1. Discuss the differences and synergy between Six Sigma, Lean Management and the 8D Problem Solving Process

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1 Welcome to Root Cause Analysis & The Global 8D Problem Solving Process Quality Day Conference 05: Creating & Sustaining a Quality Culture October 0, 05 Frank G. Adler, Ph.D. Principal & Managing Partner Operational Excellence Consulting LLC frankadler@oec-us.com October 05 v.0 Agenda & Key Learning Points Agenda & Key Learning Points:. Discuss the differences and synergy between Six Sigma, Lean Management and the 8D Problem Solving Process. Provide an overview of the 8D Problem Solving Process. Describe the purpose and objective of each phase of the 8D Problem Solving Process 4. Introduce the 8D Problem Solving Worksheet and some of the key problem-solving tools integrated into the 8D Problem Solving Process 5. Illustrate the 8D Problem Solving Process using a simple case study October 05 v.0

2 Six Sigma Reducing Process Variability Y = f(x,x,x,...,x k ) Process Inputs X s Step The Process Step Process Outputs Y s 6M s = MANPOWER MEASURE METHODS MATERIALS MACHINES MOTHER NATURE Step Step 4 Customer October 05 v.0 Six Sigma The Roadmap to Reduce Variation Project Ys Define Measure Analyze Improve Project Charter Process Variables Maps Cause &Effects Matrix Capability Study MSA Process FMEA Multi-Vari Studies Hypothesis Testing Design of Experiments (DOE) Mistake Proofing X X X X 4 X 5 X 6 X 7 X 7 X 8 X 9 X 40 X X X 7 X 4 X 4 X X 8 X X 4 X X 4 X 8 X X 4 X 6 X 8 All Xs st Hit List 0-5 X s Screened List 8-0 X s Found Critical Xs 4-8 X s Control Control Plans X X 4 X 8 Controlling Critical Xs - 5 X s Improved Process 4 October 05 v.0

3 Lean The Five Lean Principles Define Value - Specify value from the Customer perspective. Map Value Stream - Identify the value stream for each product or service and challenge all of the non-value adding steps (wastes) currently necessary to create and deliver this product or service. Add nothing than value. Create Flow - Make the product or service creation and delivery process flow through the remaining value-added steps. Establish Pull Introduce pull based on Customer demand between all process steps where continuous flow is possible. Pursuit Perfection Manage toward perfection so that the number of steps and the amount of time and information needed to create and deliver products or services is optimized. All we are doing is looking at the time line, from the moment the customer gives us an order to the point when we collect the cash. We are reducing the time line by reducing the non-value added activities. Taiichi Ohno 5 October 05 v.0 Lean The 7 Deadly Wastes Lean defines non-value added activities as waste. Waste elimination is one of the most effective ways to increase the profitability of any business. The seven wastes originated in Japan, where waste is known as Muda." Inventory Motion Defects Waiting Over-Processing The 7 Wastes Over-Production Transportation T I M W O O - D 6 October 05 v.0

4 Lean The Roadmap to Reduce Lead Time Project Ys Define Measure Analyze Improve Control Project Charter Value Stream Map MSA Spaghetti Diagram Waste Walk Ohno Circle 5S Visual Workplace Quick Changeover (SMED) Kanban & Pull Systems Mistake-Proofing & Poka-Yoke Standardized Work Control Plans X X X X 4 X 5 X 6 X 7 X 7 X 8 X 9 X 40 X X X 7 X 4 X 4 X X 8 X X 4 X X 4 X 8 X X 4 X 6 X 8 X X 4 X 8 All Xs st Hit List Screened List Found Critical Xs Controlling Critical Xs Improved Process 7 October 05 v.0 Change-Induced vs. Day-One-Deviation 8D Problem Solving Process Lean or Six Sigma DMAIC Process Performance SHOULD Performance SHOULD Change DEVIATION DEVIATION Performance ACTUAL Past Present Day One Present When the process performance once met the SHOULD and no longer does, then you have a Change-Induced problem. Special Cause Variation When a condition required for achieving the SHOULD never existed, then you have a Day-One-Deviation problem. Common Cause Variation 8 October 05 v.0

5 Problem Solving Process - The Terminology Symptom A quantifiable event or effect, experienced by a Customer (internal & external), that may indicate the existence of one or more problems. Problem A deviation from an expectation or standard; a perceived gap between the existing state and a desired state. In the context of the 8D Problem Solving Process the cause(s) of the problem is not known. Possible Cause Any cause, identified for example through Process Variables Mapping, Brainstorming or a Fishbone Diagram, that describes how a Problem or Failure Mode effect may occur. Most Likely Cause A cause, identified based on available or collected data, that best explains the Problem Description or Failure Mode. Root Cause A verified cause that convincingly supports and explains ALL facts available and thus accounts for the problem. Root causes are the fundamental, underlying reasons for a Problem or Failure Mode. 9 October 05 v.0 The 8D Problem Solving Process Establish the Team Describe the Problem Develop Interim Containment Actions Define and Verify Root Cause(s) and Escape Point(s) Choose and Verify Permanent Corrective Actions Implement and Validate Permanent Corrective Actions Prevent Recurrence Recognize Team and Individual Contributions 0 October 05 v.0

6 Establish the Team Key Activities Purpose: Establish a small group of people with the process and/or product knowledge, allocated time, authority, and skills in the required technical disciplines to solve the problem and implement corrective actions. Review the problem or improvement opportunity Review priorities, scope and complexity Identify if a team is needed Identify team members and establish the team Nominate a team leader and project champion Establish basic team guidelines Consider team building exercises October 05 v.0 Phase D Checklist Questionnaire The Problem Solving Team: Are the people affected by the problem represented? Does each person have a reason for being on the team? Do the team members agree on membership? Is the team large enough to include all necessary inputs, but small enough to act effectively? The Champion of the team has been identified? The Team Leader has been identified? Need for a Facilitator to coach the process has been considered? Have all the roles and responsibilities been reviewed and are agreed upon? October 05 v.0

7 The 8D Problem Solving Process Establish the Team Describe the Problem Develop Interim Containment Actions Define and Verify Root Cause(s) and Escape Point(s) Choose and Verify Permanent Corrective Actions Implement and Validate Permanent Corrective Actions Prevent Recurrence Recognize Team and Individual Contributions October 05 v.0 Purpose: Describe the internal or external problem by identifying what is wrong with what and detailing the problem in quantifiable terms. Develop a Problem Statement (5 Whys) Describe the Problem Key Activities Develop a Problem Description using the IS IS NOT Matrix Develop a flowchart of the process and identify critical process steps with respect to the Problem Description Develop a Fishbone Diagram or Process Variables Map to identify possible causes? Determine whether this problem describes a something changed or a day-one-deviation situation Establish a high-level project plan, including milestones, project goals and objectives 4 October 05 v.0

8 If I had an hour to save the world I would spend 59 minutes defining the problem and one minute finding solutions. Albert Einstein 5 October 05 v.0 Problem Solving Process - The Terminology Symptom A quantifiable event or effect, experienced by a Customer (internal & external), that may indicate the existence of one or more problems. Problem A deviation from an expectation or standard; a perceived gap between the existing state and a desired state. In the context of the 8D Problem Solving Process the cause(s) of the problem is not known. Possible Cause Any cause, identified for example through Process Variables Mapping, Brainstorming or a Fishbone Diagram, that describes how a Problem or Failure Mode effect may occur. Most Likely Cause A cause, identified based on available or collected data, that best explains the Problem Description or Failure Mode. Root Cause A verified cause that convincingly supports and explains ALL facts available and thus accounts for the problem. Root causes are the fundamental, underlying reasons for a Problem or Failure Mode. 6 October 05 v.0

9 The Problem Statement (Step ) There are two steps to develop a good Problem Statement. The first step is used to identify the object and the defect and develop the initial Problem Statement. The object and the defect are defined by asking What is wrong with what? What is wrong? is the defect The defect is an unwanted characteristic present in a product or process broken, missing, wrong, too short, with what? is the object The object is the name given to a specific product, process or service that exhibits the defect 7 October 05 v.0 The Problem Statement (Step ) Once the initial problem statement (object & defect) is established, the second step is to use the 5 Why s and ask Why would this situation occur? or Why is that happening to that object? The objective is to refine the initial problem statement to determine the problem, rather than the symptom of the problem focus efforts on a single problem with a single root cause get as near as possible to the root cause using existing knowledge & information check if the root cause of the problem is really unknown 8 October 05 v.0

10 Problem Statement & 5 Whys Example What is the Problem Statement (Object & Defect)? We did not have the right rework tool. Initial Problem Statement WHY? The tool was not in inventory. WHY? The supplier did not deliver the replacement tools. WHY? The supplier did not receive our purchase order on-time. WHY? We did not submit the purchase order on time. WHY? We don t know. Final Problem Statement 9 October 05 v.0 The Problem Description The Problem Description defines the boundaries of the problem, in terms of what it is and what it is not but could be. Scientific description of any event can be made by providing information on What the problem is and what it is not but could be? - Identity IS - The long brackets are missing, IS NOT - The short brackets are not missing (but could be) Where the problem is and where it is not but could be? - Location IS - The order entry defects are in direct ship orders IS NOT - The order entry defects are not in stock orders (but could be) When the problem occurs and when it does not but could? - Timing IS - The clips started breaking in early 00 IS NOT The clips did not break before early 00 (but could have) How big the problem is and how big it is not but could be? - Size IS - About 50% of the paychecks IS NOT Not all paychecks are incorrect (but could be) 0 October 05 v.0

11 The IS IS NOT Matrix 8D PROBLEM SOLVING PROCESS WORKSHEET Problem Statement (What is wrong with what?): Red Felt Tip Marker Leaks IS IS NOT DISTINCTIONS CHANGES TEST FOR MOST LIKELY CAUSES (+) (-) (?) Describe what does occur Describe what does not occur, but could occur What could explain the IS-IS NOT? (People, Methods, Material, Machines, Environment) What has changed in, on, around or about this distinction? When did it change? <Define Possible Root Cause Theory> What? Object: Defect: Where? Where is the object when the defect is observed? Where is the defect on the object? Are there any pattern or trends identifiable? When? When was the defect observed first? Can or was the defect be observed before, during or after other events? When since has the defect occurred? Are there any pattern or trends identifiable? 4 4 How Big? How many objects have the defect? What is the size of a single defect? How many defects are on each object? Are there any 5 5 pattern or trends identifiable? October 05 v.0 Problem Solving Process - The Terminology Symptom A quantifiable event or effect, experienced by a Customer (internal & external), that may indicate the existence of one or more problems. Problem A deviation from an expectation or standard; a perceived gap between the existing state and a desired state. In the context of the 8D Problem Solving Process the cause(s) of the problem is not known. Possible Cause Any cause, identified for example through Process Variables Mapping, Brainstorming or a Fishbone Diagram, that describes how a Problem or Failure Mode effect may occur. Most Likely Cause A cause, identified based on available or collected data, that best explains the Problem Description or Failure Mode. Root Cause A verified cause that convincingly supports and explains ALL facts available and thus accounts for the problem. Root causes are the fundamental, underlying reasons for a Problem or Failure Mode. October 05 v.0

12 Identifying All Possible Causes To learn more about a specific problem and to identify all possible causes, the 8D Problem Solving Team needs to better understand the process that causes the problem. The following tools are widely used to facilitate this activity. Process Flowchart Map and Fishbone Diagram or Process Variables Map These tools work very well in a team environment to ensure that everyone has a voice and every voice is being heard. Select the Fishbone Diagram or Process Variables Map based on the problem you need to solve and/or your personal or team s preference. October 05 v.0 Fishbone or Ishikawa Diagram The Fishbone Diagram, sometimes also called Cause-and-Effect Diagram or Ishikawa Diagram, is another way of looking at the possible causes of a problem. It organizes large numbers of potential causes into pre-defined categories, e.g. 6Ms or 4 Ps, or team-defined categories. 6M s = MEN MEASURE METHODS MATERIALS MACHINES + MOTHER NATURE Second-Level Possible Causes Materials Methods Trunk Main Branch Problem Statement 4P s = PLANT POLICIES PEOPLE PROCEDURES Men/People Machines Primary Possible Cause Category MotherNature Minor Branch 4 October 05 v.0

13 Process: Coffee Making Process Process Variables Map Process Step Inputs & Characteristics (Xs) Type Process Step Process Step Outputs & Characteristics (Ys) INPUTS Coffee Machine (clean) C "Clean" Coffee Machine Think 6 M's Coffee Maker or Operator (experienced) U Preparing Coffee Coffee Machine plugged in Power Outlet Man Power Outlet (functional) C Machine Machine Material Method Measure Mother Earth (. Checking for Cleanliness. Checking that machine is plugged into power outlet) Coffee Machine (clean) C Filter in Coffee Machine Adding Coffee into Coffee Maker or Operator (experienced) U Water in Coffee Machine Coffee Machine Coffee Powder (right, fresh) C/U (. Getting coffee filter Coffee Filter (right size, non-defective) C/U. Placing coffee filter Spoon (clean, right size) C into coffee machine Instructions (correct) C. Getting coffee powder 4. Adding coffee powder into coffee filter) Coffee Machine (clean) C "Correct" Amount of Water in Coffee Machine Coffee Maker or Operator (experienced) U Adding Water into Coffee Pot (clean, non-broken) C Coffee Machine Water Faucet (functional) C (. Filling coffee pot with Water (clean, fresh) C/U water Instructions (correct) C. Filling water into coffee machine) 5 October 05 v.0 The 8D Problem Solving Process Establish the Team Describe the Problem Develop Interim Containment Actions Define and Verify Root Cause(s) and Escape Point(s) Choose and Verify Permanent Corrective Actions Implement and Validate Permanent Corrective Actions Prevent Recurrence Recognize Team and Individual Contributions 6 October 05 v.0

14 Develop Interim Containment Actions Key Activities Purpose: Define, verify and implement Interim Containment Action to isolate the effects of the problem from any internal and/or external Customer until Permanent Corrective (Preventive) Action are implemented. Define potential Interim Containment Action Verify effectiveness of potential Interim Containment Action Select and implement Interim Containment Action Validate effectiveness of implemented Interim Containment Action with the Customer 7 October 05 v.0 Key Concepts of Interim Containment Actions Typically chosen without much data or knowledge about the situation. Temporary fix that works against the effect of the problem. Protects the downstream process or the Customer from the effect of the problem. Contains the problem from a cost, quality, timing perspective. Buys time to identify and resolve the root cause of the problem. Needs normally to be documented. Is not a Band Aid, which may be forgotten. 8 October 05 v.0

15 The 8D Problem Solving Process Establish the Team Describe the Problem Develop Interim Containment Actions Define and Verify Root Cause(s) and Escape Point(s) Choose and Verify Permanent Corrective Actions Implement and Validate Permanent Corrective Actions Prevent Recurrence Recognize Team and Individual Contributions 9 October 05 v.0 Define and Verify Root Causes Key Activities Purpose: Isolate and verify the root cause by testing each root cause theory against the Problem Description and test data. Isolate and verify the place in the process where the effect of the root cause could have been detected and contained but was not (escape point). Establish any additional data collection plans needed to learn more about the problem and/or possible causes. Utilize the Fishbone Diagram or Process Variables Map created earlier to identify the most likely cause(s). Isolate and verify the most likely cause(s) by testing each Root Cause Theory against the Problem Description and the collected data. Isolate and verify the place in the process where the effect of the root cause could have been detected and contained but was not (escape point). 0 October 05 v.0

16 You re neither right not wrong because people agree with you. You re right because your facts and your reasoning are right. Warren Buffett Investor & Billionaire October 05 v.0 Problem Solving Process - The Terminology Symptom A quantifiable event or effect, experienced by a Customer (internal & external), that may indicate the existence of one or more problems. Problem A deviation from an expectation or standard; a perceived gap between the existing state and a desired state. In the context of the 8D Problem Solving Process the cause(s) of the problem is not known. Possible Cause Any cause, identified for example through Process Variables Mapping, Brainstorming or a Fishbone Diagram, that describes how a Problem or Failure Mode effect may occur. Most Likely Cause A cause, identified based on available or collected data, that best explains the Problem Description or Failure Mode. Root Cause A verified cause that convincingly supports and explains ALL facts available and thus accounts for the problem. Root causes are the fundamental, underlying reasons for a Problem or Failure Mode. October 05 v.0

17 Strategies to identify Most Likely Causes Possible Causes Most Likely Causes Eliminating Possible Causes or identifying Most Likely Causes through Process Knowledge Experience with similar Situations or Processes Logbooks of past Events Checks and Audits 5 Whys Analysis Comparative Analysis (Distinctions & Changes) Correlation Analysis (Box Plots & Scatter Plots & ) Process Failure Mode and Effects Analysis October 05 v.0 Comparative Analysis 8D PROBLEM SOLVING PROCESS WORKSHEET Problem Statement (What is wrong with what?): Red Felt Tip Marker Leaks IS IS NOT DISTINCTIONS CHANGES TEST FOR MOST LIKELY CAUSES (+) (-) (?) Describe what does occur Describe what does not occur, but could occur What could explain the IS-IS NOT? (People, Methods, Material, Machines, Environment) What has changed in, on, around or about this distinction? When did it change? <Define Possible Root Cause Theory> Object: Red felt tip marker Blue, black or green marker What? Defect: Leaks Totally dry Where? Tip Barrel (side or base) Where is the object when the defect is observed? Where is the defect on the object? Are there any pattern or trends identifiable? When? First seen two weeks ago Before two weeks ago When was the defect observed first? Can or was the defect be observed before, during or after other events? When since has the defect occurred? Are there any pattern or trends identifiable? All red felt tip markers How Big? (00%) How many objects have the defect? What is the size of a single defect? How many Just some red felt tip markers (less than 00%) defects are on each object? Are there any pattern or trends identifiable? 4 October 05 v.0

18 Comparative Analysis The Comparative Analysis is the third part of the 8D Problem Solving Process Worksheet. The Comparative Analysis connects the facts from the Problem Description ( IS IS NOT Matrix) with the analysis of possible and most likely causes using the Process Flowchart and the C&E Matrix or Why-Why Diagram or Fishbone Diagram, as well as any other information and data available. Step : Compare each IS with its corresponding/contrasting IS NOT. List any known distinctions and uncommon factors that could explain the IS and IS NOT. Ask: What is unique, odd, different, distinctive, unusual about the IS? Consider the most likely causes identified so far. Step : List all known changes in distinctions and uncommon factors. Ask: What has changed in, on, around or about this distinction and uncommon factors? 5 October 05 v.0 Problem Solving Process - The Terminology Symptom A quantifiable event or effect, experienced by a Customer (internal & external), that may indicate the existence of one or more problems. Problem A deviation from an expectation or standard; a perceived gap between the existing state and a desired state. In the context of the 8D Problem Solving Process the cause(s) of the problem is not known. Possible Cause Any cause, identified for example through Process Variables Mapping, Brainstorming or a Fishbone Diagram, that describes how a Problem or Failure Mode effect may occur. Most Likely Cause A cause, identified based on available or collected data, that best explains the Problem Description or Failure Mode. Root Cause A verified cause that convincingly supports and explains ALL facts available and thus accounts for the problem. Root causes are the fundamental, underlying reasons for a Problem or Failure Mode. 6 October 05 v.0

19 Root Cause Theory Testing 8D PROBLEM SOLVING PROCESS WORKSHEET Problem Statement (What is wrong with what?): Red Felt Tip Marker Leaks IS IS NOT DISTINCTIONS CHANGES TEST FOR MOST LIKELY CAUSES (+) (-) (?) What? Where? Describe what does occur Object: Defect: Describe what does not occur, but could occur What could explain the IS-IS NOT? (People, Methods, Material, Machines, Environment) What has changed in, on, around or about this distinction? When did it change? <Define Possible Root Cause Theory> + -? Where is the object when the defect is observed? Where is the defect on the object? Are there any pattern or trends identifiable? When? When was the defect observed first? Can or was the defect be observed before, during or after other events? When since has the defect occurred? Are there any pattern or trends identifiable? How Big? How many objects have the defect? What is the size of a single defect? How many defects are on each object? Are there any pattern or trends identifiable? 7 October 05 v.0 Root Cause Theory Testing Step : Use the 8D Problem Solving Process Worksheet, supported by the Process Variables Map or Fishbone Diagram and any additional data analysis used, to formulate Root Cause Theories based on the identified most likely cause(s) of the problem. Step : Enter a short description of a Root Cause Theory as header into the last column of the 8D Problem Solving Process Worksheet. Step : Assess the Root Cause Theory against each IS IS-NOT statement. Enter a + if the theory explains or does not conflict with the IS IS-NOT statement. Enter a - if the theory conflicts with the IS IS-NOT statement. Enter a? if you are not sure and further investigation may be necessary. The Root Cause(s) convincingly supports and explains ALL IS IS-NOT statements and thus accounts for the problem. 8 October 05 v.0

20 Root Cause Verification Active Verification is a process where the problem solver uses the variable thought to be the root cause to make the effect come and go. Both coming and going are important tests to confirm root causes. Passive Verification is done by observation. With passive verification, you look for the presence of the root cause without changing anything. If you cannot prove the presence of the root cause, then chances are great that this most likely cause is not the root cause. Step : Identify, document and perform a passive and/or active root cause verification method. Step : Continue with the 8D Problem Solving Process if the passive and/or active root cause verification was successful. Otherwise, develop and test additional Root Cause Theories. 9 October 05 v.0 Escape Point Identification Control System: A control system is a system deployed to monitor the product or process and ensure compliance to Customer requirements. It consists of responsibilities, procedures and resources. You may have one or more control points where the product or process is checked. Control Point: A control point is a location within the control system where the product or process is checked for compliance to certain specified requirements. There may be multiple locations within a control system. Escape Point: The escape point is the earliest location in the process, closest to the root cause, where the problem could have been detected, but was not. Step : Using the Process Flowchart, identify Escape Point(s) for the verified root cause(s). Step : Determine if Control Points were missing or ineffective to detect the root cause of the problem at the escape point. 40 October 05 v.0

21 The 8D Problem Solving Process Establish the Team Describe the Problem Develop Interim Containment Actions Define and Verify Root Cause(s) and Escape Point(s) Choose and Verify Permanent Corrective Actions Implement and Validate Permanent Corrective Actions Prevent Recurrence Recognize Team and Individual Contributions 4 October 05 v.0 Choose Permanent Corrective Actions Key Activities Purpose: Select the best Permanent Corrective Actions to remove the root cause and to address the escape point in the process. Verify that both decisions will be successful when implemented and not cause any undesirable effects. Develop solution(s) to remove the root cause(s) Develop solution(s) to address the escape point(s) Select the best solution(s) to remove the root cause(s) Select the best solution(s) to address the escape point(s) Verify that effectiveness of the selected solutions Verify that selected solutions do not cause any undesirable effects 4 October 05 v.0

22 Sixteen Human Error Modes. Omission. Excessive / insufficient repetition. Wrong order 4. Early / late execution 5. Execution of restricted work 6. Incorrect selection 7. Incorrect counting 8. Misrecognition 9. Failing to sense danger 0. Incorrect holding. Incorrect positioning. Incorrect orientation. Incorrect motion 4. Improper holding 5. Inaccurate motion 6. Insufficient avoidance 4 October 05 v.0 Six Mistake Proofing Principles. Elimination seeks to eliminate an error-prone process step by redesigning the product or process so that the task or part is no longer necessary. Example: An example of elimination is the use of ambientlight sensors to turn outside lighting on and off.. Prevention modifies the product or process so that it is impossible to make a mistake or that a mistake becomes a defect. Example: An example would be the change from a rectangular to a round manhole. 44 October 05 v.0

23 Six Mistake Proofing Principles. Replacement substitutes a more reliable process to improve repeatability. This includes use of robotics or automation that prevents a manual assembly error. Example: An example would be the coin dispenser in food stores preventing that customers are getting short changed. 4. Facilitation is the most used principle and employs techniques and combining steps to make a process step easier to perform or less errorprone. This includes visual controls including color coding, marking or labeling parts; checklists that list all tasks that need to be performed; exaggerated asymmetry to facilitate correct orientation of parts. Example: An example would be to color code parts that are similar in shape or the use of a slipping-type torque wrench to prevent over tightening. 45 October 05 v.0 Six Mistake Proofing Principles 5. Detection involves identifying a mistake before further processing occurs so that the operator can quickly correct the defect. Example: Examples would include a weld counter to ensure the correct number of welds or a software modification that will not allow incorrect entries. 6. Mitigation seeks to minimize the effects of the mistake. This includes mechanisms that reduce the impact of a error and defect; products designed with low-cost, simple rework procedures when an error is discovered; extra design margin or redundancy in products to compensate for the effects of errors. Example: An example would be a smoke or heat detector detecting a hazardous situation. 46 October 05 v.0

24 The 8D Problem Solving Process Establish the Team Describe the Problem Develop Interim Containment Actions Define and Verify Root Cause(s) and Escape Point(s) Choose and Verify Permanent Corrective Actions Implement and Validate Permanent Corrective Actions Prevent Recurrence Recognize Team and Individual Contributions 47 October 05 v.0 Implement Corrective Actions Key Activities Purpose: Plan and implement selected Permanent Corrective Actions, remove the Interim Containment Action. Monitor long-term results. Implement the best solution(s) to remove the root cause(s) Implement the best solution(s) to address the escape point(s) Validate the effectiveness of the implemented solutions from the Customer perspective Monitor the effectiveness of the implemented solutions and assure that they do not cause any undesirable effects Remove Interim Containment Action 48 October 05 v.0

25 The 8D Problem Solving Process Establish the Team Describe the Problem Develop Interim Containment Actions Define and Verify Root Cause(s) and Escape Point(s) Choose and Verify Permanent Corrective Actions Implement and Validate Permanent Corrective Actions Prevent Recurrence Recognize Team and Individual Contributions 49 October 05 v.0 Prevent Recurrence Key Activities Purpose: Modify the necessary systems, including policies, methods, and procedures, to prevent recurrence of the problem and similar ones. Identify opportunities to improve and standardize systems, policies, methods and procedures for the present problem Identify opportunities to improve and standardize systems, policies, methods and procedures for similar problems 50 October 05 v.0

26 Process Control Plan Objective A Control Plan is a written statement of an organization s quality planning actions for a specific process, product, or service. The Objective of an effective Process Control Plan is to operate processes consistently on target with minimum variation, which results in minimum waste and rework assure that product and process improvements that have been identified and implemented become institutionalized provide for adequate training in all standard operating procedures, work instructions and tools Customer Requirements Product & Part Characteristics Process Input & Output Characteristics Process Controls Process Control Plan 5 October 05 v.0 The 8D Problem Solving Process Establish the Team Describe the Problem Develop Interim Containment Actions Define and Verify Root Cause(s) and Escape Point(s) Choose and Verify Permanent Corrective Actions Implement and Validate Permanent Corrective Actions Prevent Recurrence Recognize Team and Individual Contributions 5 October 05 v.0

27 Recognize the Team Key Activities Purpose: Complete the team experience and sincerely recognize both team and individual contributions. Celebrate success and identify lessons learned. Perform a final review of the problem solving project Finalize and archive project documentation Recognize the team s success and individual contributions Capture lessons learned and integrate findings into the 8D Problem Solving Process Reward and celebrate 5 October 05 v.0 The rate at which organizations learn may soon become the only sustainable source of competitive advantage. Peter Senge OPERATIONAL EXCELLENCE C O N S U L T I N G Frank G Adler, Ph.D. Principal & Managing Partner Operational Excellence Consulting LLC Phone: + (888) frankadler@oec-us.com Website: 54 October 05 v.0