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RE: [Root_Cause_State_of_the_Practice] Re: RCA Making headlines in Inc. Magazine!

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  • DR WILLIAM CORCORAN
    Why is trouble. What s the word or phrase? What s the definition? What s good about it? What are the problems with it? Example, illustration, or
    Message 1 of 8 , Oct 18, 2006
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      "Why" is trouble.
      What's the word or phrase? vWhat's the definition?What's good about it?What are the problems with it?Example, illustration, or reference.Example, illustration, or reference.1Example, illustration, or reference.21. Comment or 2. Other benefits of this definition.Sources of definition or other information in this record.Actions
      Why (did X occur)?1. What made X happen? 2. What was the purpose for X to have happened? 3. What allowed X to occur? 4. What was the motivation for X?It's the way it's often used.One begins to lose a grip on plain English.1. Why did God make you? 2. Why did the U.S. invade ______? 3. Why did I run out of gas (on a dark rainy night)?4. Why did I run out of gas on the way to a meeting I did not want to go to? 5. Why did the operator shut off safety injection at TMI?6. Why did the operators make Chernobyl Unit 4 go prompt critical?For investigators a better question is "What are the factors that directly resulted in the nature, the magnitude, and the timing of X?"Good entry at: http://www.answers. com/topic/ why
       

      Jim Bowles <j_m-bowles@...> wrote:
      Hi Bill
      Interesting items on the 5 Whys.
      I have been through this debate before and there is an interesting point about different cultures. In the UK you learn not to ask why at a very early age. Recall the young child asking its father about a delicate subject matter – Dad will give two maybe three answers before saying either – go and ask your mother or when you grow you’ll know. But when you grow what you really know is to not to ask why.
      But there is a method that overcomes this. That is to use the word because.
      You ran out of petrol because:
      You didn’t fill up because:
      Etc.
      Each because drills down a level closer to the root cause.
      For local or process problems the method works fine.
      The same is true for the fish bone diagram – great as a training aid for local or process problems.
      But they quickly fall short when you want to look at wider organisational or human behaviour issues. Then we need a method that helps you unravel some of the complex inter-relationship issues and interactions.
      Jim Bowles
      Dave,
      Thanks ever so much.
      Would you be so kind as to explain how "5 Why?" can come up with multiple root causes?
      Here are some "famous" one root cause examples:

      5 Why's

      The 5 why's typically refers to the practice of asking, five times, why the failure has occurred in order to get to the root cause/causes of the problem. There can be more than one cause to a problem as well. In an organizational context, generally root cause analysis is carried out by a team of persons related to the problem. No special technique is required.

      An example is in order:
      You are on your way home from work and your car stops:
      ·  Why did your car stop? Because it ran out of gas.
      ·  Why did it run out of gas? Because I didn't buy any gas on my way to work.
      ·  Why didn't you buy any gas this morning? Because I didn't have any money.
      ·  Why didn't you have any money? Because I lost it all last night in a poker game.

      I hope you don't mind the silly example but it should illustrate the importance of digging down beneath the most proximate cause of the problem. Failure to determine the root cause assures that you will be treating the symptoms of the problem instead of its cause, in which case, the disease will return, that is, you will continue to have the same problems over and over again.

      Also note that the actual numbers of why's is not important as long as you get to the root cause. One might well ask why did you lose all your money in the poker game last night?

      _____
      Here's another example. I learned the example using the Washington Monument used when demonstrating the use of the 5 Whys.

      The Washington Monument was disintegrating
      Why? Use of harsh chemicals
      Why? To clean pigeon poop
      Why so many pigeons? They eat spiders and there are a lot of spiders at monument
      Why so many spiders? They eat gnats and lots of gnats at monument
      Why so many gnats? They are attracted to the light at dusk.
      Solution: Turn on the lights at a later time.

      _____
      Read the iSixSigma article on the 5 Whys.

      If you use "5 Why" as taught don't you always come up with one root cause?
      Take care,
       
      Bill Corcoran
      Mission : Saving lives, pain, assets, and careers through thoughtful inquiry.
      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
       
      W. R. Corcoran, Ph.D., P.E.
      NSRC Corporation
      21 Broadleaf Circle
      Windsor , CT 06095-1634
      Voice and voice mail: 860-285-8779
      Fax and voice mail to e-mail: 206-888-6772
      ROOT CAUSE INVESTIGATION HELP LINE 860-295-8779
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      Join the on-going discussion of Root Cause Analysis problems, puzzles, and progress at http://groups. yahoo.com/ group/Root_ Cause_State_ of_the_Practice/  
      Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com

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      Take care,

      Bill Corcoran
      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.

      W. R. Corcoran, Ph.D., P.E.
      NSRC Corporation
      21 Broadleaf Circle
      Windsor, CT 06095-1634
      Voice and voice mail: 860-285-8779
      Fax and voice mail to e-mail: 206-888-6772


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    • Dave Simpson
      Bill, In the simplest form, multiple root causes occur when one why question gets multiple answers. Those of us experienced in Toyota Production System
      Message 2 of 8 , Oct 18, 2006
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        Bill,
         
        In the simplest form, multiple root causes occur when one why question gets multiple answers. Those of us experienced in Toyota Production System concepts recognize the "5Ms". Problems are caused by one of "Material, Method, Machine, Measurement, or Man". We look for symptoms of any of these in the answers to a why question, and frequently find multiple Whys to ask for any answer.
         
        Here is part of an investigation conducted one day early in my time here to determine how we ran for a period of time with our metal detectors (we check for metal in our food products before we package them) incorrectly set-up. Starting from the righ-most column labelled Why, each is an answer to the item to the left of it, or to the left and up a row(or two). Once a "root" is reached, an action is created, along with the person who will complete the action and a commitment for completion.
         
        The investigation reveals 6 causes. I recognize that not all of these are pure "root" causes in the sense that it is used by this list, but all contributed to the problem occuring in some way, and all have been addressed.
         
        Problem
        Why
        Why
        Why
        Why
        Why
        Actions to Resolve the Problem
        Who
        When
        Wrong Parameter Set Up  of Metal Detector Machine
        Metal detector setup missed during product size change over
        Overlooked the set up guidelines
        No verification check after doing machine set-up to ensure that all set up requirements are complete
        No checklist to support the verification process after set-up
         
        Generate Set-Up checklist
         CV/Maintenance
        7/27/05 
         
        LH missed checking the metal detector set up requirements after product to product change over
        No checklist for LH to follow
        No defined system for product change over and shift change over
         
         
        Define Change Over Business Process
         CV
        7/27/05
         
        Non compliance to check the set up
        Lack of accountability on product quality and rework
        Lack of feedback process of the problem
        Lack of feedback loop system
         
        Define feedback loop system. Implement Trouble Report for deviation.
        CV/QA
        8/2/05
         
         
         
        Lack of training
        Lack of business process standard
         
        Document Business Process and Conduct Training for affected personnel
        CV/Training 
        8/2/05 
         
         
        No Tools available for checking (Ferrous,Non-ferrous and Metal)
        Missing
        No defined proper place and accountability for Metal Check Tools
         
        Identify proper place for Tools and take weekly inventory
        CV/Supvrs
        7/26/05 
         
         
         
        Too much effort to look for the tools
         
        Check machine capability  for check record retrieval from the system itself 
         
         


        ----- Original Message ----
        From: Dr. Bill Corcoran <williamcorcoran@...>
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Sent: Tuesday, October 17, 2006 1:25:18 PM
        Subject: Re: [Root_Cause_State_of_the_Practice] Re: RCA Making headlines in Inc. Magazine!

        Dave,
         
        Thanks ever so much.
         
        Would you be so kind as to explain how "5 Why?" can come up with multiple root causes?
         
        Here are some "famous" one root cause examples:
        5 Why's

        The 5 why's typically refers to the practice of asking, five times, why the failure has occurred in order to get to the root cause/causes of the problem. There can be more than one cause to a problem as well. In an organizational context, generally root cause analysis is carried out by a team of persons related to the problem. No special technique is required.

        An example is in order:
        You are on your way home from work and your car stops:

        Why did your car stop? Because it ran out of gas.

        Why did it run out of gas? Because I didn't buy any gas on my way to work.

        Why didn't you buy any gas this morning? Because I didn't have any money.

        Why didn't you have any money? Because I lost it all last night in a poker game.

        I hope you don't mind the silly example but it should illustrate the importance of digging down beneath the most proximate cause of the problem. Failure to determine the root cause assures that you will be treating the symptoms of the problem instead of its cause, in which case, the disease will return, that is, you will continue to have the same problems over and over again.

        Also note that the actual numbers of why's is not important as long as you get to the root cause. One might well ask why did you lose all your money in the poker game last night?

        _____
        Here's another example. I learned the example using the Washington Monument used when demonstrating the use of the 5 Whys.

        The Washington Monument was disintegrating
        Why? Use of harsh chemicals
        Why? To clean pigeon poop
        Why so many pigeons? They eat spiders and there are a lot of spiders at monument
        Why so many spiders? They eat gnats and lots of gnats at monument
        Why so many gnats? They are attracted to the light at dusk.
        Solution: Turn on the lights at a later time.

        _____
        Read the iSixSigma article on the 5 Whys.
         
         
        If you use "5 Why" as taught don't you always come up with one root cause?
         
        Take care,
         
        Bill Corcoran
        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
        Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
         
        W. R. Corcoran, Ph.D., P.E.
        NSRC Corporation
        21 Broadleaf Circle
        Windsor, CT 06095-1634
        Voice and voice mail: 860-285-8779
        Fax and voice mail to e-mail: 206-888-6772
        ROOT CAUSE INVESTIGATION HELP LINE 860-295-8779
         
        Join the USS Scorpion Electronic Court of Inquiry by sending an e-mail to USS_Scorpion_ SSN-589-subscrib e@yahoogroups. com
         
        Join the on-going discussion of Root Cause Analysis problems, puzzles, and progress at http://groups. yahoo.com/ group/Root_ Cause_State_ of_the_Practice/  
         
        Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com
        ----- Original Message -----
        Sent: Tuesday, October 17, 2006 10:33 AM
        Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: RCA Making headlines in Inc. Magazine!

        Bill,
         
        As a regular 5Why user and teacher, I don't have a problem with your comments. I also believe that there is nothing wrong with the set of questions you ask. Each serves a useful purpose when used as intended. Each can go wrong if misapplied.

        Like all the Toyota Production System "countermeasures" (that term is deliberately used by Toyota to imply that a particular device is being used temporarily until something better is identified), 5Whys has a specific purpose, and a limiting set of assumptions.
         
        In this case, the assumptions included that the tool would be used by less educated people (who don't know what exacerbated means, much less be able to spell it) to solve relatively simple problems (issues currently affecting production) which have little inherent risk of catastrophe associate with them.
         
        There is a lot of implicit trust in the person asking the questions to draw out concerns around safety and quality, where a potential idea may have implications in these areas.
         
        Outside these limits, there surely are better tools for investigation into root causes.
         
        BTW, frequently in using 5Whys, we come up with 5 or more root causes (some of which fall into the other categories you list), and almost never come up with just one.
         
        Anyone using a tool, without testing the assumptions which underlie it, is blindly accepting risks.
         
        Regards,
         
        Dave Simpson, CPIM, P.Eng, jonah
        Director of Operations,
        The Original Cakerie
        ----- Original Message ----
        From: Dr. Bill Corcoran <williamcorcoran@ sbcglobal. net>
        To: Undisclosed- Recipient@ yahoo.com
        Sent: Tuesday, October 17, 2006 4:10:05 AM
        Subject: [Root_Cause_ State_of_ the_Practice] Re: RCA Making headlines in Inc. Magazine!

        Bob and Bob,
         
        I pasted the article below.
         
        "5 Why?" is fundamentally flawed and yet it gets more press than solid approaches.
         
        What's so hard about the following?
        1. Asking "What are the factors that directly resulted in the nature, the magnitude, and the timing of the effect you are dealing with?"
        2. Realizing that every effect had a) set-up factors that established the vulnerability, b) triggering factor(s) that consummated the vulnerability, 3) exacerbating factors that made the effect as bad as it was, and 4) mitigating factor(s) that kept the effect from being worse.
        3. Realizing that in real life there is never one single root cause.
        The only thing that approaches "5 Why?" in fallacy is thinking that the Fishbone Diagram is rigorous.
         
        Don't let your morale ruin your attitude.
         
        OBTW: I am looking forward to the outraged rants of the lovers of "5 Why?" and Fishbone.
         
        Take care,
         
        Bill Corcoran
        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
        Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
         
        W. R. Corcoran, Ph.D., P.E.
        NSRC Corporation
        21 Broadleaf Circle
        Windsor, CT 06095-1634
        Voice and voice mail: 860-285-8779
        Fax and voice mail to e-mail: 206-888-6772
        ROOT CAUSE INVESTIGATION HELP LINE 860-295-8779
         
        Join the USS Scorpion Electronic Court of Inquiry by sending an e-mail to USS_Scorpion_ SSN-589-subscrib e@yahoogroups. com
         
        Join the on-going discussion of Root Cause Analysis problems, puzzles, and progress at http://groups. yahoo.com/ group/Root_ Cause_State_ of_the_Practice/  
         
        Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum- subscribe@ yahoogroups. com
         

        Having Problems?

        Use the "5 Why?" method to help your company master the art of problem solving.

        From: Inc.com By: Rebecca A. Morgan

        Problems. That is one of the things that all businesses have in common. Cash flow? It's a consideration for all businesses as well, but significant mainly when it becomes a problem. Solving problems, it would seem, is an important skill for every organization. Because so few companies are actually good at it, organizations that are proficient problem solvers have a competitive advantage over those that are not.

        Mark Ruder, president of Universal Metals, an international toll steel processing company located south of Chicago, recognizes the importance of effective problem solving to his firm. Serving the automotive industry, Universal became QS9000 registered several years ago. QS9000, required of most suppliers to domestic automotive companies, defines the framework of an effective quality system, and problem solving is an important element of that system. Despite meeting those requirements, Ruder knew his organization could gain advantage by becoming even better. Ruder wanted the discipline of a structured problem solving mechanism and a simple means to communicate and track issues.

        Universal Metals turned to PHRED Solutions, Inc., a 14-year-old Colorado company that has developed robust compliance and control software for problem solving. The question-based reasoning system provides a disciplined process, and as an important added benefit, also provides a means to convert tribal knowledge into organizational learning in a searchable database accessible to your other problem solvers now and in the future. As baby boomers enter retirement, a lot of valuable knowledge will go with them. A mechanism to effectively capture that experience can make the difference between economic success and failure.

        Why are there so many ineffective problem solvers? Two reasons: First, it is easy to confuse motion with results; Second, the "don't just stand there, do something!" mentality encourages people to start making changes in an attempt to solve a problem when they've skipped the most important step-- defining the problem. These "shoot from the hip" heroic efforts give the comforting sense of progress when in fact the changes will likely miss the mark and confuse the issues even more.

        The problem we see is often a symptom of a deeper issue: the root cause. Addressing symptoms without an understanding of root cause means that the underlying problem remains intact. It will resurface again and again until you identify it and implement a permanent countermeasure.

        An effective technique to identify root cause is called "5 Why?" When looking at the apparent problem ask yourself why the condition exists. Many people stop here, and as a result do not identify the fundamental issue causing the problem. It is important to ask "why?" again and again.

        An example: Our costs are too high. Why? Severe absenteeism forces us to compensate with extra employees and unplanned overtime. Why is absenteeism so severe? Because the work is physically demanding and employees get tired. Why is the work so demanding? Because we have not integrated ergonomics into the work. Why haven't we? Because our engineers are busy with other projects. Why? This process continues until the real root cause of absenteeism is identified. Only then will the problem be addressed successfully.

        In search of the root cause ask "why?" at least five times. Absenteeism was a symptom, not the real problem in this example. The relatively low priority of ergonomics was the issue. Attempts to address absenteeism directly--e. g. putting in a point system, replacing these workers with others--will not address the root cause and will therefore be ineffective in the long run.

        As you read the "5 Why?" example, some of you may have responded to the second "why?" with "because employees are lazy," or "our employees don't care." One of the most common, yet ineffective, supervision responses in addressing a problem is "I'll talk with the employee." It is easy to assume the problem is the result of human carelessness, disinterest, or error. The phrase "idiot proof" reflects that attitude. Yet the vast majority of problems result from poorly designed processes, not from lousy, malicious employees.

        Be careful not to drive "5 Why?" down the wrong road. For example, one company regularly stored sensitive inventory in a refrigerated truck. The truck refrigeration unit failed, ruining the inventory. In its "5 Why?" process its asked why the refrigeration unit failed. Answering that question, and then the next, could reduce the future occurrence of that particular failure, but the real question is "Why do we have so much inventory that we need to store it outside in trucks?" Root cause analysis is a skill to be developed and mastered.

        How do you know if your company is good at solving problems? By the absence of "d éj à vu all over again" in discussing issues. By the confidence your customers have in partnering with you. By leveraging your advantageous cost structure into increased profits. What can you do if you're not? Ask why.


        Copyright © 2006 Mansueto Ventures LLC. All rights reserved.
        Inc.com, 375 Lexington Avenue, New York, NY 10017.
        ----- Original Message -----
        Sent: Monday, October 16, 2006 6:31 PM
        Subject: RE: [rootcauseconferenc e] FW: RCA Making headlines in Inc. Magazine!

        Hi Bob!

         

        Thanks for sharing this with us.  As for the article, well, I almost fell asleep reading it.  I wonder how many people truly understand the potential of our endeavors.

         

        Thanks again,

         

        C. Robert (Bob) Nelms

        bob@failsafe- network.com (note NEW ADDRESS)

        http://tinyurl. com/jbjg8(NEW RCA WEBCAST)

        Failsafe Network, Inc.

        www.failsafe- network.com

         

        -----Original Message-----
        From: rootcauseconference @yahoogroups. com [mailto:rootcauseco nference@ yahoogroups. com] On Behalf Of Bob Latino
        Sent: Monday, October 16, 2006 5:31 PM
        To: rootcauseconference @yahoogroups. com
        Subject: [rootcauseconferenc e] FW: RCA Making headlines in Inc. Magazine!

         

        Hi All

         

        How do you all feel this "RCA" article in INC Magazine this month portrays our RCA community?

         





      • Salot, William
        Dave, Your 5-Why matrix below is in effect a factor tree , built from left-to-right. Each Why is a step down the tree toward the roots . Each step
        Message 3 of 8 , Oct 18, 2006
        • 0 Attachment

          Dave,

           

          Your “5-Why” matrix below is in effect a “factor tree”, built from left-to-right.  Each “Why” is a “step” down the tree toward the “roots”.  Each “step” contains the “factors” that collectively answer the associated “Why?” question.  

           

          Such a tree is needed to associate all of the factors.  The format of the tree is unimportant.  What is important is what type into the boxes on the tree. .

           

          I know of an organization that uses a system that they call “Why, why, why . . . ?”  The name is supposed to mean that the number of “Whys” is unlimited.  My point is that I expressed disapproval of their system until they showed me that they use a “factor tree” too.  

           

          I’m through quibbling about system names.

           

          Bill Salot

           


          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto: Root_Cause_State_of_the_Practice@yahoogroups.com ] On Behalf Of Dave Simpson
          Sent: Wednesday, October 18, 2006 11:32 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: Re: [Root_Cause_State_of_the_Practice] Re: RCA Making headlines in Inc. Magazine!

           

          Bill,

           

          In the simplest form, multiple root causes occur when one why question gets multiple answers. Those of us experienced in Toyota Production System concepts recognize the "5Ms". Problems are caused by one of "Material, Method, Machine, Measurement, or Man". We look for symptoms of any of these in the answers to a why question, and frequently find multiple Whys to ask for any answer.

           

          Here is part of an investigation conducted one day early in my time here to determine how we ran for a period of time with our metal detectors (we check for metal in our food products before we package them) incorrectly set-up. Starting from the righ-most column labelled Why, each is an answer to the item to the left of it, or to the left and up a row(or two). Once a "root" is reached, an action is created, along with the person who will complete the action and a commitment for completion.

           

          The investigation reveals 6 causes. I recognize that not all of these are pure "root" causes in the sense that it is used by this list, but all contributed to the problem occuring in some way, and all have been addressed.

           

          Problem

          Why

          Why

          Why

          Why

          Why

          Actions to Resolve the Problem

          Who

          When

          Wrong Parameter Set Up  of Metal Detector Machine

          Metal detector setup missed during product size change over

          Overlooked the set up guidelines

          No verification check after doing machine set-up to ensure that all set up requirements are complete

          No checklist to support the verification process after set-up

           

          Generate Set-Up checklist

           CV/Maintenance

          7/27/05 

           

          LH missed checking the metal detector set up requirements after product to product change over

          No checklist for LH to follow

          No defined system for product change over and shift change over

           

           

          Define Change Over Business Process

           CV

          7/27/05

           

          Non compliance to check the set up

          Lack of accountability on product quality and rework

          Lack of feedback process of the problem

          Lack of feedback loop system

           

          Define feedback loop system. Implement Trouble Report for deviation.

          CV/QA

          8/2/05

           

           

           

          Lack of training

          Lack of business process standard

           

          Document Business Process and Conduct Training for affected personnel

          CV/Training 

          8/2/05 

           

           

          No Tools available for checking (Ferrous,Non-ferrous and Metal)

          Missing

          No defined proper place and accountability for Metal Check Tools

           

          Identify proper place for Tools and take weekly inventory

          CV/Supvrs

          7/26/05 

           

           

           

          Too much effort to look for the tools

           

          Check machine capability  for check record retrieval from the system itself 

           

           

           

        • robert.smallwood@dnv.com
          Bill You have so much fun quibbling about system names and I enjoy your comments, so don t stop/ Best regards, Robert Smallwood _______________________________
          Message 4 of 8 , Oct 18, 2006
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            Bill

            You have so much fun quibbling about system names and I enjoy your comments, so don’t stop/

             

            Best regards,
            Robert Smallwood
            _______________________________
            Principal Consultant
            DNV CONSULTING

            Phone: (281) 721-6774
            Mobile : (281) 685-9118
            Fax: (281) 721-6906

            Web: www.dnv.com


            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto: Root_Cause_State_of_the_Practice@yahoogroups.com ] On Behalf Of Salot, William
            Sent: Wednesday, October 18, 2006 2:05 PM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: RE: [Root_Cause_State_of_the_Practice] Re: RCA Making headlines in Inc. Magazine!

             

            Dave,

             

            Your “5-Why” matrix below is in effect a “factor tree”, built from left-to-right.  Each “Why” is a “step” down the tree toward the “roots”.  Each “step” contains the “factors” that collectively answer the associated “Why?” question.  

             

            Such a tree is needed to associate all of the factors.  The format of the tree is unimportant.  What is important is what type into the boxes on the tree. .

             

            I know of an organization that uses a system that they call “Why, why, why . . . ?”  The name is supposed to mean that the number of “Whys” is unlimited.  My point is that I expressed disapproval of their system until they showed me that they use a “factor tree” too.  

             

            I’m through quibbling about system names.

             

            Bill Salot

             


            From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto: Root_Cause_State_ of_the_Practice@ yahoogroups. com ] On Behalf Of Dave Simpson
            Sent: Wednesday, October 18, 2006 11:32 AM
            To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
            Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: RCA Making headlines in Inc. Magazine!

             

            Bill,

             

            In the simplest form, multiple root causes occur when one why question gets multiple answers. Those of us experienced in Toyota Production System concepts recognize the "5Ms". Problems are caused by one of "Material, Method, Machine, Measurement, or Man". We look for symptoms of any of these in the answers to a why question, and frequently find multiple Whys to ask for any answer.

             

            Here is part of an investigation conducted one day early in my time here to determine how we ran for a period of time with our metal detectors (we check for metal in our food products before we package them) incorrectly set-up. Starting from the righ-most column labelled Why, each is an answer to the item to the left of it, or to the left and up a row(or two). Once a "root" is reached, an action is created, along with the person who will complete the action and a commitment for completion.

             

            The investigation reveals 6 causes. I recognize that not all of these are pure "root" causes in the sense that it is used by this list, but all contributed to the problem occuring in some way, and all have been addressed.

             

            Problem

            Why

            Why

            Why

            Why

            Why

            Actions to Resolve the Problem

            Who

            When

            Wrong Parameter Set Up  of Metal Detector Machine

            Metal detector setup missed during product size change over

            Overlooked the set up guidelines

            No verification check after doing machine set-up to ensure that all set up requirements are complete

            No checklist to support the verification process after set-up

             

            Generate Set-Up checklist

             CV/Maintenance

            7/27/05 

             

            LH missed checking the metal detector set up requirements after product to product change over

            No checklist for LH to follow

            No defined system for product change over and shift change over

             

             

            Define Change Over Business Process

             CV

            7/27/05

             

            Non compliance to check the set up

            Lack of accountability on product quality and rework

            Lack of feedback process of the problem

            Lack of feedback loop system

             

            Define feedback loop system. Implement Trouble Report for deviation.

            CV/QA

            8/2/05

             

             

             

            Lack of training

            Lack of business process standard

             

            Document Business Process and Conduct Training for affected personnel

            CV/Training 

            8/2/05 

             

             

            No Tools available for checking (Ferrous,Non- ferrous and Metal)

            Missing

            No defined proper place and accountability for Metal Check Tools

             

            Identify proper place for Tools and take weekly inventory

            CV/Supvrs

            7/26/05 

             

             

             

            Too much effort to look for the tools

             

            Check machine capability  for check record retrieval from the system itself 

             

             

             

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