Tài liệu WHY - WHY ANALYSIS TRAINING doc

1 Missing Carton Pulling Force Not Strong Enough Forces Holding Carton too high Why?. 2 Seal between Suction Cup and Carton inadequate Vacuum Force Not High Enough Cartons Sticking To Ea

WHY - WHY ANALYSIS

TRAINING

☯ OBJECTIVES:

☯ To understand the definition of Why - Why Analysis.

☯ To clarify the procedure for developing a Why - Why Analysis.

☯ To stress the importance of each step in the Why

-Why Analysis.

☯ COURSE SCOPE / JUSTIFICATION:

☯ Why-Why Analysis is a basic, fundamental tool in the development of the IWS cornerstones, so it is essential that each Leader in the implementation of IWS know this technique and transmit it to his/her work teams.

WHY - WHY ANALYSIS

☯ What is Why-Why Analysis?

☯ It is a tool to identify root causes of a problem

so that countermeasures can be applied to prevent reoccurence.

☯ Why-Why Process:

☯ Basically the process is to keep asking why for all possible causes until you can find the root cause for each effect and, therefore, find

a countermeasure for each root cause.

How do tools fit?

Effect

HuMan Machine

Methods Material EnvironMent

Already existing Control Method Results of the check

Verify existence of cause and effect for this situation

Cause and Effect Worksheet

Problem Why Why Why Why Why

☯ Go On the Floor, at the point of the problem

☯ Listen to the people who live the problem

Recommneded Why-Why

Analysis Approach

What is the Product of a Why-Why Analysis ?

It is a structured, field checked, relationship with each

cause-effect relationship linked from the lowest

element back

to the

phenomenon.

P h e n o m e n o n

W h y

?

W h y

?

W h y

?

W h y

?

Why?

R o o t

C a u s e

Std.’

s

E x i s t

?

A c t i o n

T a k e n

?

A c t i o n

Standards

(4M’s)

h u M a n

e q u i p M

M e t h o d

M a t e r i a l

SOP E x i s t

?

True

NTru e

X

X X

A p p l i e d

?

F i e l d

C h e c k

Y N

Y

New Std.

New Maint.

Std.

Y N

WHY-WHY

NTru e

Let’s Break the Analysis into the Following Steps

1 Understanding the Problem

2 Defining the Phenomenon to be analyzed.

3 Establishing Cause-Effect Relationship

through Why questioning and Field Checks.

4 Logical Review of the Analysis

5 Checking for Standards and SOP’s

Let’s See What’s going on?

1 The light bulb

“doesn’t go on” 2 “He slipped”

3 The match

“doesn’t light”

4 The pen

“doesn’t write”

Time: 10’

1 Understanding the Problem

Understanding the problem

• Form a team of qualified,

How you focus on the Problem Greatly impacts the

success of the Analysis.

1 Understanding the Problem

a) According to the Process or Work Flow requirements.

b) According to the physical causes.

Two Clarifying approaches

1 Understanding the Problem

Identify those conditions required by the Process to correctly operate and check all of

them before start doing the analysis.

(Checklist)

Advantages:

+Simpler +More practical +Faster

According to Process or Work Flow requirements

1 Understanding the Problem

Identify the mechanics that generates the phenomenon and start the analysis based on it

Advantages:

+More complete +More precise +More effective

This material considers this approach as the standard way to perform why-why analysis.

According to physical causes.

1 Understanding the Problem

☯ Define the the Phenomenon

☯ We intend to define the mechanics that generate the phenomenon, in other words, the way or process through which what we are

describing occurs.

☯ Break the problem down into specific, observable phenomena.

☯ Align the team on what success looks like.

2 Defining the Phenomenon to be analyzed.

General Problem vs

Phenomenon

☯ An intricate, unsettled question or issue

☯ A source of perplexity or distress

☯ Made up of many observable

phenomenon

☯ Specific, observable facts or events

Problem vs Phenomenon Example

Problem: The room is too dark

Better: The light bulb “doesn’t go on”

Best: There is no flow of electric current through

the filament

Problem vs Phenomenon Examples

Process reliability is below 90%

The heat exchanger plates are cracked

The reactor pump seals leak

Product quality deviations are excessive

Bottle product labels are scratched

Bottle are being underfilled by 2 ounces per bottle

The family car is worn out

The engine is using one quart of oil every 500 miles

The car seats are ripped

Scotoma Training

☯ Definition

☯ Scotoma literally means “limited vision within our field of vision.” It is used to explain the fact that we sometimes see what we expect to see.

☯ How it links to this training

☯ Scotomas can keep us from recognizing the

causes to some problems We might not even

recognize the problem (Like the way we overlook defects if we have gotten to the point where we

consider them as normal.)

What’s the problem?

What’s the problem?

What does Success Look Like?

What’s going on?

☯ Define each of the following phenomena:

1 The light bulb

“doesn’t go on” 2 “He slipped”

3 The match

“doesn’t light”

4 The pen

“doesn’t write”

Workgroup activity (4)

Time: 10’

2 Defining the Phenomenon to be analyzed.

What’s going on?

1 The light bulb “doesn’t go on”

The phenomenon that produces light

is the heating of the filament when

electrons or electric current flows

through it.

DESCRIPTION OF THE PHENOMENON:

There is insufficient or no flow of electric current through the filament.

2 Defining the Phenomenon to be analyzed.

What’s going on?

2 “He slipped”

Slipping occurs when the force of friction is less than the force that caused him to slide.

F = Impulse that caused him to slide.

f = Force of friction DESCRIPTION OF THE PHENOMENON:

F > f

2 Defining the Phenomenon to be analyzed.

What’s going on?

3 The match “won’t light”

In order for a match to light, 3

conditions need to be met:

a) Fuel.- Met with the striking

material and the match head (OK.)

b) Oxygen.- Provided by the

environment (OK.)

c) Heat.- Caused by the friction of

the match head against the rough

strip on the matchbox.

DESCRIPTION OF THE PHENOMENON:

There is not enough friction between the match head and the rough strip on the matchbox to produce the heat needed for ignition.

2 Defining the Phenomenon to be analyzed.

What’s going on?

4 The pen “doesn’t work.”

In order for the pen to write, ink

needs to flow to the pen’s ballpoint

and over it onto a surface

where it is deposited.

DESCRIPTION OF THE PHENOMENON:

Ink doesn’t flow over the pen’s point.

2 Defining the Phenomenon to be analyzed.

☯ First “Why” about the Phenomenon

☯ This question needs to be answered from a physical and/or logical point of view.

☯ The question needs to be answered for each element involved in the description made in the previous step.

☯ At this point, focus on the evidence of the flaws, that is:

☯ a) Verify the evidence of the causes of the problem

in the field (whether it exists or not, stopping the analysis for that branch when the cause doesn’t exist).

☯ b) If it is possible to put a direct countermeasure to the cause into place, do it and stop the analysis

ensure that procedures or standards are in place to maintain condition achieved

3 Establishing Cause-Effect Relationship.

Why does it happen?

☯ Ask the first “Why?” question and answer it for each phenomenon.

1 The light bulb

“doesn’t go on” 2 “He slipped”

3 The match

“won’t light”

4 The pen

“doesn’t work”

Work group activity (4)

Time: 15’

3 Establishing Cause-Effect Relationship.

Why does that happen?

1 The light bulb “doesn’t go on”

FIRST WHY:

Why is the flow of electric current through the filament insufficient

o non-existent?

(The flow of electric current in a flow

of free electrons in the material).

a) There aren’t any free electrons in the material

(The filament material is a dielectric) b) There’s no energy to move the electrons

c) There is not enough energy

d) There is nowhere for the electrons to flow

(The filament is broken)

Eliminated by evidence.

3 Establishing Cause-Effect Relationship.

b) There is a lubricant between the surfaces.

3 Establishing Cause-Effect Relationship.

3 The match “won’t light”

FIRST WHY:

Why is there not enough friction between the match

head and the matchbox strip to produce the heat

needed to cause ignition?

Why does that happen?

(In this case of friction, what is important is that heat be generated)

a) The pressure applied between the match and the

matchbox is too low.

b) The surface of the matchbox is not rough enough.

c) The surface of the match head is not rough enough.

d) There is a lubricant between the surfaces.

e) The friction duration is not long enough to heat the

match head and produce ignition.

3 Establishing Cause-Effect Relationship.

4 The pen “doesn’t work.”

FIRST WHY:

Why doesn’t the ink flow over

the pen’s point?

Why does that happen?

a) Ink isn’t reaching the pen’s point.

b) There’s no pressure on the ink to the

pen’s point (Gravity, others)

c) There’s nowhere for the ink to flow.

(The ballpoint is blocked.)

d) The ink doesn’t flow over the other

surface.

(Writing “in the air,” or on ice, etc.)

3 Establishing Cause-Effect Relationship.

Steps for developing a Why - Why Analysis:

☯ Second “Why”

☯ For each answer to the “Why?” in the previous step, the question “Why?” is asked again.

☯ The answer in this case, and from here

on, should consider the “4 - M’s.”

3 Establishing Cause-Effect Relationship.

How to Verify Causes

a guide

☯ Go look, listen, feel, ask - “Watch

with a purpose”

☯ Make the fix (restore) and monitor

Do the verification on the floor

Why? 1

Missing Carton

Pulling Force Not Strong Enough

Forces Holding Carton too high

Why? 2

Seal between Suction Cup and Carton inadequate Vacuum Force Not High Enough

Cartons Sticking

To Each Other Holding Fingers Miss Adjusted Holding Frame Too Tight

Why? 4

Dust on Carton Scratches

on carton

Surface Finish outside tolerance

Why? 3

Suction Cup Damage

Poor Carton Surface Condition

Vacuum Setting too low Vacuum Line Leaks Suction Cup Too Small

Suction Cup Inadequate Material

Suction Cup Wear

Field Check

No Wear

No Damage Could be Yes

Yes Not True No

No Could be

Phenomenon

Once you have exhausted your Why-Why Questioning,

do the Cause-Effect Relationships Make Sense and flow

back to the Phenomenon ?

4 Logical Review of the Analysis

“If we solve these causes, (1, 2, 8)

is it possible that ZERO will be reached (Branch “A”)?”

CAUSE # 1

Branch “A”

CAUSE # 2 CAUSE # 3 CAUSE # 4 CAUSE # 5 CAUSE # 6 CAUSE # 7 CAUSE # 8

4 Logical Review of the Analysis

Repeat the question branch by branch until

the entire analysis has been verified.

BRANCH “A”

Main branch “AA”

BRANCH “C” BRANCH “D” BRANCH “E” BRANCH “F” BRANCH “G” BRANCH “H” BRANCH “B”

4 Logical Review of the Analysis

5 Checking for Standards and SOP’s

?

W h y

?

W h y

?

Why?

R o o t

C a u s e

Std.’

s

E x i s t

?

A c t i o n

T a k e n

?

A c t i o n

Standards(4M’s)

h u M a n

e q u i p M

M e t h o d

M a t e r i a l

SOP E x i s t

A p p l i e d

?

F i e l d

C h e c k

Y N

Y

N Restore

New Std.

New Maint.

Std.

Y N

Analysis Steps

1 Understanding the Problem

2 Defining the Phenomenon to be analyzed.

3 Establishing Cause-Effect Relationship

through Why questioning and Field Checks.

4 Logical Review of the Analysis

5 Checking for Standards and SOP’s

Notes and Advice:

☯ The analysis should be done at the problem area, not in another location that is isolated from the case.

☯ The analysis is a team effort, not by just one person.

☯ The most important thing is the physical and/or

logical description of the phenomenon to be studied (Step 1)

☯ The Analysis ends when countermeasures TO

AVOID RECURRENCE of the phenomenon are

found.

ALWAYS make a sketch or drawing of the

phenomenon.

The 4-M’s don’t always apply to every cause to

be analyzed, but we should always consider

them so as not to forget possible “causes of

causes.”

The more simplicity and objectivity in steps 1 and 2, the easier it is to ensure that all possible causes are covered.

Practice develops skill.

This tool makes us more objective in our way

of looking at things.

Notes and Advice:

Why/Why - NOT!!!

Already had the answer, used the tool to “document” it

Brainstorming,

in a room,

no verification

Real WHY-WHY Analysis Example

Problem: Through put of the line 23 is below ideal.

Phenomena: Carton not Picked off the supply stack.

Result: This causes a loss in through put (Missing Carton)

Missing Carton

Forces Holding Carton too high

Why? 1

Missing

Carton

Pulling Force Not Strong Enough

Forces Holding Carton too high

Why? 2 Seal

between Suction Cup and Carton inadequate

Vacuum Force Not High Enough

Cartons Sticking

To Each Other Holding Fingers Miss Adjusted Holding Frame Too Tight

Why? 1

Missing Carton

Pulling Force Not Strong Enough

Forces Holding Carton too high

Why? 2 Seal

between Suction Cup and Carton inadequate

Vacuum Force Not High Enough

Cartons Sticking

To Each Other Holding Fingers Miss Adjusted Holding Frame Too Tight

Suction Cup Wear

Why? 3

Suction Cup Damage

Poor Carton Surface Condition

Vacuum Setting too low Vacuum Line Leaks Suction Cup Too Small

Suction Cup Inadequate Material

Loose Carton Stack Flaps folded Backward

Why? 1

Missing Carton

Pulling Force Not Strong Enough

Forces Holding Carton too high

Why? 2

Seal between Suction Cup and Carton inadequate Vacuum Force Not High Enough

Cartons Sticking

To Each Other

Holding Fingers Miss Adjusted Holding Frame Too Tight

Why? 4

Dust on Carton Scratches

on carton

Surface Finish outside tolerance

Why? 3

Suction Cup Damage

Poor Carton Surface Condition

Vacuum Setting too low Vacuum Line Leaks Suction Cup Too Small

Suction Cup Inadequate Material

Suction Cup Wear

Loose Carton Stack Flaps folded Backward

Why? 1

Missing Carton

Pulling Force Not Strong Enough

Forces Holding Carton too high

Why? 2

Seal between Suction Cup and Carton inadequate Vacuum Force Not High Enough

Cartons Sticking

To Each Other

Holding Fingers Miss Adjusted Holding Frame Too Tight

Why? 4

Dust on Carton Scratches

on carton

Surface Finish outside tolerance

Why? 3

Suction Cup Damage

Poor Carton Surface Condition

Vacuum Setting too low Vacuum Line Leaks Suction Cup Too Small

Suction Cup Inadequate Material

Suction Cup Wear

Field Check

Not worn Not Damaged Could be

No Dust Not true

Problem

Found to be low Some Leaks

W h y

?

W h y

?

Why?

R o o t

C a u s e

Std.’s

E x i s t

?

A c t i o n

T a k e n

?

SOP

E x i s t

?

A p p l i e d

?

F i e l d

C h e c k

Dust on Carton Scratches

on carton Surface Finish outside tolerance

Suction Cup Damage

Vacuum Setting too low Vacuum Line Leaks Suction Cup Too Small

Suction Cup Inadequate Material

Suction Cup Wear

Ntrue Ntrue

True True True

NTrue

Y Y N

Standards

(4M’s)

h u M a n

e q u i p M

M e t h o d

M a t e r i a l

X X

X X X X

X

N N

A p p l i e d

?

Train

Develop Stds

Y Y

Y Develop SOP

Train

Draw the problem

Get an understanding of the process:

Drawing, Parts

Exhaust Five Port Valve

Adjustable Restrictor

Get an understanding of the process:

Drawing, Parts, Process

Exhaust Five Port Valve

Adjustable Restrictor

Get an understanding of the process:

Drawing, Parts, Process, Forces, Counterforces

Exhaust Five Port Valve

Adjustable Restrictor

1 2 Counterforce too high

2 Why 3 Why 4 Why 5 Why

Not True True

Conduct Why/Why

Defect 1 Why

1 1 Force (pressure) too low

1 2 Counterforce too high

2 Why

1.1.1 pressure p 0 too low

Defect 1 Why

1 1 Force (pressure) too low

1 2 Counterforce too high

2 Why

1.1.1 pressure p 0 too low

True Not True

Conduct Why/Why