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Course Objectives
At Completion YOU should: Understand HBCs 8D process Know when to use the 8D Process Be able to write an 8D Summary Report Be comfortable using typical problem solving tools Know how to get additional help/training
I hear...I forget I see...and I remember I do...and I understand Ancient Chinese Proverb
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Agenda
Round Robin Introductions Your Name Where you work position/responsibilities Personal objectives for this course
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Definitions
Root Cause: The very basic reason why, how, & when the condition occurred.
A Root Cause Mentality: An insatiable desire to understand why things go wrong, why people do what they do, and how things got into their present state. (C. Robert Nelms)
This takes persistence
Interim Containment Action: This is the action taken which should address and correct the actual nonconforming condition. Permanent Corrective Action: This should address the root cause of a nonconformance and prevent future occurrences of the problem which caused the nonconformance. Contributing Cause: This factor contributed to the problem, but it is not the root cause. Keep going to get to Root Cause. Verification: Making sure that something is going to work prior to implementation. Validation: Checking to make sure that the change is working (after implementation)
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Popularized by Ford Motor Company in the 1960s and 1970s (called Global 8D or G8D) 8D now a standard in the Auto Industry 8D fills a void we currently have at HBC
We reference root cause (internally, with our suppliers and customers)
BUT, we dont provide a standard process to get to root cause
HBC 8D a Structured Process (and Tool Set) for Root Cause Corrective Action
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In general, Lean Six Sigma projects take longer; 8D is for everyday, immediate problems.
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8D Process Fit
Policy & Procedures 12 0008 Corrective Action System
Quality Assurance Instruction (QAI) -- QAI 03-01-015 Corrective Action Response and Review Requirements
Via:
What is 8D?
3.
Reporting Format
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8 Disciplines (8Ds)
D-0 D-1 D-2 D-3 D-4 D-5 D-6 D-7 D-8 Decide to use the 8D Process existing processes Describe Problem Establish Team Implement Interim Containment Find Root Cause Choose Corrective Action Implement Permanent Corrective Action Prevent Recurrence Congratulate Team
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Examples:
Whenever you open a QN, ask yourself if Root Cause/8D should be done.
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HBC Employee
Initially, by contacting QA reps Eventually, anyone
Working out details defining when it makes sense Not all problems need an 8D level of analysis
Management
Anyone can use the process. Using SAP makes sure we capture/share knowledge.
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Place in 8D Process
D-0 Decide to use the 8D Process
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What is the problem? Where was it detected? How serious is the problem? How many occurrences? Who is affected? When did it surface?
Remember:
on the problem.
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High Level information belongs in the Problem Description, Investigate all others in Step 3 & 4.
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Focuses team on same objective Direction set here is used throughout the HBC 8D process (foundation) Forces all to agree on the scope and goal Note: Operational Definitions MUST accompany the Problem Description
What does failure mean? What is bad? What does success look like?
Ice-scraping video
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Development of IS NOT
IS IS NOT
(What, Where, When, How Big) would you EXPECT to.. SEE, HEAR, FEEL, SMELL, OBSERVE . . . .....but DO NOT? (close cousins)
<<<<<<<<<<<<<<<<>>>>>>>>>>>>>>>>>>>>>>>>>>
(What, Where, When, How Big) IS it? (What, Where, When, How Big) could it be but it IS NOT?
Once you have the Problem Defined, get feedback from others (coworkers, manager, others) who have done 8D/RCCA
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Establishes points of comparison Leads to a more complete problem description Provides a Test base for Root Cause Gives you a fingerprint of the problem Draws better boundaries around the problem
SCOPE whats in, whats out
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Advantages/Disadvantages of Teams
Problem solving process rushed Poor team participation No logical (group) process Lack of technical skills Management impatience Permanent Corrective Action Not Implemented
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Typical Team Organization Champion/Sponsor Leader Recorder rotate this role Team Members
(SMEs - Subject Matter Experts)
Recommend: 4-7 members (10 max.) <4, consider leader driving results by consulting with SMEs >10, consider subteams
Ask the initial team: Who else needs to be involved, but isnt here?
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D-0 Decide to use 8D Process D-1 Define the Problem D-2 Establish a Team
D-3 CHOOSE, IMPLEMENT AND VERIFY INTERIM CONTAINMENT ACTION - basically youre Dispositioning the QN
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H L Benefit H
Test feasibility of the containment action (Verify it will work) Commit to it Implement Validate containment action effectiveness
Action Plan
ALWAYS +s and s to every decision. BALANCE (and action) are the Keys!
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Attacks Symptoms Added Costs Monitored while being used Documented &Data Collected Verified for effectiveness Replaced by Perm. Correction
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Pick the best overall Containment Action(s) Consider actions that may be needed to address other areas:
Product in the field WIP Work In Process Product in transit/at the Supplier Spares
Use Action Plan to make sure nothing falls through the cracks
Examples:
VERIFICATION and VALIDATION Airworthiness Directives Service Bulletins Kits for field
Action Plan
X
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Data Thought Map Process Map Brainstorming 5 Whys Cause and Effect (Fishbone) Diagram Graphical Analysis (misc. graphs) +
Thought Map
Dont try to do solutions before the analysis is complete. It is futile to continue doing things the same way while expecting different results. Dont fall into the trap of jumping to conclusions.
This cant be a part time job. Assign a Point Of Contact (POC) to focus on closure. The RCCA response ECD must be based on a planned list of things to do (Action Item Lists).
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Data Collection
Insufficient data can result in solving only the specific instance. 1. 2. 3. 4. 5. 6. 7. 8. 9. Types of data to collect: Location: where problem was detected Personnel: who found problem Specifications: what are the requirements Environment: noise, lighting, temperature, etc Sequence of events Challenge the basis for why its been Equipment determined to be an isolated event and why it couldnt potentially be a Training systemic problem Other occurrences Recent changes: personnel, process, weather
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3) 4) 5)
Answer each question with data Questions (and data) will lead to more questions Capture dead-ends as well as fruitful paths
1) Why?
Is there a statistically significant difference in the number of holes drilled before dull?
Is it possible to attribute QNs and other sheet metal defects to bit quality?
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Storage
Machine
Transport
Assembly
Transport Inspection
Graphical Depiction of How Its Done Terminator (start/stop) Process Step Decision Point Connector (off-page) General Rules:
Left to Right Yess/Nos consistent
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How would you map out the process for 8D so far? Used: When? ________________________ Why?__________________
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You are a root cause detective. Use all the tools you can.
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Tools: Brainstorming
When the best solution isnt obvious, one technique for generating ideas (possible root causes, potential interim corrective or permanent actions) is brainstorming. 1. 2. 3. 4. 5. 6. Generates a large number of ideas Encourage free-thinking Dont criticize Encourage everyone to participate Record all ideas. There is no bad idea. Let ideas incubate give it a little time
A minimum group of at least three people to make this work
Tools: 5 Whys
An employee in the plant slipped and fell while performing their regular duties. 1. 2. 3. 4. 5. 6.
Peel the onion- challenge the basis for root cause. Most people can only support 1-2 layers of questions with their basis for root cause or corrective action.
Why? There was oil on the floor. Why? The machine in that cell was leaking oil. Why? A pressure fitting on the machine failed. Why? Inspection of hoses and fittings is not part of the preventive maintenance (PM) schedule. Why? The PM system does not consider Equipment Manufacturers recommendations to develop PM schedules. Why?- Theres check to make sure this is done.
Dont stop with Because we dont have enough people, money, time its a fact of life. Solve the problem with the people, money, time you DO HAVE.
Used: When? ________________________ Why?__________________
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Methods
- incorrect prep of metal surface -inadequate technique
Machinery
Materials
Histogram
Used to show patterns/distribution in ordered data Categories on the x-axis, # of occurrences on the y axis.
Scatter Diagram
Used to illustrate relationships between 2 variables. 1 variable on each axis. "Correlation does not imply causality."
Ex. Shark Bites and Ice Cream
Goal
2.
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2.
3. 4. 5. 6.
Decide relative importance of wants 1-10 Identify the possible choices Compare possible choices against the decision criteria Analyze risk
IF/THEN terms:
If we choose to___________, Then _________ will happen.
7.
Action Plan
NOTE: Use the Action Item Tracking Sheet to Capture and Track Actions
ALWAYS +s and s to every decision. BALANCE (and action) are the Keys!
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Use the Corrective Action Plan Worksheet in the 8D File and Summarize in Section 5 of the 8D Summary Report
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Be verified Objectively
Three knowledgeable people must agree
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Persistence
Natural Tendency to slack off once the Fix is determined and partially implemented Follow the Action Plan to Completion
Action Plan
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Summarize the Key Permanent Corrective Actions Fill Out Section 6 of the 8D Form
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Tool: Mistake-Proofing
Poka-yoke is the Japanese term that means fail-safing or "mistake-proofing" Examples:
Cant start car until in park, Child-proof caps, laser beam shutoffs for machinery Others??
One of the best ways to prevent problems from occurring/recurring Use mistake-proofing techniques when there are:
Process steps where human intervention is required Decision points in the process Repetitive tasks where physical manipulation of objects is required Steps where errors are known to occur Opportunities for predictable errors to occur
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More Proactive
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Negative
Defects are inevitable People make mistakes Place blame Detect at final inspection Sampling inspection Some are bound to reach the customer
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Communication Same/similar problem other plants Same/similar problem different systems Effect Content Quality Appropriate Quantity Potential Causes
Root Cause Current/Future Problems in other areas
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How Would You Congratulate Your Team? What are some things that have worked well in the past? What are some things that didnt?
5 minutes
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Fill Out Section 8 of the 8D Form (and attach completed file to the appropriate QN)
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Reference Material
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QA Intranet Website
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