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January 2, 2006


Does the non-conformance path tie to design, operations, dimensional ... that manufactures metal stampings and light ... 5-Why Critique Sheet ... – PowerPoint PPT presentation

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Title: January 2, 2006

5 Why Analysis
  • January 2, 2006

5-Why Training Agenda
  • Where does 5-Why Fit within the PRR process
  • Understanding of 5-Why
  • Quick 5-Why Exercise as a group
  • Critique Sheet
  • 5- Why Examples
  • Wrap Up/Discussion

Where does it fit within the PRR process?
  • After a supplier has submitted an initial
    response and containment plan (Step 2 in the
    PRR process), a detailed investigation is
    necessary to determine what caused the problem.
    Step 4 (Supplier determines the root cause)
    requires a 5-Why analysis to help in identifying
    the root cause of the problem.
  • Going back to one of the elements within the
    Purpose of a PRR to facilitate problem
    resolution, 5-Why is the prescribed tool for
    determining the root cause of the problem to
    facilitate problem resolution.

Is the powerful question own it!!
Power of Asking Questions
Power of Asking Questions
Who are the best at asking questions to solve
Power of Asking Questions
because they keep asking objective, open-ended
questions until the answer is simple and clear
When working with people to solve a problem, it
is not enough to tell them what the solution is.
They need to find out and understand the solution
for themselves. You help them do this by asking
open-ended , thought provoking questions.
Close-Ended vs. Open-Ended Questions
Benefits of Open-Ended Questions
  • Requires thought
  • Promotes additional research
  • Enhances problem solving skills
  • Does not assume there is one right answer
  • Avoids predetermined answers
  • Stimulates discussion
  • Empowers the person answering

In many circumstances, it is not only the answer
itself, but the process by which the answer was
determined that is important when asking an
Open-Ended question
More Examples
Example 1
Did the lack of a PM system cause this tool to
break? (Close-Ended question, can be answered by
a yes or no, gives the person a predetermined
answer that PM is to blame)
What could have caused the tool to
break? (Open-Ended, probing question forces the
person to think about all possibilities, not just
Example 2
Would improving material flow help reduce lead
times? (Good question but its still
Close-Ended, focuses the person on material flow
as a means to reduce lead time. Is this the best
What are some options on improving lead
time? (Open-Ended, triggering more thought and
research on all variables impacting lead time.)
Example 3
Is equipment capability causing the variation in
your process? (Close-Ended, can be answered by a
yes or no, focuses the person on equipment
being the source of variation)
What could potentially cause variation in your
process? (Open-Ended, triggering more thought
and research, opens up possibilities of variation
with man, material method, not just machine)
5 Why Overview
5-Why Analysis Three Paths
  • 5-Why
  • Specific problem
  • Why did we have the problem?
  • Problem not detected
  • Why did the problem reach the Customer?
  • System failure
  • Why did our system allow it to occur?

5-Why Analysis
Root Cause Analysis
Delco fuse box Insert example
What tool do We use for this?
Grasp the Situation
  • Part I Grasp the Situation
  • Step 1 Identify the Problem
  • In the first step of the process, you become
    aware of a problem that may be large, vague, or
    complicated. You have some information, but do
    not have detailed facts. Ask
  • What do I know?
  • Step 2 Clarify the Problem
  • The next step in the process is to clarify the
    problem. To gain a more clear understanding,
  • What is actually happening?
  • What should be happening?
  • Step 3 Break Down the Problem
  • At this point, break the problem down into
    smaller, individual elements, if necessary.
  • What else do I know about the problem?
  • Are there other sub-problems?

 Grasp the Situation
  • Step 4 Locate the Point of Cause (PoC)
  • Now, the focus is on locating the actual point of
    cause of the problem. You need to track back to
    see the point of cause first-hand. Ask
  • Where do I need to go?
  • What do I need to see?
  • Who might have information about the problem?
  • Step 5 Grasp the Tendency of the Problem
  • To grasp the tendency of the problem, ask
  • Who?
  • Which?
  • When?
  • How often?
  • How much?
  • It is important to ask these questions before
    asking Why?

5-Why Analysis
  • Step 1 Problem Statement
  • Is the problem statement clear accurate?
  • Is the analysis on the problem as the customer
    sees it?
  • Step 2 Three Paths
  • Are all three legs filled in?
  • Are there any leaps in logic?
  • Can you ask one, two, or three more Whys?
  • Is there a cause-and-effect relationship in each
  • Can the problem be turned on and off?
  • Does the path make sense when read in reverse?
  • Do the whys relate to the actual error?
  • Does the non-conformance path tie to design,
    operations, dimensional issues, etc.?
  • Does the detection path tie to the customer,
    control plans, etc.?
  • Does the systemic path tie to management issues
    or quality system failures?

5-Why Analysis
  • Step 3 Corrective Actions
  • Is there a separate action for each root cause?
  • Is it possible to implement each corrective
  • Do corrective actions require Customer approval?
    If so, how will they be communicated to the
  • Is there evidence to support verification of
    corrective actions?
  • Are corrective actions irreversible?If not, do
    actions address ongoing containment?
  • Is there a plan to standardize lessons learned
    across products, departments, etc?
  • Step 4 Lessons Learned
  • How could the problem have been foreseen?
  • How will information be implemented?
  • On the line or in the plant?
  • At the point of detection?
  • Cross functionally at the Supplier?
  • Other products/plants?

5-Why Analysis
  • Step 5 Overall
  • Are there gaps or holes?
  • Are there things missed or not documented?
  • Do corrective actions address actions the
    Supplier owns?
  • How many iterations of 5 Why Analysis have there
  • Who prepared the 5 Why Analysis?
  • One person?
  • Sales representative ?
  • Clerk?
  • The best answer is a cross functional team that
    understand the product and process!

Therefore Test
5-Why Analysis
  • 5-Why Example
  • (Non-conformance)

5-Why Example - PPAP Submittal (Non-conformance)
  • 5-Why Example - PPAP Submittal
  • (Detection)

  • 5-Why Example - Business Plan
  • (Non-conformance)

  • 5-Why Example - Business Plan
  • (Detection)

  Flex Industries Case Study-Background
  • Jake Ryan is the Quality Manager at Flex
    Industries. Flex is a component supplier that
    manufactures metal stampings and light assembly
    products. The company has a reputation for
    supplying high quality parts on a consistent
    basis. Seldom has there been a customer
    complaint. Flex has Quality representatives
    called Customer Support Engineers (CSEs) at
    every customer assembly plant. The CSEs report
    any problems to Jake for investigation and
  • At 700 a.m. this morning, Jake received a call
    from Janet, CSE at the Winding River Assembly
    Plant. Janet informed him that the customer had
    found five defective stabilizing brackets on
    second shift last night. She checked the
    remaining inventory and there were no defects in
    the remaining 326 pieces. The manufacturing
    sticker on the back of the brackets indicated
    that they were made by the second shift operator.
    Normally, the stabilizing bracket is fastened to
    the regulator motor with three rivets. The five
    defective brackets had only two rivets in them.
    The lower set of rivets on all five brackets was
    missing a rivet. This was the first time that
    the problem occurred.


Jake set-up containment procedures at the plant
warehouse to sort for discrepant materials. As
of this morning, two more defective brackets had
been found in the remaining 2019 pieces of
inventory at Flex.
Cause Investigation
  • Jake went out to the floor to talk with the team
    leader of the two rivet lines (East and West) and
    the area quality assurance auditor. He informed
    Sam (the team leader) of the quality problem and
    asked him to identify the line which runs the
    stabilizing bracket assembly. Sam directed Jake
    to the East line which runs Winding River
    assembly brackets only.
  • At the East Line, he spoke with Judy (the QA
    Auditor for the area) and asked to see the
    quality log sheets. Jake and Judy reviewed the
    Nov. 11th log sheet and could not find anything
    out of the ordinary. He asked her to set-up
    in-house containment procedures to sort for any
    discrepant material in the finished goods area.
  • Next, Jake tried to locate the second shift
    operator whose clock number was on the defective
    parts. Since that operator was gone, Jake spoke
    with the current machine operator (Ben). He
    asked Ben about any recent difficulties with the
    rivet machine. Ben said that he hadnt noticed
    anything out of the ordinary. Ben also
    mentioned, however, that there had never been any
    quality bulletins posted in the two years that
    this particular part has been running.
  • Jake decided to stay in the area to watch the
    machine run for a while. After about 15 minutes,
    he watched Ben dump rivets into the feeder bowl
    to prepare for the next run.

Cause Investigation
  • Shortly after restarting rivet operations, Ben
    walked over to another riveter and came back with
    a steel rod. Ben poked around the rivet chute
    and then continued working. Jake approached Ben
    and asked him about the steel rod. Ben replied
    that from time to time the chute gets jammed and
    he has to clear it out. This happens two or
    three times during a shift. He didnt mention
    this in his earlier conversation with Jake
    because the problem has existed ever since he
    started working with this machine. The previous
    operator showed him how to clear the chute. All
    the rivet machines are like this.
  • Jake called the Machine Repair Department and
    asked that someone look at the rivet track. A
    slight gap in the track was found and removed,
    and Ben continued to work.
  • Two hours later, Jake got a call from Ben saying
    that the track was still jamming. As far as Jake
    could see, only rivets were in the bowl. Next,
    Jake looked into the rivet supplier containers.
    There was some foreign material in the blue
    container, but none in the red container. The
    label on the blue container showed that it was
    from Ajax Rivet, Inc., and the label on the red
    container indicated that it was from Franks
    Fasteners. Obviously, the foreign material was
    entering the rivet feeder bowl and jamming the

Cause Investigation
  • Jake called Maintenance and requested that the
    bowl be cleaned. He also added the cleaning
    operation to the preventive maintenance schedule
    on the equipment. He then called both Ajax
    Rivet, Inc. and Franks Fasteners. He asked
    about the cleaning procedures on the returnable
    containers. Franks did a full container purge
    and clean. Ajax just re-introduced the
    containers back into their system. When Jake
    asked why Ajax did not clean their containers, he
    was told that Ajax was not aware that such a
    policy was needed.
  • Upon further investigation, Jake learned that
    Franks Fasteners supplies other major automotive
    companies. Since these companies require that
    all returnable containers be cleaned, Franks
    instituted the purge as part of its practice for
    all customers. Ajax Rivet, however, depends
    primarily on Flex as its major customer. No such
    policy has ever been required of them.

Cause Investigation
  • Jake called the Material Control Department and
    requested that a container maintenance policy be
    drafted which would apply to all their suppliers.
    He also asked that a machine modification be
    developed to sense for the presence of rivets.
    Hopefully, this would error-roof the process.
  • Key Players
  • Jake Quality Manager
  • Janet CSE, Winding River Plant
  • Sam Team Leader, East Line
  • Judy QA Auditor, East Line
  • Ben Machine Operator

Generic Information for 5-Why Example Regular
Cola Soft Drink vs. Diet Cola
  • The plant received a PR/R from a customer. (We
    use 5-Why Analysis to answer every PR/R.)
  • The PR/R states that the customer received
    Regular Cola in the right container (same for
    both products) with the Diet Cola label. The
    order called for Regular Cola.
  • The plant has two identical lines that are
    capable of running either of our two products.
    The lines are located immediately beside each
    other. The only differences in the products are
    the syrup and the labels.
  • The plant runs both lines 24 hours per day.
    There are three shifts that run 700 a.m. to 300
    p.m., 300 p.m. to 1100 p.m., and 1100 p.m. to
    700 a.m.
  • The date code indicates that the defective
    product was manufactured at 303 p.m.
  • Defective product has been contained and sorted.

Bottling Process Flow for 5-Why
Generic Information for 5-Why Real Example O
Ring Seal
  • The plant received a PR/R from a customer. (We
    use 5-Why Analysis to answer every PR/R.)
  • The PR/R states that the customer received
    Mixed/Foreign Material in Shipment.
  • The supplied part is an O Ring seal for oil
  • A cutting operation produces the part to
    specified size. As the raw material (cylindrical
    component) goes through the cutting operation,
    the irregular end-cuts are removed from the
  • Cutting Station
  • Matl Flow

Is this a good or bad Non-Conformance leg?
Is this a good or bad Detection leg?
A good 5-Why will answer Yes to the five PDCA
A problem well defined is a problem half solved
Understand the problem
1. Is the problem statement CLEAR and
ACCURATE? 2. Has the SYSTEMIC root cause(s)
been identified for all legs?
5. Has a plan been identified to STANDARDIZE and
take all lessons learned across products,
processes, plants, functional areas, etc.?
Execute the Plan
implemented for ALL root causes?
4. Has a plan been identified to verify
the EFFECTIVENESS of all corrective actions?
Is this a good Corrective Action plan?
Corrective Action w/ Responsibility
Fastener P/N 10001 would not assemble
1. Replace worn tool (K. Jones)
Burrs on the thread
2. Begin conducting PM on all dies after
every run, minimum 1 x / day, to collect
history (L. Burg)
Worn stamping tool
3. Assess adjust PM intervals for all dies
based on history mfg recommendations
(B. Clark)
Tool exceeded recommended wear life
PM interval not adequate
PM failure No system to strategically set PM
5-Why Critique Sheet
  • General Guidelines A.) Dont jump to
    conclusions! B.) Be absolutely objective. C.)
    Dont assume the answer is obvious. D.) If you
    are not thoroughly familiar with the process
    yourself, assemble a cross-functional team to
    complete the analysis.
  • Step 1 Problem Statement
  • Is the analysis being reported on the problem as
    the Customer sees it?
  • Step 2 Three Paths (Dimensional, Detection,
  • -Are there any leaps in logic?
  • -Is this as far as the Whys lead? Can you still
    ask one, two, three more whys)?
  • -Is there a true cause-and-effect path from
    beginning to end of each path? Is there
    statistical data/evidence to prove it? ---Can the
    problem be turned off and on?
  • -Does the path make sense when read in reverse
    from cause to cause? (e.g.We did this, so this
    happened, so this happened, and so on, which
    resulted in the original problem.)
  • -Do the whys go back to the actual error?
  • -Does the systemic path tie back to management
  • -Does the nonconformance path ties back to
    issues such as design, operational, tiered
    supplier management, etc?
  • -Does the detection path ties back to issues
    such as protect the customer, control plans,

5-Why Critique Sheet (cont)
  • Step 3 Corrective Actions
  • -Does each corrective action address the root
    cause from a path?
  • -Is there a separate corrective action for each
    root cause? If not, does it make sense that the
    corrective action applies to more than one root
  • -Is each corrective action possible to
  • -Are there corrective actions that affect the
    Customer or require customer approval? How will
    they be communicated to the Customer?
  • -Is there evidence and documentation to support
    the validity of the corrective actions?
  • -Are the corrective actions irreversible? If
    not, are there corrective actions in place that
    address containment?
  • Step 4 Lessons Learned
  • -How could this problem have been foreseen?
  • -How will this information be implemented
  • a.) on the line or in the plant?
  • b.) at the point of detection?
  • c.) cross-functionally at the Supplier?
  • d.) other product/plants?
  • -Are there lessons learned for the Customer?
  • Step 5 Overall
  • -Do there seem to be big holes where ideas,
  • corrective actions, or lessons learned are being
  • -Where things are missed or not documented?

5-Why Analysis Cola Example Path A
5-Why Analysis Cola Example Path B
5-Why Analysis Cola Example Path C
5-Why Analysis ORing Example Path A
5-Why Analysis ORing Example Path B
5-Why Analysis ORing Example Path C
Problem Case Audit Standards
  • 5-Why Analysis Green, Yellow, Red
  • G Can follow logic and flow of all 3 legs of 5
    why's. The legs all differentiate "What is the
    problem, why wasn't it detected, and what
    happened systemically."
  • Y All 3 legs filled out, some leaps of logic,
    needs minor corrections to improve.
  • R 1 or 2 legs missing, Leg 1 repeated as leg 2
    or 3, not understanding what the different legs
    mean--typically missing what the systemic leg is.
    Poor answers on 2 or more legs.
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