier time periods. Do all production shifts experience the same
frequency of the problem? What time of year does the problem occur?
Where? - If a defect occurs on a part, where is the defect located? A
location check sheet may help. What is the geographic distribution of
customer complaints?
Why? - Any known explanation(s) contributing to the problem should be
stated.
How? - In what mode or situation did the problem occur? What procedures
were used?
How Many? - What is the extent of the problem? Is the process in
statistical control?
2D-Stratification analysis
Stratification Analysis determines the
extent of the problem for relevant factors.
Is the problem the same for all shifts?
Do all machines, spindles, fixtures have the same
problem?
Do customers in various age groups or parts of the
country have similar problems?
The important stratification factors will vary with

each problem, but most problems will have
several factors. Check sheets can be used to
collect data.
2D-Stratification analysis
Stratification Analysis determines the extent of the
problem for relevant factors.
Essentially this analysis seeks to develop a Pareto diagram
for the important factors. The hope is that the extent of the
problem will not be the same across all factors. The
differences can then lead to identifying root cause.
When the 5W2H and Stratification Analysis are performed, it
is important to consider a number of indicators. For example,
a customer problem identified by warranty claims may also
be reflected by various in-plant indicators. Sometimes,
customer surveys may be able to define the problem more
clearly. In some cases analysis of the problem can be
expedited by correlating different problem indicators to
identify the problem clearly.
2D-Describe the problem

It has been said that there are no new problems, only different
manifestations of old problems. In problem definition, it is often useful to
quantify the problem in similar situations. The criteria to match similar
situations will vary with the type of problem. Identifying effective matches
and evaluating the presence of the problem provides useful information to
generate potential causes and possible problem solutions. If the similarity
analysis identifies a comparable situation where the problem does not exist,
the analysis can focus on the differences in where the problem is occurring
and where it is not occurring.
Once the 3 types of analysis have been completed, it is sometimes possible
to divide the problem into separate problems. It is easier to address these
smaller problems because fewer root causes are involved. In the ideal case,
a single root cause would be responsible for each problem. If the problem is
separated, different teams may be required to address each problem.
All three elements of the problem definition are not used for every problem.
However, collectively the different analyses provide a comprehensible
description. You are developing a specification of the problem.
2D-IS/Is not questions

IS
IS not
What ?
What is the object

you have problems
with ?
What could be
happening but is
not ?
Where ?
Where is the problem

in the product or
service ?
When ?
At what step of the

process you first saw
the problem ?
How big ?
How much of the

service or product is
affected by the
deffect ?
How many products

could have the defect
but did not
2D-Describe the problem Questions

What Type of Problem Is It?
Field complaint
Quality improvement
Manufacturing improvement
Component design
Labour / Personnel
Supplier / Vendor
Cost improvement
Solution implementation
Cross functional
Research
Safety
Describe the Problem Questions

Other Questions
Can you list all of the resources and documents which might help you specify the problem
more exactly?
Do you have more than 1 problem? Can this situation be separated into smaller parts?
Is / Is Not
Is there any evidence this problem surfaced before?
2D-Describe the problem in terms

of 5W
Who, What, When, Where, Why, How, How Many
What is the extent of the problem?
Has the problem been increasing, decreasing or remaining
constant?
Is the process stable?
What indicators are available to quantify the problem?
Can you determine the severity of the problem? Can you
determine the various costs of the problem? Can you
express the cost in percentages, dollars, pieces, etc.?
Do we have the physical evidence on the problem in hand?
Have all sources of problem indicators been identified and
are they being utilized?
Have failed parts been analyzed in detail?
2D
What is important ?
5 Why
Problem Statement
Affinity Diagram
Is / Is Not
Problem Description
2D-Case Study
A storage tank, designed for working
at 2 bar input pressure, is modified
by adding a nozzle in the input pipe,
in order to make an uniform filling of
the tank. After the change, the
operation manager decided to speed
up a little the process, groving the
input pressure at 4 bar. Please define
the event that may happen(0D) and
its root causes.
D2-5Why
5 Why is a problem solving technique pioneered by Toyota
Motor Corporation. The 5 Why concept is simple. If problem
solvers ask the question Why? five times
successively, the root cause will present itself by the
4th or 5th Why. Often, the 5th Why points directly at the
management systems and practices allowing the problem to
exist.
5 Why is not a deductive brainstorming technique. The 5
Why process forRCA(Root Cause Analysis) requires that
each Why be supported by data or facts. The process is a
team activity, requiring members to work at each level with
discipline to obtain supporting data. The known or collected
facts from each Why lead to the next Why as the process
continues, concluding when the root cause is found.
D2-5Why
The Three-legged 5 Why is a technique used
to follow three related paths. The purpose
of the Three-legged 5 Why is to arrive
at the root cause level, where energy
has been expended incorrectly resulting
in a failure chain. The failure chain ends at
the symptom or effect experienced by the
customer. The Three-legged 5 Why begins
with a problem symptom and ends with three
separate conclusions for improvement.
D2-5Why
The Three Legs are:
Root Cause (Energy
Misappropriation)
Barrier or Control (Quality Control)
Systemic Cause (Management)
2D-5Why
Findings from each leg can crossover between paths.
The development of subsequent legs result in a more
detailed explanation of where, when and how the
problem occurred. Prevention of future problems are
addressed in all three legs, with the following:
Avoidance of the specific root cause throughSPC
(Statistical Process Control and Process Capability)
orError / Mistake Proofing(Poka Yoke)
Poka Yoke of the process responsible for the problem
Establishment ofStandard Work Practicesto
maintain consistency
2D-Case Study
Please give a Poka Yoke example
taking into account a command
pannel that could trigger a very
unpleasant reaction if someone is
coming inside and thinking just to
play with the buttons
3D
Implement and Verify Short-Term
Corrective Actions
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.
3D
Implement and Verify - Interim
(Containment) Actions
Define and Implement containment
actions to isolate the effect of the
problem from any internal / external
customer until corrective action is
implemented.
Verify the effectiveness of the
containment action.
3D
Containment-Action objective
Define and Implement containment
actions to isolate the effect of the
problem from internal and external
customers until corrective action is
implemented.
Verify the effectiveness of the
containment action(s).
3D
Containment actions-1
The main objective of this part of the problem
solving process is to isolate the effects of the
problem by implementing containment actions.
A problem may be poor quality, marginal
product design, or a process or system that is
unpredictable. A containment action may be
stopping production of a known source of a
problem, or not shipping any parts or
assemblies until the source of the problem is
identified.
3D
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 local fixes.
Common containment actions include:
100% sorting of components
Cars inspected before shipment
Parts purchased from a supplier rather than manufactured inhouse
Tooling changed more frequently
Single source
3D
Containment actions- 2
Unfortunately, most containment actions will

add significant cost ($) to the product. However, it is
important to protect the customer from the problem until
permanent corrective actions can be verified and
implemented.Most interim actions are temporary short term
actions taken until a permanent corrective action is defined,
implemented and verified. The danger of many interim
corrective actions is that they are considered to be a permanent
solution to the problem. It must be remembered that they are
typically band-aids. It is a mistake to view containment actions
as a solution to the problem. Containment actions typically
address the effect. They should be considered immediate firstaid to be reviewed and removed as quickly as possible.
3D
Containment actions can and often should proceed in parallel with
the root cause determination investigation. During the period in
which containment actions are taking place, many useful things
must be pursued as a first step in finding the root cause. These
things include:
Establishing an investigative plan
Obtaining baseline data
Initiating an on-going control system
Developing a follow-up and communications system
Correcting products already produced
Start systematic investigations
Conduct special studies and statistical experiments
Understand the problem Review experiences and data with current trends
Forecast the future
3D-Case Study
A tank containing sulphuric acid was
corroded and a spill is the result. The
spill is small so the operation
manager decided to weld a metal
sheet over the spill hole.
Would this be an immediate
corrective action ? Why ? What are
the steps that must be followed
before making the welding ? What
are the immediate control steps ?
3D
Interim Containment Action
Verification of Effectiveness
4D
Define PRIMARY CAUSES
THROUGH ROOT CAUSES
ANALYSIS
Identify all 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.
4D
Identify all potential causes
which could explain why the
problem occurred.
Isolate and verify the root cause
by testing each potential cause
against the problem description
and test data. Identify alternate
corrective actions to eliminate
root cause.
4D-Root cause of a failure
4D
Two Root Causes
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?
4D
Define and Verify Root Cause(s)-1
An investigation into all identified potential causes
is necessary for effective problem solving. A cause
and effects diagram can be used to brainstorm all
potential causes of the described problem. The
team should decide on what C&E diagram(s) is to
be used: 5M, Process Flow and/or stratification. The
more detailed the C&E diagram, the higher the
chances the root cause will be included on the C&E
diagram. An effective C&E diagram will include
input from all team members and will be discussed
in detail.
4D
Any existing data should be reviewed for clues to potential
causes. Further data collection may be required to investigate
additional causes.
If the problem has not previously been seen, a timeline
analysis should provide significant data. The timeline will
identify events occurring about the time the problem
developed. If enough documentation is available, potential
causes can be further identified. For example, if a new
operator was put on a process or if a new supplier began
supplying parts. Investigation into the events occurring at the
same time the problem was discovered could lead to several
important potential causes.
What Changed? When? are important questions.
4D
A technique used extensively in analytical problem
solving is a comparison analysis. This analysis looks
at what is and what is not in the problem
description.
Potential causes can be discovered by conducting a
survey. By surveying the customer who has
witnessed the problem, more potential causes can
be highlighted.
Asking Whyrepeatedly is effective in driving the
process toward root cause and generating more
complete understanding of the cause and effect.
4D
Once the problem has been described and the
potential causes identified, the team should be
evaluated. Are the right members on the team to
investigate the potential causes? Are technical
advisors required to assist in any special studies?
Do new team members need to be added? Is the
authority to pursue the analysis of the potential
causes well defined? All these questions must be
answered to ensure the team will be successful in
investigating the potential causes and determining
the root cause.
4D
The cause and effect diagram is used to identify the
potential causes to be investigated. What is the
probability that a potential cause could be responsible for
the problem? Identify all potential causes that could have
been present and may have caused the problem.
Once all potential causes have been agreed upon, choose
several potential causes to investigate. If only one
potential cause is investigated, a lot of time may be lost
if that potential cause proves not to be the culprit. To
expedite a solution, investigate several potential causes
at the same time (Parallel actions on several potential
causes).
4D
If the problem is a manufacturing process, begin to
establish a stable process. Once the process is stable,
definition of the potential cause will be clarified.
If design causes are identified, screening experiments may
help identify the key variables which are affected by
subsequent processes. Design changes may be appropriate.
Four or five potential causes should be identified to
investigate. Identifying several potential causes forces the
team to address multiple possibilities rather than searching
endlessly for a single cause. An implicit part of problem
analysis is investigating potential causes in parallel rather
that in series.
4D
Six Steps Of Investigation
State how the potential cause could have resulted in the
described problem.
Establish what type of data can most easily prove or disprove
the potential cause. Develop a plan on how the study will be
conducted. Identify the actions on an action plan.
Prepare the required materials to conduct the study. Training
may also be required.
Collect the required data.
Analyze the data. Use simple statistical tools emphasizing
graphical illustrations of the data.
State conclusions. Outline conclusions from the study. Does
the data establish the potential cause as being the reason for
the problem?
4D
Identify Alternate Solutions
Generate a Cause & Effects diagram.
Survey the customer.
Identify similar problem(s) previously solved.
Avoid implementing the interim actions for
permanent actions /solutions.
Consider new and current technology for the
solution.
Incorporate the solution into future products.
4D
Identify Potential Causes
Define the effects for cause and effect diagram(s).
Prepare a 5M, Process or Stratification cause & effects diagram for each
effect (you may want to use a combination).
Team members should each assume their activity causes the problem and
ask themselves :How could what I do possibly generate the problem?
Prepare a time line analysis if the problem was not always present.
Identify what changed when.
Perform a comparison analysis to determine if the same or a similar
problem existed in related products or processes. Identify past solutions
and root causes which may be appropriate for the current problem.
Identify the top few potential causes. Develop a plan for investigating
each cause and update the action plan.
Evaluate a potential cause against the problem description. Does a
mechanism exist so that the potential cause could result in the problem?
4D
Analyze Potential Causes- Identify Root Cause
Analyze Potential Causes
Use the iterative process to analyze each potential cause.
Hypothesis generation: How does the potential cause result in the problem?
Design: What type of data can most easily prove/disprove the hypothesis?
Preparation: Obtain materials and prepare a check list.
Data Collection: Collect the data.
Analysis: Use simple, graphical methods to display data.
Interpretation: Is the hypothesis true?
Investigate several potential causes independently.
Use an action plan to manage the analysis process for each potential cause
being studied.
Validate Root Causes
Clearly state root cause(s) and identify data which suggests a conclusion.
Verify root cause factors are present in the product and/or process.
Conduct with / without study to verify root cause. Can you generate the
problem?
Analyze Potential Causes - Validate Root Cause
4D
Defining the five elements of
production:
Objects of Production: Materials: Raw, Finished,
Semi-finished, In-process
Agents of Production: People, Machines, Tools,
Jigs, Machine Tools, Incidental Devices, Inspection
Equipment, The Environment, etc.
Methods: Processing System, Load & Capacity
Balance, Processing Conditions
Space: Left to Right, Front to Back, Top to Bottom
Time: Process Time, Production Time, Task Time
4D-4 process Phenomena
4D
Poka Yoke Devices, Systems & Inspection
Poka Yoke Systems
Control Systems
Halt the operations, and require feedback and action
before process can resume.
Warning Systems
Uses signals to warn the operator that the operations
needs feedback and action
SQC systems have fairly long periods of time

between check stages and feedback execution
4D
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.
4D-Systems for 0 defects ?
4D-Case Study
Please describe- in your opinion- a
system with 0 defects.
4D
What is important ?
RCA(Root Cause Analysis) and
Escape Point
Differences and Changes
Root Cause Theories
Verification
Process Flow Diagram
Escape Point
4D-RCA
RCA (Root Cause Analysis) is not a method or process
itself, but a class of problem solving methods aimed
at identifying the root cause of problems or events.
RCA is any structured approach that identifies factors
resulting in the problem outcome including
symptoms, effects or consequences.
The practice of RCA is based in the belief that
problems are permanently solved by addressing the
root cause, rather than addressing obvious
symptoms. Counter measures directed at the root
cause are more likely to prevent problem
reoccurrence.
4D-RCA
There may be several effective measures that address
the root causes of a problem. Due to this fact, RCA is
often performed iteratively and is frequently used as a
continuous improvement tool. RCA is reactive,
identifying events or causes, revealing problems and
solving them. Analysis is done after a problem has
occurred.FMEA(Failure Mode and Effects Analysis) is
the usage of RCA to forecast or predict probability of
events before they occur. RCA and FMEA are related
and similar but separated by their place in the Product
or Process life cycle. FMEA is used prior to product or
process launch whereas RCA is used after.
D4-RCA
The root cause of any problem is found at the
point of creation. The root cause is never an
operator error or a broken tool. The specifics of a
root cause occur at the conversion of a product or
service from one state to a new desired state.
This conversion must be measurable and typically
require proper energy usage. Examples of energy
include, but are not limited to force, temperature
or motion. The incorrect application of energy is
the point at which the root cause can be found.
The root cause can only be known if it can be
turned on and off at will.
D4-RCA
The RCA process is selected depending upon
many factors such as culture and knowledge
of problem solving tools. Quality-One has
decades of experience in determining the
proper tools and techniques for problem
solving suited to your specific needs. Q-1 is
the leader in Training and Facilitating the
most effective RCA techniques available. We
specialize in8D(Eight Disciplines of Problem
Solving),5 WhyandSix Sigma.
4D-RCA
User / Operator Safety-based
RCA
Accident Analysis
Occupational Safety and Health
Production-based RCA
Quality Control
Manufacturing
4D-RCA
Process-based RCA
Business Processes
Failure-based RCA
Failure Analysis in Engineering and
Maintenance
Systems-based RCA
Change Management
Risk Management
Systems Analysis
4D-Risk Based Inspection

Risk Based Inspection could establish
through complex quantitative
analysis the principal causes of the
nonconformity.
RIB is an American based inspection
method developed by API (American
Petroleum Industry)

An inspection strategy based on risk avoids the
inadequacies of the traditional approach. The
concept of risk takes into account, not only the
probability of failure, but also the consequences
of failure. These may encompass consequences in
terms of lost profits, repair and re-justification
costs, human casualties and environmental clean
up costs. Such a strategy ensures that inspection
effort is targeted appropriately to optimize costs
and benefits, and provides an auditable
demonstration that this has been done with due
diligence.

In some cases, initial turnaround inspection planning
is based on qualitative risk ranking (QRR). Whereas,
quantitative risk assessment attempts to perform a
precise numerical evaluation of the risk exposure
represented by equipment, qualitative risk-based
inspection (RBI) planning provides a means of
making a risk categorization. Therefore, qualitative
RBI planning provides a useful methodology for
correctly targeting inspection expenditure to
components of the plant where it will be most
effective in maximizing the safety of plant personnel
and minimizing the cost exposure to failure.

A qualitative RBI methodology presents, to an expert study
team, each of the factors influencing the likelihood of
equipment failure and each of the factors influencing the
consequences of that failure in the event it were to occur.
Based on the study teams combined expertise, judgments are
then made as to the magnitude of each factor, for each item,
according to a pre-determined scheme. The result of such an
assessment is an evaluation of risk category (or ranking) for
each item, the severity of which then dictates the appropriate
required effectiveness of the inspection response.
In cases where the assessment procedure for determining the
magnitude of any of the factors influencing either likelihood or
consequences of failure, replace expert judgment by
numerical rules, the approach is termed semi-quantitative.

Risk Based Inspection:
is a consequent development of traditional
maintenance strategies that minimizes
maintenance expenses,
belongs to the knowledge based methodologies
focussing on safety and plant availability on
demand by increasing on-stream time due to less
turn-around time and a consequent reduction of
unexpected failures,
is a systematic tool that helps users to make
informed business decisions regarding inspection
and maintenance expenses,

Risk Based Inspection:
identifies Weak Points and Bad Actors,
enables evolution from a Bandage Approach to a
sustaining reliability culture,
is a recognized way towards Best In Class Performance
and Operational Excellence,
means fostering replacement strategy,
is measuring risk as a key performance indicator,
implies prioritization in maintenance efforts,
extends inspection intervals where local authorities
recognize Risk Based Inspection (RBI), and
allows determination of external alternative inspection
methods to avoid internal entry

Obtainable effects:
Identification of Weak Points
Asset Policies
Replacement Strategy
Less internal inspections:
Increased Inspection Intervals
Alternative Inspection Methods
Up-front On-Line Inspections

Short description of methodology
Step 1:Define probability of failure
Failure probability rules have been developed such that
data requirements are minimized as much as possible.
Generally, data required can be obtained from P&ID
and PFD drawings, piping and valve specifications,
process mass balance data etc., with only minimal
requirement to reference design drawings, piping
isometrics etc. The principle is that such detailed data
should only need to be reviewed for more detailed
analysis if deemed appropriate following risk ranking
using the standard easily applied rules. Major features
include:

Step 1:Define probability of failure
Two probabilities of failure are derived for pressure vessels and pipework,
probabilities of failure due to internal damage and due to external damage.
Where appropriate failure probabilities are defined in terms of remaining life
where the life is calculated according to an assessed or measured

degradation rate, a life in service, and a degradation tolerance.
For damage mechanisms for which a remaining life is not appropriate, such as
Stress Corrosion Cracking, a failure probability score is derived

according to how the actual process conditions compare with
permissible process conditions for the materials in question.
Failure probability rules address a wide variety of degradation mechanisms
grouped under the following:
Wall thinning mechanisms e.g. Corrosion

Cracking mechanisms e.g. Stress Corrosion Cracking
Mechanical damage e.g. Fatigue
Metallurgical Damage e.g. Embrittlement

Step 2:Define consequence of failure
Three categories of failure consequence are
assessed.
Safety: toxic, fire, explosion, pressure and
temperature hazards
Environment: pollution hazard to surrounding
population or landscape
Business: instant and longer term effects on
production

Step 3:Define maintenance/inspection effectiveness
RBI/RBM rules allow for inspection effectiveness in apportioning
confidence grades to each equipment item. In the first instance
these grades are taken to be the same as the plants existing
inspection grades. In effect the grading represents confidence
in the current and future condition of an item, confidence is
lowest if there is no inspection evidence and highest if there is
lots of appropriate inspection evidence or well behaved
degradation. Major features include:
For any given risk ranking, items graded high will be allocated longer
inspection intervals than items graded low confidence.
Probabilities of detection are not used in the standard methodology but
can be taken account of in Inspection Value Analyses.

Step 4:Risk mitigation methodology
Inspection alone is not sufficient to mitigate risk,
action arising out of inspection is also required.
Through use of Confidence Grading and remaining
wall thickness measurements etc., allows for
information on known condition of items and this
is then used to influence perceived risk. For
example, a wall thickness measurement can be
used to refine judgments on historical corrosion,
this is refinement of perceived risk.

Step 5:Fitness for purpose and remaining life evaluation
Within ESR Technologys RBI/RBM methodology fitness for
purpose is represented by either remaining life or failure
susceptibility. Remaining lives in the first instance are
calculated according to assessed or measured corrosion rates,
design corrosion allowances, time in service, and presence and
condition of any protective coatings. In almost all instances
such a basic remaining life can be extended through use of
improved determination of corrosion allowance e.g. through
more detailed application of design codes, finite element
analysis etc, or through more in depth corrosion assessment, or
through better corrosion rate trending from wall thickness
measurements.

Step 6:Inspection strategy
Inspection activities are assigned in terms of
damage needing to be checked for as follows:
Wall thinning inspection.

Cracking inspection.
Mechanical damage inspection.
Metallurgical damage inspection.
Internal visual inspection (an activity intended to check
for more than one type of damage category and
assigned in instances of either low confidence and/or
high risk).

Inspection frequencies are assigned for each of the
above activities as the soonest of two calculated dates
as follows:
A frequency obtained from a lookup table according
to risk rank and confidence grade (where the risk is
defined by the overall failure consequences and the
failure likelihood rank for the type of damage).
A percentage of the remaining life calculated for the
type of damage, where the percentage is obtained
from a look up table according to the derived overall
failure consequence ranking.

Cost and benefit analysis
Field experience reports that good quality and
thorough RBI/RBM will result in more efficient
inspection scheduling through which high risk items
can be concentrated on using better inspection
whilst inspection requirements are relaxed on lower
risk items. ESR Technology has experience of
calculating the impact of RBI/RBM programmes, the
results can be dramatic. In practice the success of
any cost benefit analysis depends very much on the
data that can be obtained from the plant.

Short description of methodologyPROBABILITY- CONSEQUENCE MATRIX

Short description of methodology-Inspection
schedule

Short description of methodology- API RBI
matrix
5D
Verify Corrective Actions
Confirm that the selected corrective
actions will resolve the problem for
the customer and will not cause
undesirable side effects. Define other
actions, if necessary, based on
potential severity of problem.
5D
Choose, Verify and Implement CA
objective:
Through pre-production test
programs quantitatively confirm that
the selected corrective actions will
resolve the problem for the
customer, and will not cause any
undesirable side effects.
Define contingency actions, if
necessary, based upon Risk
5D
Choose, Implement & Verify Corrective Actions-1
By far the most critical step in the problem-solving process is to verify
that the solution will in fact eliminate the problem. In addition, it is
often the most difficult step. The most common method to evaluate a
problem solution is to wait for implementation of the solution, then see
if the problem goes away. However, too much time may be lost before
conclusive information is available. Verification, where ever possible,
should come before implementation.
Several approaches to verification are available. In engineering, design
verification and production validation testing provides significant
information. In the short term, a bench/lab test can be used to verify. In
some cases dynamometer testing can provide verification. Long term
one can monitor fleet response. For manufacturing, verification is by inplant indicators. SPC can verify the elimination of the problem.
Sometimes scrap rate reports and conformance audits provide
information. Sometimes a designed experiment is part of verification.
5D
Choose, Implement and Verify Corrective Actions-2
Whatever verifications you choose, a detailed verification / action plan
is required to outline who will be taking what actions by when. The
action plan should show what data or statistics will be collected and
analyzed, who is responsible and must track actual progress and
scheduled completion. The action plan is the detailed Dynamic record
of all phases of the problem solving process.
Good problem solution verifies the customer is satisfied with the
solution. If possible, involve the customer in choosing solutions.
All verification of the problem solution will require decision analysis.
Decision analysis is part of the cost and timing consideration of the
solution. Decisions affecting cost must include effects on quality,
future problem recurrence and complete elimination of the problem. In
addition, management and operating procedures may be involved
when choosing the solution. Evaluation of any adverse effects caused
by the solution are important. The FMEA will most surely be affected.
5D
Choose, Verify and Implement Corrective
Actions-3
Run Pilot Tests
Artificially simulate the solution to allow actual
process or field variation.
Field test the solution using pilot customer
groups.
Verify carefully that another problem is not
generated by the solution.
Monitor Results
Quantify changes in key indicators.
Stress the customer / user evaluation.
5D-Case Study
-Please define a Pilot Test in order to
verify the reparation of a fractured
distilation collumn or other
equipment. The fracture was due to
the fatigue of the material .
5D
What is important ?
Permanent Corrective Action
Acceptance Criteria
Risk Assessment /FMEA(Failure
Mode and Effects Analysis)
Balanced Choice
Control Point Improvement
Verification of Effectiveness
5D-FMEA
FMEA (Failure Mode and Effects Analysis) is an analytical
methodology used to ensure that potential problems have
been considered and addressed throughout the product and
process development cycle. Examples of common
development cycles areAPQP(Advanced Product Quality
Planning),CPPD(Collaborative Product Process Design) and
NPI(New Product Introduction).
A DFMEA (Design FMEA) is performed prior to the
completion of the design of the product. A PFMEA (Process
FMEA) is performed prior to the release of the design for the
process. It is critical that a FMEA be performed with
sufficient time to take counter measures against the risk
and still capture the changes within the design before its
release.
5D-FMEA
The primary reason for doing a FMEA is
taking action to prevent a failure, improve
design control through testing or evaluation,
or process control through inspection. In a
FMEA, risk is the substitute for failure. This
risk is treated as if the failure had already
occurred and corrective action is required.
The reversal of this principle is the8D(Eight
Disciplines of Problem Solving). A FMEA is an
8D before an 8D is necessary.
5D-FMEA
The RPN (Risk Priority Number) is the product
of Severity, Occurrence and Detection (RPN
= SOD), and is often used to determine
the relative risk of a FMEA line item. In the
past, RPN has been used to determine when
to take action. RPN should not be used this
way. Actions are determined by Criticality.
Criticality is the combination of Severity and
Occurrence as displayed in the Criticality
Matrix shown in the next slide.
5D-FMEA
5D-FMEA
How is a FMEA done ?
FMEA Development Methodology follows a Three
Path Model. With the combination of pre-work
documentation, evolving team structure and
action closure, a FMEA becomes the road map for
improvement in the design of products or
processes. Severity for each Effect of Failure is
defined in Path 1 by a core team; Occurrence is
selected in Path 2 by an expanded team of SMEs
(Subject Matter Experts); and Detection is chosen
in Path 3 with testing or inspection personnel.
D5-FMEA
D5-FMEA
6D
Implement Permanent Corrective
Actions(PCA)
Define and implement the
permanent corrective actions
needed. Choose on-going controls to
insure the root cause is eliminated.
Once in production, monitor the longterm effects and implement
additional controls as necessary.
6D
IMPLEMENT PERMANENT CA
OBJECTIVE
Define and implement the best permanent
corrective actions. Choose on-going controls
to ensure the root cause is eliminated. Once in
production, monitor the long-term effects and
implement contingency actions, if necessary.
Identify Alternative Solutions
Evaluate how other groups solved similar
problems.
6D
IMPLEMENT PERMANENT CA OBJECTIVE
Use brainstorming to generate Alternate
Solution C&E diagram.
Consider redesign of the part or process to
eliminate the problem.
Anticipate failure of the solution. Develop
contingency action(s).
Implement Solution
Use an action plan approach to implement the
solution.
Test and verify contingency actions, if possible
6D
Implement PCA-1
Define and implement the
appropriate corrective action(s).
Choose on-going controls to ensure
the root cause is eliminated.
Once in production, monitor the long
term effects and implement
contingency actions (if necessary).
6D
Implement PCA-2
Once the root cause(s) have been identified, the
team establishes an action plan on the permanent
actions to be taken. Again, the action plan includes
who will do what by when. The permanent actions
are implemented to solve the problem. The
question Why did this occur? must be answered.
Establish ongoing controls on the process to
ensure the process remains in control. Once the
permanent corrective actions are in place, the
ongoing controls will verify the effects of the
actions.
6D
Implement PCA-2
To forecast reduction of the problem, indicators such
as scrap reports, etc., can be used. A statistical plan
will verify the effectiveness of the actions. A
systematic approach involves a plan to establish the
facts using data or evidence as a requirement for
making decisions. Data is obtained by investigations
and experiments to test assumptions. These
assumptions are identified by translating the
customer concerns into understandable definitions of
what the problem is and relating these definitions of
the problem to product and processes. These
definitions and data are used to verify solutions.
6D
Implement PCA-3
Once permanent solutions are in place, document
the changes. In addition, all customers need to
be informed about what actions were taken. In
most cases, some type of training is required to
institute permanent corrective actions. Training
may be required to implement a product design
or process change. In addition, implementation of
the permanent actions may need to include the
effect on design or process issues. In
manufacturing, maintenance personnel often
need to be informed of the changes.
6D
Implement PCA-3
Another important part is to correct the obvious. This
includes correcting defective parts already produced,
changing product design, changing tooling, reworking
defective machines and/or equipment, revising ineffective
operating systems or working with and/or replacing suppliers.
Contingency actions should be identified if for some reason
the permanent actions cannot be implemented. For example,
in manufacturing a recommendation to single source a part
may be recommended. But, if one vendor is unable to meet
the increased productivity alternate action is necessary.
Contingency actions based upon risk assessment are
essential to the success of permanent corrective actions for
customer protection and problem solution.
6D
CA Questions
Do the actions represent the best possible longterm solution from the customers viewpoint?
Do the actions make sense in relation to the
cycle plan for the products?
Has an action plan been defined?
Have responsibilities been assigned?
Has timing been established?
Has required support been defined?
What indicators will be used to verify the outcome of
the actions, both short-term and long-term?
6D-Case Study
Please describe the permanent
corrective action you ll take if there
are systemic errors on the products
which were lathed. You should take
into connsideration the eventual
problems with the machine and the
operator.
6D
What is important ?
Implement and Validate
Project Plan
Validation of Improvements
7D
Prevent Recurrence
Modify specifications, update
training, review work flow, improve
practices and procedures to prevent
recurrence of this and all similar
problems.
7D
Prevent Recurrence Objective
Modify those management systems, operating
systems, practices and procedures to prevent
recurrence of this problem and all similar problems.
Prepare a process flow diagram of the
management / operating system that should have
prevented the problem and all similar problems.
Make needed changes to the system. Address
system follow-up responsibilities.
Standardize practices.
Use action plan to coordinate required actions.
7D
Prevent Recurrence-1
Modify the management systems,
operating systems, practices, and
procedures to prevent recurrence of
this and all similar problems.
7D
This next step in the Problem-Solving Process is the seventh
step. It is important to understand what in the process
allowed the problem to occur. A cause-and-effect diagram
can be used to outline the reasons the problem occurred. By
asking Because? the C&E diagram can be constructed.
Another effective tool is a process flow diagram. The process
flow of the manufacturing or engineering process can be
effective in identifying where in the process the problem
could have been prevented. To prevent recurrence of the
problem, most of the time a change to the management
system will be required. Managers must understand why
their system allowed a problem develop. The same system
will allow future problems to occur.
7D
Management systems, practices and procedures
need to be fully understood to be effective. Most
of them are carry-overs from previous model
years and organized structures. Some are
outdated and need to be revised. Understanding
the elements of a management system can be
achieved by maintaining an up-to-date flow
diagram of the system and process. Also, there
should be easy to follow instructions for those
who are part of the system.
7D
Management systems, practices and procedures
should provide management support for Never
ending improvement in all areas and activities. The
system should encourage individuals to participate
freely in the problem solving process. It should help
to understand more about their job and how each
individuals effort affects the outcome of the final
product on customer satisfaction. The system
should encourage everyone to learn something new.
And it should recognize individual and team effort
when these new skills are applied.
7D
Changes in the management system can require documenting
new standard procedures, streamlining to remove obsolete
procedures and revising previous standards. Changes in the
management system need to be communicated clearly to all
customers.
To prevent recurrence additional training is often required.
Training may be needed in statistical techniques and
methodologies, new engineering or manufacturing technologies
or disciplines, better process and/or project management.
If concerns develop regarding changes to the system, these
issues will be addressed. A new team may need to be assigned
with the authority to address the management system.
7D
What is important ?
Prevention
Similar Products and Process
Prevention
Systems Prevention
Standard Work or Practice
Procedures / Policy Updates
8D
Congratulate Your Team
Recognize the collective efforts of
your team. Publicize your
achievement. Share your knowledge
and learning.
8D
The final step in a team oriented problem solving effort
is to recognize the team s collective efforts in solving
the problem and show gratitude by applauding
individual contributions. Management will need to
determine the best way to recognize the team s
contribution to the origination. In addition, individual
effort and talents need to be highlighted and rewarded.
Team oriented problem solving involves risk taking,
some conflict, hard work and participation by everyone.
It includes a free exchange of ideas,, individual talent,
skill, experience and leadership. The team approach,
when led effectively, produces a driving force of
individuals motivated and committed to solving a
specific problem.
8D
Closure and Team Celebration

Archive Documents
Team Lessons Learned
Before and After Comparison
Celebrate Successful Completion
8D and the Is/Is Not

Approach
8D is a counterintuitive approach to problem solving. As a
problem is encountered, it is intuitive to try solutions to
uncover what the root causeIs. 8D takes the opposite
approach by removing possible causes that are not
contributors. TheIs Not approach limits the number of trial
and error attempts at fixing the problem. 8D achieves this by
defining the problem with increasing detail based on facts as
they are available.
The problem description is the result of a scientific study of;
what, where, when and how much. The method develops
theories with collected facts after removing possible causes
not agreeing with the problem description. These root cause
theories are compared to the problem description prior to
physical verification. Trial and error is not permitted in 8D.
8D and FMEA
FMEAis a tool used in the planning of product or process design. The
Failure Modes in a FMEA are equivalent to the problem statement or
description in an 8D. Causes in a FMEA are equivalent to potential causes
in an 8D. Effects of failure in a FMEA are problem symptoms in an 8D. The
relationships between 8D and FMEA are outlined below:
The problem statements and descriptions can be linked between both
documents. An 8D can be completed faster by utilizing easy to locate, prebrainstormed information from a FMEA to solve problems.
Possible causes in a FMEA can immediately be used to jump start 8D
Fishbone or Ishikawa diagrams. Brainstorming information that is already
known is not a good use of time or resources.
Data and brainstorming collected during an 8D can be placed into a FMEA
for future planning of new product or process quality. This allows a FMEA
to consider actual failures, occurring as failure modes and causes,
becoming more effective and complete.
The design or process controls in a FMEA can be used in verifying the root
cause and Permanent Corrective Action in an 8D
8D Final Flowchart

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8D-Problem solving

Goal of this course

GOAL OF THIS COURSE

History of 8D-Military usage

8D and typical operation

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

8D-X factory procedure

What is done ?Prepare for the 8D

Model for Effective Teamwork:

Design Engineering (Typically the leader)

Participation appropriate for phase being conducted

*Should* involve customer or subcontractor

Determine if there should be a meeting

Problem analysis methodologies:

To reduce the risk of making wrong decisions, consideration

The important stratification factors will vary with

2D-Describe the problem

2D-IS/Is not questions

What is the object

Where is the problem

At what step of the

How much of the

How many products

2D-Describe the problem Questions

Describe the Problem Questions

2D-Describe the problem in terms

Unfortunately, most containment actions will

4D-Root cause of a failure

4D-4 process Phenomena

SQC systems have fairly long periods of time

4D-Systems for 0 defects ?

4D-Risk Based Inspection

4D-Risk Based Inspection

4D-Risk Based Inspection

4D-Risk Based Inspection

4D-Risk Based Inspection

4D-Risk Based Inspection

4D-Risk Based Inspection

4D-Risk Based Inspection

4D-Risk Based Inspection

4D-Risk Based Inspection

where the life is calculated according to an assessed or measured

Stress Corrosion Cracking, a failure probability score is derived

grouped under the following:

Should involve customer or subcontractor