How to solve problems (or at least try) with 8D

8D-Problem solving method
Dr.ing. Ștefan KOVACS

Contents
• Goal of this course
• Historic of 8D
• Glossary
• What is 8D ?
• Global 8D
• 8D-X factory procedure
• The main steps of 8D

GOAL OF THIS COURSE
• The students should be able to use 8D in their
current activity, based on the guidelines of the
X factory procedure or independently if
needed.
• The students should retain some operative
methods like 5W, 5W2H, Fishbone, etc.

History of 8D
• The development of a Team Oriented Problem Solving
strategy, based on the use of statistical methods of
data analysis, was done at Ford Motor Company. The
executives of the Powertrain Organization
(transmissions, chassis, engines) wanted a
methodology where teams (design engineering,
manufacturing engineering, and production) could
work on recurring problems. In 1986, the assignment
was given to develop a manual and a subsequent
course that would achieve a new approach to solving
tough engineering design and manufacturing
problems.

History of 8D
• The manual for this methodology was documented and
defined in "Team Oriented Problem Solving"(TOPS),
first published in 1987. The manual and subsequent
course material was piloted at World Headquarters in
Dearborn, Michigan. Many changes and revisions were
made based on feedback from the pilot sessions. This
has been Ford's approach to problem solving ever
since. It was never based on any military standard or
other existing problem solving methodology. The
material is extensive and the 8D titles are merely the
chapter headings for each step in the process. Ford
also refers to their current variant as G8D (Global 8D)

History of 8D-Military usage
• The US Government first standardized a process during the Second
World War as Military Standard 1520 'Corrective Action and
Disposition System for Nonconforming Material' . This military
standard focused on nonconforming material and the disposition of
the material.
• The 8D Problem Solving Process is used to identify, correct and
eliminate recurring problems. The methodology is useful in product
and process improvement. It establishes a permanent corrective
action based on statistical analysis of the problem. It focuses on the
origin of the problem by determining Root Causes.
• This 'Determine a Root Cause' step is a part of the military usage of
the 8D's but was not a reference in the development of the 8D
problem solving methodology and is not referenced or included in
the TOPS manual or course.

Glossary
• Action plan-This is a formal record of assignments, responsibilities
and timing.
• Advanced product quality planning-A cross functional approach
that enables communication and feedback to flow throughout the
organization for improved quality and productivity. APQP focuses
on linking ‘Prevent Recurrence’ with:
• Defined product development process (event, timing, quality
of event)
• G-Y-R (Green, Yellow, Red) program control process (macro
view of critical path).
• Design Quality Review (DQR) or micro view of working
documents.
• Engineering change management (Verification and
Validation)
• Analytical Tools

Glossary
• Common cause-Process inputs and conditions
that regularly contribute to the variability of
process outputs. Because Common Causes are
‘regular’ contributors, the ‘Process’ or ‘System’
Variability is defined in terms of them.
• Containment action-Verified action that
immediately stops the Symptom from reaching
the customer.
• Corrective action-Action that permanently
eliminates the Root Cause of a problem. Selected
in D5 and implemented in D6.

Glossary
• Champion-Someone who has authority but
does not participate directly in the team’s
problem solving activities. A supporter and
persuader of the team’s actions.
• Common cause- Process inputs and conditions
that regularly contribute to the variability of
process outputs. Because Common Causes are
‘regular’ contributors, the ‘Process’ or
‘System’ Variability is defined in terms of them

Glossary
• Decision making-Process used to select the best Corrective Action.
Assess impact and risks.
• Design Quality Reviews-A process that measures the Product
Development Process. Examines information across the cross-
functional Product Development Team in terms of:
• The ability of the design to meet customer needs and wants.
• Comparison with Best-In-Class (BIC)
• Ability to meet Affordable Targets (AFT)
• Level of robustness of both the process and the product.
• Things-Gone-Wrong / Things-Gone-Right in process (including
Team functioning).
• Defining ‘Quality of the Event” for the engineering process.
• Design Verification Plan & Report

Glossary
• Empowerement-A proactive process, to
delegate, authorize, or enable the Team
members to have Ownership and to be
responsible for changing the rules.
• Escape- Primary question in problem solving
which explains how the problem reached the
customer.

Glossary
• Information database-A tool for Root Cause
Analysis that organizes all known data about a
problem into four categories:
• What, Where, When and How Big
by using Is / Is Not comparisons in D2. The
database is analyzed for Differences and
Changes leading to Root Cause in D4.
Corrective actions are evaluated using
Decision Making and Verification in d%.
Actions are implemented in D6

Glossary
• Management review-Jointly agreed to by
Management and Team for periodic review of progress
to objectives. This is the team’s opportunity to obtain
management assistance where required.
• Management decision making-The technique chosen
by Ford to achieve structural changes to meet
customer satisfaction. This approach consists of theory,
methods and philosophy for extracting information
from data, converting data into information that
enables us to improve the quality of managerial
decisions.

Glossary
• Pareto chart-Type of bar chart used in problem
description to quantify concerns / defects in
descending order of importance. It works on the
principle that 20% of the problems are responsible for
80% of the occurrences.
• Paynter chart-Chart that identifies multiple problem
descriptions and provides validation of containment
and corrective actions over time. The chart consists of
two-dimensional tracking of a specific number of
problems along the Y axis and occurrences of failures in
weeks or months along the X axis.

Glossary
• Poka-Yoke-Error Proofing - Techniques use
simple and inexpensive devices to prevent
errors about to occur or detect errors and
defects that have occurred.
• Policy deployment-System focus providing
direction and alignment focusing on process
What’s and How’s to develop different
measures at different organizational levels to
achieve common policy and/or goal

Glossary
• Problem Description Analysis-Process to organize and gather
appropriate information about the Symptom into a Problem
Description through the use of Repeated WHY's and the
Information database.
• Problem Improvement Methodology-Structured approach to
ensure that our processes better met customer needs and wants
over time, in an efficient manner, with a minimum of waste and
error. The stages are:
• Identify the opportunity
• Define the scope
• Analyze the current process
• Envision future processes
• Pilot and Verify the proposed changes
• Implement changes
• Continually improve

Glossary
• Process measurables- Indicators identified and monitored on an ongoing basis that
result in consistent product quality and greater customer satisfaction.
• Product development process-A group of events and processes that includes:
• System design specification
• Quality function deployment
• Technology reviews
• Risk assessment
• Quality road map
• Serviceability
• Design and process verification plan and report
• Design and process FMEA (Failure Modes Effects Analysis0
• Critical, safety and significant characteristics
• Control plans and flow charts
• Process capability
• Initial sample review
• Process review

Glossary
• Quality Function Deployment- A planning tool
used by multi-disciplinary teams for
translating customer needs and expectations
into appropriate system and component
requirements. The output of QFD process is
the identification of system and component
significant characteristics as well as key
process and production characteristics.

Glossary
• Quality Operating System-Manufacturing plant -
A data driven management process designed by
Ford to get to the Root Cause of problems by
employing the Prevent Recurrence methodology.
A system format which includes and Executive
Summary of key plant measurables, a Preventive
Focus on performance of products during product
development, a Customer focus group of
measurables reflecting Voice of the Customer,
and in internal Focus of process measurables.

Glossary
• Recognize gaps-Process of finding the distance
between what should be happening and what is
actually happening. Examples of gaps are Best-In-Class
versus current performance, Customer Expectations
versus what customer receives, Plan versus actual.
• Repeated WHYs-Method for improved Problem
Description that moves from the problem Symptom to
the Problem Description by asking WHY to obtain
better definition of object, concern and quantification.
This question is asked repeatedly until a level is
reached which can be acted upon.

Glossary
• Special cause-Process inputs and conditions which
SPORADICALLY contribute to the variability of process
outputs. The variability due to one or more Special
Causes can be identified by the use of control charts.
The ‘process’ or ‘system’ variability is defined without
them.
• System design specification-A tool which utilizes QFD
methodology to identify the need to add or revise
engineering and test specifications to correspond to all
specific customer requirements. The output of SDS is
revised system and component engineering
requirements and testing specifications (DVP&R).

Glossary
• V-Loop- Process of Verifying Containment and
Corrective Actions before implementation and
Validating the actions over time after implementation.
This process is performed by using the same indicator
that demonstrated the problem.
• Validate-Proof developed AFTER implementation and
over time. The action taken must do what is intended
by providing before and after data comparison, and
must not introduce a new problem. Proof must be
developed by using the same indicator that
demonstrated the problem and should be tracked on
the Paynter chart.

What is 8 D ?
• 8D is a problem-solving methodology for
product and process improvement. It is
structured into eight disciplines, emphasizing
team synergy. The team as whole is better
and smarter than the quality sum of the
individuals. Each discipline is supported by a
checklist of assessment questions, such as
"what is wrong with what", "what, when,
where, how much".

What is 8D ?
• It could be used to identify, correct and
eliminate the recurrence of quality problems.
• Actually, we could speak about 8(9) steps,
described in detail in this course.

8D and typical operation flowchart

Global 8D
• In the late 1990s, Ford developed a revised
version of the 8D process, that they call
"Global 8D" (G8D) which is the current global
standard for Ford and many other companies
in the automotive supply chain. The major
revisions to the process are as follows:

Global 8D
• Addition of a 0D (D-Zero) step as a gateway to
the process. At D0, the team documents the
symptoms that initiated the effort along with any
Emergency Response Actions (ERAs) that were
taken before formal initiation of the G8D. D0 also
incorporates standard assessing questions meant
to determine whether a full G8D is required. The
assessing questions are meant to ensure that in a
world of limited problem-solving resources, the
efforts required for a full team-based problem-
solving effort are limited to those problems that
warrant these resources.

Global 8D
• Addition of Escape Point to D4 through D6. The idea
here is to consider not only the Root cause of a
problem, but equally importantly, what went wrong
with the control system in allowing this problem to
escape. Global 8D requires the team to identify and
verify this Escape Point (defined as the earliest control
point in the control system following the Root Cause
that should have detected the problem but failed to do
so) at D4. Then, through D5 and D6, the process
requires the team to choose, verify, implement, and
validate Permanent Corrective Actions to address the
Escape Point.

When is an 8D recquired ?
• Often, a 8-D is a customer response at a problem.
Feedback from the customer shows concern with a
product or service.
• Ideally, a measurable will indicate when a 8-D should
start. When an undesirable trend in a process develops
,corrective action can be taken to reduce the cause of
the variation before a symptom occurs in the process
and escapes to the customer.
• A decision must be made regarding if the symptom
could be fixed or requires further analysis. If so, a 8-D
team must assembled.

Case study
• Should a customer ask for solving of the
problem ? Perhaps it is a minor problem
(which could became serious) and he is not
thinking to report it.
• Should the enterprise applying 8D be avare of
every problem, no matter how small it is ?
• Please, give some examples of major, medium
and minor problems in your opinion.

8D-X factory procedure
• 1.1 This procedure establishes the process used
at X factory Romania for the analysis of existing
or potential problems in order to identify their
root causes, to establish and implement the
corrections and corrective / preventive actions,
verification and review the effectiveness of the
implemented actions. Also this procedure
describes the way to record in SAP system the
identified causes, the corrections and the
corrective/preventive actions initiated to
eliminate nonconformities and their causes.

• 1.2 The procedure applies to X factory
Romania’s Business Units and Departments for
the nonconformities detected at internal
audits (according to CRP-822), at the control
of nonconforming products (according to CRP-
83), at solutioning of customers claims / FPRs,
at suppliers performance evaluation, or for
potential nonconformities

• References:
– - X factory Romania’s Quality Manual, code: CR-MQ;
– - ISO 9000, Quality Management Systems. Basic
principles and terminology;
– - ISO 9001, Quality Management Systems.
• Requirements;
– - DP-001014, Corrective/Preventive Actions;
– - DP-006001, Suppliers performance measurements;
– - CRP-822, Internal audits;
– - CRP-83, Control of nonconforming product;

• 3.1 Corrective action (ISO 9000) – action to
eliminate the cause of a nonconformity, defect or
other undesirable situation.
• Note 1: There can be more than one cause for
nonconformity.
• Note 2: Corrective action is taken to prevent
recurrence whereas preventive action is taken to
prevent occurrence.
• Note 3: There is a distinction between correction
and corrective action.

• 3.2 Preventive action (ISO 9000) – action to
eliminate the cause of a potential
nonconformity or other undesirable potential
situation.
• Note 1: There can be more than one cause for
a potential nonconformity.
• Note 2: Preventive action is taken to prevent
occurrence whereas corrective action is taken
to prevent recurrence.

• 3.4 Root Cause – Cause of a
problem/nonconformity that goes beyond the
obvious, visible aspect of the problem/
nonconformity and seeks to identify the base
reason for the problem/nonconformity. This is
the cause or causes, which if eliminated, will
prevent the problem/nonconformity from
reoccurring in the future.

• 5.1 Identification and recording of the
nonconformities and their causes
– 5.1.1 The nonconformities can be detected on:
• - receiving, manufacturing flow, and final inspection;
• - internal and external quality audits;
• - feedback from customers (complaints, suggestions, etc.);
• - projects for improvement;
• - current reviews performed in Production Centers/
Departments;
• - evaluation of suppliers performance;
• - audits performed by suppliers.

• 5.2 Internal corrective and preventive actions
– To establish and implement the corrective and
preventive actions, the 8D principles described
below shall be used.

• D0 – CPAR initiation:
• When a problem is identified, the Quality/Quality
Assurance Engineer analyses the opportunity for
corrective/ preventive actions. When it is determined that
formal corrective/preventative action is warranted, a CPAR
is initiated in SAP R/3 (in accordance with Annex 6.1).
– CPAR shall be issued in the following situations:
• - Nonconformities found in internal/external audits (customers / ISO /
API);
• - Repeatable nonconformities (more than 3 times in a month);
• - Repair and rework with values more than 5.000 USD;
• - Intracompany (FPR / NCR) or direct customers complaints;
• - Nonconformities which leads to late delivery (more than 15 days);
• - Scrap whose root cause is "operator error".

• D1 – Building the team for 8D analysis of the
problem
• The assigned Manager has the responsibility
to initiate the 8D process and in this
respect,he shall establish and organize an 8D
team.

problem
• The 8D team members can be (as applicable) the
following persons: Process Engineers,Production
Supervisors, Quality Engineer/Supervisor, Quality
Assurance Engineer,Design Engineer,
Programmers, Welding Engineer, Purchasing
Referent, Planner, Operators. The 8D team leader
is the assigned Manager.

problem
• This team has the following tasks:
– - 8D process preparing (information, data,documents,
product samples, etc).
– - attending the cause analysis meetings when
necessary.
– - analyzing and identification of the root causes.
– - establishing and proposing of corrective/preventive
actions and implementing due dates.
– - applying of the proposed solutions.

8D-Cameron procedure
• D2 – Precise definition of the problem
• The 8D team makes an initial analysis of the
problem, and if it is necessary, reformulates
the nonconformity description (in CPAR too).
• The method 5W2H shall be used
(Who?;What?; Why?; Where?; When?; How
much?;How often?)

• D3 – Establishing of immediate measures
(corrections, etc.) to eliminate the problem /
nonconformity or to eliminate /minimize the
effects.
• The 8D team analyses the necessity of
immediate actions, i.e. hold on
anufacturing,nonconform products isolation,
other customers’ notification, etc.

• D4 – The problem / nonconformity analysis to
identify the root cause The 8D team analyses the
problem /nonconformity to identify the
rootcause/causes.
• Specific methods like Analysis 5 Why? Or Fish
bone - Ishikawa diagram (cause –effect
diagram)shall be used.
• The 8D team leader fills the „TASK – 001 –Root
Cause Analysis” in CPAR and this task shall be
closed.

• D5 – Establishing of corrective /preventive
actions and their implementation to eliminate
the cause/ causes

the cause/ causes
• - The 8D team 8D, after identification of causes,
establishes the actions to eliminate them. A
responsible person and a due date shall be
assigned to each action.
• - The preventive actions are established in order
to avoid potential nonconformities,accidents or
damages, or to improve the processes or
products.

the cause/ causes
• -The sources of nonconformities
(Nonconformity reports for products, Reports
for complaints, etc) are also recorded in the
corrective/ preventive actions reports to
ensure identification of the documents which
were the basis for initiating those actions.

the cause/ causes
• Some example of types of corrective or
preventive actions (without limiting thereto) can
be:
– - modify the manufacturing specification or the
manufacturing process;
– - prepare new technologies or instructions for non-
documented sub-processes;
– - modify/supplement the procedures or instructions
to clarify specific aspects;

the cause/ causes
• Some example of types of corrective or
preventive actions (without limiting thereto) can
be:
– - train the personnel in charge (also after preparing a
new procedure or instruction or after modifying the
existing ones);
– - endowment with new technologies or tools/devices/
measuring instruments, etc.

• D6 – Verification of implementation and
effectiveness of corrective/preventive actions
• The status, implementation results and
effectiveness of the taken actions are
recorded in the Corrective/ Preventive Actions
Report by the initiating person.

• D7 – Preventive actions.
• Identify if is the case to extend the corrective
actions also to other similar
products/processes or if are necessary also
other long term actions (modify procedures,
processes,etc.)

• D8 –CPAR closing up (according to
• Annex 6.5).
• If all actions have been implemented at the
due date and this action have been considered
effective, the appointed person for the task
„005 – Follow Up” shall close the CPAR.

0D
• What is done ?Prepare for the 8D
• Collect the Symptoms
• Symptoms Checklist
• Emergency Response Action

0D
• Identify the problem.
• Is there a singular problem or a repeating
problem ? Would it be above or belov ALARP ?
• It deserves to be studied ?
• It could lead towards problems that would
manifest in loss, incidents and accidents ?

0D-Case study
• Any problem, here ?

1D
• Use Team Approach
• Establish a small group of people with the
knowledge, time, authority and skill to solve
the problem and implement corrective
actions. The group must select a team leader.

1D
• When a problem cannot be solved quickly by an individual, it is necessary to form
a Team. The team will engage in the investigation and resolution of the problem.
Many factors are critical to establish a group and to ensure that the group can
work effectively together. Using a team approach is not just a step in the problem
solving process, but an overriding framework for decision making.
• It is necessary to reevaluate team membership continually.
• Model for Effective Teamwork:
• Structure
• Goals
• Roles
• Procedures
• Interpersonal Relationships

1D
• Common causes are the myriad of ever-present factors (e.g., process
inputs or conditions) that contribute in varying degrees to relatively small,
apparently random shifts in outcomes day after day, week after week,
month after month. The collective effect of all common causes is often
referred to as system variation because it defines the amount of variation
inherent in the system.
• Special causes are factors that sporadically induce variation over and
above that inherent in the system. Frequently, special cause variation
appears as an extreme point or some specific, identifiable pattern in data.
Special causes are often referred to as assignable causes because the
variation they produce can be tracked down and assigned to an
identifiable source. (In contrast, it is usually difficult, if not impossible, to
link common cause variation to any particular source.) Special Cause
variation results from events which are occurring outside the process. For
example, a relatively major change in temperature or humidity could
cause significant variation (points outside control limits) in the process.

1D
• Brainstorming- how to:
• The following rules are important to brainstorming successfully:
• A leader should take control of the session, initially defining the
problem to be solved with any criteria that must be met, and then
keeping the session on course. He or she should encourage an
enthusiastic, uncritical attitude among brainstormers and
encourage participation by all members of the team. The session
should be announced as lasting a fixed length of time, and the
leader should ensure that no train of thought is followed for too
long. The leader should try to keep the brainstorming on subject,
and should try to steer it towards the development of some
practical solutions.
• Participants in the brainstorming process should come from as wide
a range of disciplines with as broad a range of experience as
possible. This brings many more creative ideas to the session.

1D
• Brainstorming-how to:
• Brainstormers should be encouraged to have fun brainstorming, coming
up with as many ideas as possible, from solidly practical ones to wildly
impractical ones in an environment where creativity is welcomed.
• Ideas must not be criticised or evaluated during the brainstorming session.
Criticism introduces an element of risk for a group member in putting
forward an idea. This stifles creativity and cripples the free running nature
of a good brainstorming session.
• Brainstormers should not only come up with new ideas in a brainstorming
session, but should also 'spark off' from associations with other people's
ideas and develop other peoples ideas.
• A record should be kept of the session either as notes or a tape recording.
This should be studied subsequently for evaluation. It can also be helpful
to jot down ideas on a board which can be seen by all brainstormers.

1D
• Individual vs. Group Brainstorming
• Brainstorming can either be carried out by individuals or groups:
• Individual brainstorming tends to produce a wider range of ideas than
group brainstorming, but tends not to develop the ideas as effectively,
perhaps as individuals on their own run up against problems they cannot
solve. Individuals are free to explore ideas in their own time without any
fear of criticism, and without being dominated by other group members.
• Group brainstorming develops ideas more deeply and effectively, as when
difficulties in the development of an idea by one person are reached,
another person's creativity and experience can be used to break them
down. Group brainstorming tends to produce fewer ideas (as time is spent
developing ideas in depth) and can lead to the suppression of creative but
quiet people by loud and uncreative ones.
• Individual and group brainstorming can be mixed, perhaps by defining a
problem, and then letting team members initially come up with a wide
range of possibly shallow solutions. These solutions could then be
enhanced and developed by group brainstorming.

1D
• Define Scope Of Team
– Select team members and functions
– Define roles and responsibilities
– Identify external customer needs, expectations and
requirements
– Identify internal customer needs, expectations and
requirements
– Complete preliminary studies
– Identify costs, timing and constraints
– Identify documentation process and method
– Develop investigation plan

1D
• Team Organization
– Cross-functional
• Design Engineering (Typically the leader)
• Quality Assurance
• Purchasing
• Manufacturing Engineering
• Material Control
• Sales/Marketing
• Etc.
– Participation appropriate for phase being conducted
– Resources - Team defines ”Needs”
• *Should* involve customer or subcontractor
participation (not always feasible)

1D
• Roles In A Team
– Several roles need to be established for the team. These roles are:
Leader, Champion, Record Keeper (Recorder), Participants and (if
needed) Facilitator.
• Leader-Group member who ensures the group performs its duties and
responsibilities. Spokesperson, calls meetings, establishes meeting
time/duration and sets/directs agenda. Day-to-day authority, responsible
for overall coordination and assists the team in setting goals and
objectives.
• Record Keeper-Writes and publishes minutes.
• Participants:
– Respect each others ideas.
– Keep an open mind.
– Be receptive to consensus decision making.
– Understand assignments and accept them willingly.
• Champion-Guide, direct, motivate, train, coach, advocate to upper
management.

1D
• Inputs To Team
– Field service reports
– Problems and issues reported from Internal customers
– Internal evaluations using surrogate customers
– Road trips (e.g.: Struts)
– Management comments and/or direction
– Government requirements and/or regulations
– Contract review
– Input from higher system level or past QFD projects
– Media commentary and analysis
– Customer letters and suggestions
– Things gone Right/Wrong reports
– Dealer comments
– Fleet operator comments

1D
• Basic Team Rules
– Team must develop their own ground rules
• Once developed, everyone must live by them
• Ground Rules are an aid to ”self-management”
• Team can modify or enhance the rules as they continue to meet
– Determine if there should be a meeting
– Decide who should attend
– Provide advance notices
– Maintain meeting minutes or records
– Establish ground rules
– Provide and Follow an agenda
– Evaluate meetings
– Allow NO interruptions

1D
• What s important ?
– Form a Team
– Core Team Structure
– Team Preparation

1D-Case study
• What criteria would you choose in selecting a team that
should solve the problema of a tank that was produced in X
factory, tested in X factory but when arrived at the
beneficiary, it was looking like in the figure ?

1D-Case Study
• Who should be the leader of the team ? Is this
man a good leader ?

2D
• Describe the Problem
• Describe the problem in measurable terms.
Specify the internal or external customer
problem by describing it in specific terms.
• Specify the internal / external customer
problem by identifying in quantifiable terms
the Who, What, When, Where, Why, How,
How Many (5W2H) for the problem.

2D
– Problem definition is the basis of problem solving.
The definition is used during brainstorming
sessions to identify root causes in step 2 and main
(potential) causes in step 4. Potential causes are
those most likely causes that appear on the
surface to be the source of the problem. A
potential cause may be the root cause but must
be supported by evidence.

2D
• Part of the problem solving process is to identify the root
cause of the problem and understand why it existed in the
first place. Only then can a permanent solution be chosen
and implemented. to make certain the problem will never
surface again. The root cause is the reason the problem
exists. When it is corrected or removed from the system,
the problem will disappear. It is important to improve our
understanding of today's technology to make possible the
planning required to achieve quality and productivity
breakthroughs for tomorrow and into the future.

2D
• Customer Complaints
• Many problems arise from customer complaints. An
internal customer complaint could involve one
department complaining that they cannot use the
output of another department. An external customer
complaint could involve a customer complaining to a
dealer that a transmission ”shifts funny”.
• Frequently the wrong problem is solved and the
customer complaint is not addressed. It is very
important that the customer complaint be clearly
understood. The only method to ensure this is to have
direct customer contact.

2D
• Customer Complaints
• For internal customers, it is advisable to have
representatives from the complaining organization as
part of the problem solving team. In many cases this
approach is the only way a problem can truly be
solved.
• External customer complaints typically require direct
interviews to understand why the customer is not
satisfied. It is not unusual for a customer complaint to
be misrepresented by a company reporting system that
classifies problems in prearranged standard categories.

2D
• Operational Definition of the Problem
• It is important that the problem be described in terms that have the same
meaning to everyone. This is best achieved through an operational
definition.
• An operational definition consists of verifiable criteria that have the
same meaning to the production workers, manager, customer, engineer,
buyer, technician, team members, etc., and are used for past, present
and future comparisons and analysis.
• Sometimes problems are mistakenly described in terms of symptoms:
– Machine is down due to electrical problem. No backup machine or alternative
available.
– The scrap rate has increased from from 3% to 22%.
– Customer warranty claims on engine component is 12%.
– Failure of durability tests of a transmission component at 50,000 miles will
delay launch.

2D
• Symptoms vs. Causes
• It is not uncommon for problems to be reported as symptoms.
More examples are: noise, won t work, no power, machine down,
broken tool, head froze up, contaminated, rough surface, porosity,
shortage of parts, rattles, quality problem, worn out, line stopped,
not to specification, labour problem, management problem, too
much variation, etc.
• The problem solving team must use a systematic approach to
define the real problem in as much detail as possible. A definition of
the problem can best be developed using approaches that organize
the facts to get a comparative analysis. These approaches do this by
asking what is against what is not. Then they draw distinctions from
this comparison, testing these against the problem definition and
forming a statement or description of the problem which must be
resolved.

2D
• Problem Solving
– Systematic approaches to problem solving:
• Business as a System (Business as a Process)
• Analytical problem solving
• Process flow
– Problem analysis methodologies:
• 5W2H
• Stratification
• Comparative analysis
• Similarity analysis

2D-5W2H Analysis
• It is sometimes difficult to define the problem and sort out real
differences. The first, most important step, however, it to
determine that the customer complaint is fully understood.
• 5W2H :
– Who? Identity customers complaining
– What? Identity the problem adequately and accurately
– When? Timing - When did the problem start?
– Where? Location - Where is it occurring?
– Why? Identify known explanations
– How? In what mode or situation did the problem occur?
– How Many? Magnitude - Quantify the problem
• To reduce the risk of making wrong decisions, consideration and
analysis of potential problems in advance will provide contingency
actions to maintain control and protect the customer.

2D-5W-2H Analysis
– Who? - Identity individuals associated with the problem. Characterize
customers who are complaining. Which operators are having difficulty?
– What? - Describe the problem adequately. Does the severity of the problem
vary? Are operational definitions clear (e.g. defects)? Is the measurement
system repeatable and accurate?
– When? - Identify the time the problem started and its prevalence in earlier
time periods. Do all production shifts experience the same frequency of the
problem? What time of year does the problem occur?
– Where? - If a defect occurs on a part, where is the defect located? A location
check sheet may help. What is the geographic distribution of customer
complaints?
– Why? - Any known explanation(s) contributing to the problem should be
stated.
– How? - In what mode or situation did the problem occur? What procedures
were used?
– How Many? - What is the extent of the problem? Is the process in statistical
control?

2D-Stratification analysis
• Stratification Analysis determines the extent of
the problem for relevant factors.
– Is the problem the same for all shifts?
– Do all machines, spindles, fixtures have the same
problem?
– Do customers in various age groups or parts of the
country have similar problems?
• The important stratification factors will vary with
each problem, but most problems will have
several factors. Check sheets can be used to
collect data.

2D-Stratification analysis
• Stratification Analysis determines the extent of the
problem for relevant factors.
• Essentially this analysis seeks to develop a Pareto diagram
for the important factors. The hope is that the extent of the
problem will not be the same across all factors. The
differences can then lead to identifying root cause.
• When the 5W2H and Stratification Analysis are performed,
it is important to consider a number of indicators. For
example, a customer problem identified by warranty claims
may also be reflected by various in-plant indicators.
Sometimes, customer surveys may be able to define the
problem more clearly. In some cases analysis of the
problem can be expedited by correlating different problem
indicators to identify the problem clearly.

2D-Describe the problem
• It has been said that there are no new problems, only different manifestations of
old problems. In problem definition, it is often useful to quantify the problem in
similar situations. The criteria to match similar situations will vary with the type of
problem. Identifying effective matches and evaluating the presence of the problem
provides useful information to generate potential causes and possible problem
solutions. If the similarity analysis identifies a comparable situation where the
problem does not exist, the analysis can focus on the differences in where the
problem is occurring and where it is not occurring.
• Once the 3 types of analysis have been completed, it is sometimes possible to
divide the problem into separate problems. It is easier to address these smaller
problems because fewer root causes are involved. In the ideal case, a single root
cause would be responsible for each problem. If the problem is separated,
different teams may be required to address each problem.
• All three elements of the problem definition are not used for every problem.
However, collectively the different analyses provide a comprehensible description.
You are developing a ”specification” of the problem.

2D-IS/Is not questions
IS IS not
What ? What is the object you
have problems with ?
What could be happening
but is not ?
Where ? Where is the problem in
the product or service ?
When ? At what step of the process
you first saw the problem ?
How big ? How much of the service
or product is affected by
the deffect ?
How many products could
have the defect but did not

2D-Describe the problem Questions
• What Type of Problem Is It?
– Field complaint
– Quality improvement
– Manufacturing improvement
– Component design
– Labour / Personnel
– Supplier / Vendor
– Cost improvement
– Solution implementation
– Cross functional
– Research
– Safety
• Describe the Problem Questions
• Other Questions
– Can you list all of the resources and documents which might help you specify the problem
more exactly?
– Do you have more than 1 problem? Can this situation be separated into smaller parts?
– Is / Is Not
– Is there any evidence this problem surfaced before?

2D-Describe the problem in terms of
5W
• Who, What, When, Where, Why, How, How Many
– What is the extent of the problem?
– Has the problem been increasing, decreasing or remaining
constant?
– Is the process stable?
– What indicators are available to quantify the problem?
– Can you determine the severity of the problem? Can you
determine the various costs of the problem? Can you
express the cost in percentages, dollars, pieces, etc.?
– Do we have the physical evidence on the problem in hand?
– Have all sources of problem indicators been identified and
are they being utilized?
– Have failed parts been analyzed in detail?

2D
• What is important ?
• 5 Why
• Problem Statement
• Affinity Diagram
• Is / Is Not
• Problem Description

2D-Case Study
• A storage tank, designed for working at 2 bar
input pressure, is modified by adding a nozzle
in the input pipe, in order to make an uniform
filling of the tank. After the change, the
operation manager decided to speed up a
little the process, groving the input pressure at
4 bar. Please define the event that may
happen(0D) and its root causes.

D2-5Why
• 5 Why is a problem solving technique pioneered by Toyota Motor
Corporation. The 5 Why concept is simple. If problem solvers ask
the question “Why?” five times successively, the root cause will
present itself by the 4th or 5th Why. Often, the 5th Why points
directly at the management systems and practices allowing the
problem to exist.
• 5 Why is not a deductive brainstorming technique. The 5 Why
process for RCA (Root Cause Analysis) requires that each Why be
supported by data or facts. The process is a team activity, requiring
members to work at each level with discipline to obtain supporting
data. The known or collected facts from each Why lead to the next
Why as the process continues, concluding when the root cause is
found.

D2-5Why
• The Three-legged 5 Why is a technique used
to follow three related paths. The purpose of
the Three-legged 5 Why is to arrive at the
root cause level, where energy has been
expended incorrectly resulting in a failure
chain. The failure chain ends at the symptom
or effect experienced by the customer. The
Three-legged 5 Why begins with a problem
symptom and ends with three separate
conclusions for improvement.

D2-5Why
• The Three Legs are:
• Root Cause (Energy Misappropriation)
• Barrier or Control (Quality Control)
• Systemic Cause (Management)

2D-5Why
• Findings from each leg can crossover between paths.
The development of subsequent legs result in a more
detailed explanation of where, when and how the
problem occurred. Prevention of future problems are
addressed in all three legs, with the following:
• Avoidance of the specific root cause
through SPC (Statistical Process Control and Process
Capability) or Error / Mistake Proofing (Poka Yoke)
• Poka Yoke of the process responsible for the problem
• Establishment of Standard Work Practices to maintain
consistency

2D-Case Study
• Please give a Poka Yoke example taking into
account a command pannel that could trigger
a very unpleasant reaction if someone is
coming inside and thinking just to ”play with
the buttons”

3D
• Implement and Verify Short-Term Corrective
Actions
• Define and implement those intermediate
actions that will protect the customer from
the problem until permanent corrective action
is implemented. Verify with data the
effectiveness of these actions.

3D
• Implement and Verify - Interim
(Containment) Actions
– Define and Implement containment actions to
isolate the effect of the problem from any internal
/ external customer until corrective action is
implemented.
– Verify the effectiveness of the containment action.

3D
• Containment-Action objective
– Define and Implement containment actions to
isolate the effect of the problem from internal and
external customers until corrective action is
implemented.
– Verify the effectiveness of the containment
action(s).

3D
• Containment actions-1
• The main objective of this part of the problem
solving process is to isolate the effects of the
problem by implementing containment actions. A
problem may be poor quality, marginal product
design, or a process or system that is
unpredictable. A containment action may be
stopping production of a known source of a
problem, or not shipping any parts or assemblies
until the source of the problem is identified.

3D
• Once a problem has been described, immediate
actions are to be taken to isolate the problem from the
customer. In many cases the customer must be notified
of the problem. These actions are typically local fixes.
• Common containment actions include:
– 100% sorting of components
– Cars inspected before shipment
– Parts purchased from a supplier rather than manufactured
in-house
– Tooling changed more frequently
– Single source

3D
• Containment actions- 2
– Unfortunately, most containment actions will add
significant cost ($) to the product. However, it is important to
protect the customer from the problem until permanent
corrective actions can be verified and implemented.Most
interim actions are temporary short term actions taken until a
permanent corrective action is defined, implemented and
verified. The danger of many interim corrective actions is that
they are considered to be a permanent solution to the problem.
It must be remembered that they are typically ”band-aids”. It is
a mistake to view containment actions as a solution to the
problem. Containment actions typically address the effect. They
should be considered ”immediate first-aid” to be reviewed and
removed as quickly as possible.

3D
• Containment actions can and often should proceed in parallel with the
root cause determination investigation. During the period in which
containment actions are taking place, many useful things must be pursued
as a first step in finding the root cause. These things include:
– Establishing an investigative plan
– Obtaining baseline data
– Initiating an on-going control system
– Developing a follow-up and communications system
– Correcting products already produced
– Start systematic investigations
– Conduct special studies and statistical experiments
– Understand the problem Review experiences and data with current trends
– Forecast the future

3D-Case Study
• A tank containing sulphuric acid was corroded
and a spill is the result. The spill is small so the
operation manager decided to weld a metal
sheet over the spill hole.
• Would this be an immediate corrective action
? Why ? What are the steps that must be
followed before making the welding ? What
are the immediate control steps ?

3D
• Interim Containment Action
• Verification of Effectiveness

4D
• Define PRIMARY CAUSES THROUGH ROOT
CAUSES ANALYSIS
• Identify all potential causes which could
explain why the problem occurred. Test each
potential cause against the problem
description and data. Identify alternative
corrective actions to eliminate root cause.

4D
• Identify all potential causes which could
explain why the problem occurred.
• Isolate and verify the root cause by testing
each potential cause against the problem
description and test data. Identify alternate
corrective actions to eliminate root cause.

4D
• Two Root Causes
• Root Cause of Event (Occur or Occurrence)
• What system allowed for the event to occur?
• Root Cause of Escape
• What system allowed for the event to escape
without detection?

4D
• Define and Verify Root Cause(s)-1
• An investigation into all identified potential causes is
necessary for effective problem solving. A cause and
effects diagram can be used to brainstorm all potential
causes of the described problem. The team should
decide on what C&E diagram(s) is to be used: 5M,
Process Flow and/or stratification. The more detailed
the C&E diagram, the higher the chances the root
cause will be included on the C&E diagram. An
effective C&E diagram will include input from all team
members and will be discussed in detail.

4D
• Any existing data should be reviewed for clues to potential causes.
Further data collection may be required to investigate additional
causes.
• If the problem has not previously been seen, a timeline analysis
should provide significant data. The timeline will identify events
occurring about the time the problem developed. If enough
documentation is available, potential causes can be further
identified. For example, if a new operator was put on a process or if
a new supplier began supplying parts. Investigation into the events
occurring at the same time the problem was discovered could lead
to several important potential causes.
• ”What Changed?” ”When?” are important questions.

4D
• A technique used extensively in analytical problem
solving is a comparison analysis. This analysis looks at
what is and what is not in the problem description.
• Potential causes can be discovered by conducting a
survey. By surveying the customer who has witnessed
the problem, more potential causes can be highlighted.
• Asking ”Why”repeatedly is effective in driving the
process toward root cause and generating more
complete understanding of the cause and effect.

4D
• Once the problem has been described and the
potential causes identified, the team should be
evaluated. Are the right members on the team to
investigate the potential causes? Are technical advisors
required to assist in any special studies? Do new team
members need to be added? Is the authority to pursue
the analysis of the potential causes well defined? All
these questions must be answered to ensure the team
will be successful in investigating the potential causes
and determining the root cause.

4D
• The cause and effect diagram is used to identify the
potential causes to be investigated. What is the probability
that a potential cause could be responsible for the
problem? Identify all potential causes that could have been
present and may have caused the problem.
• Once all potential causes have been agreed upon, choose
several potential causes to investigate. If only one potential
cause is investigated, a lot of time may be lost if that
potential cause proves not to be the culprit. To expedite a
solution, investigate several potential causes at the same
time (Parallel actions on several potential causes).

4D
• If the problem is a manufacturing process, begin to
establish a stable process. Once the process is stable,
definition of the potential cause will be clarified.
• If design causes are identified, screening experiments may
help identify the key variables which are affected by
subsequent processes. Design changes may be appropriate.
• Four or five potential causes should be identified to
investigate. Identifying several potential causes forces the
team to address multiple possibilities rather than searching
endlessly for a single cause. An implicit part of problem
analysis is investigating potential causes in parallel rather
that in series.

4D
• Six Steps Of Investigation
– State how the potential cause could have resulted in the
described problem.
– Establish what type of data can most easily prove or disprove
the potential cause. Develop a plan on how the study will be
conducted. Identify the actions on an action plan.
– Prepare the required materials to conduct the study. Training
may also be required.
– Collect the required data.
– Analyze the data. Use simple statistical tools emphasizing
graphical illustrations of the data.
– State conclusions. Outline conclusions from the study. Does the
data establish the potential cause as being the reason for the
problem?

4D
• Identify Alternate Solutions
– Generate a Cause & Effects diagram.
– Survey the customer.
– Identify similar problem(s) previously solved.
– Avoid implementing the interim actions for
permanent actions /solutions.
– Consider new and current technology for the
solution.
– Incorporate the solution into future products.

4D
• Identify Potential Causes
– Define the effects for cause and effect diagram(s).
– Prepare a 5M, Process or Stratification cause & effects diagram for each effect
(you may want to use a combination).
– Team members should each assume their activity causes the problem and ask
themselves :How could what I do possibly generate the problem?
– Prepare a time line analysis if the problem was not always present. Identify
what changed when.
– Perform a comparison analysis to determine if the same or a similar problem
existed in related products or processes. Identify past solutions and root
causes which may be appropriate for the current problem.
– Identify the top few potential causes. Develop a plan for investigating each
cause and update the action plan.
– Evaluate a potential cause against the problem description. Does a mechanism
exist so that the potential cause could result in the problem?

4D
• Analyze Potential Causes- Identify Root Cause
• Analyze Potential Causes
• Use the iterative process to analyze each potential cause.
– Hypothesis generation: How does the potential cause result in the problem?
– Design: What type of data can most easily prove/disprove the hypothesis?
– Preparation: Obtain materials and prepare a check list.
– Data Collection: Collect the data.
– Analysis: Use simple, graphical methods to display data.
– Interpretation: Is the hypothesis true?
• Investigate several potential causes independently.
• Use an action plan to manage the analysis process for each potential cause being studied.
• Validate Root Causes
• Clearly state root cause(s) and identify data which suggests a conclusion.
• Verify root cause factors are present in the product and/or process.
• Conduct with / without study to verify root cause. Can you generate the problem?
• Analyze Potential Causes - Validate Root Cause

4D
• Defining the five elements of production:
– Objects of Production: Materials: Raw, Finished,
Semi-finished, In-process
– Agents of Production: People, Machines, Tools,
Jigs, Machine Tools, Incidental Devices, Inspection
Equipment, The Environment, etc.
– Methods: Processing System, Load & Capacity
Balance, Processing Conditions
– Space: Left to Right, Front to Back, Top to Bottom
– Time: Process Time, Production Time, Task Time

4D
• Poka Yoke Devices, Systems & Inspection
– Poka Yoke Systems
• Control Systems
• Halt the operations, and require feedback and action before
process can resume.
– Warning Systems
• Uses signals to warn the operator that the operations needs
feedback and action
– SQC systems have fairly long periods of time
between check stages and feedback execution

4D
• Poka Yoke Devices
– Are Built within the Process
– In General Have Low Cost
– Have the Capacity for 100% Inspection
– Remember SQC is performed outside the process
which adds cost and allows defects to escape the
system.

4D-Case Study
• Please describe- in your opinion- a system
with 0 defects.

4D
• RCA (Root Cause Analysis) and Escape Point
• Differences and Changes
• Root Cause Theories
• Verification
• Process Flow Diagram
• Escape Point

4D-RCA
• RCA (Root Cause Analysis) is not a method or process
itself, but a class of problem solving methods aimed at
identifying the root cause of problems or events. RCA is
any structured approach that identifies factors
resulting in the problem outcome including symptoms,
effects or consequences.
• The practice of RCA is based in the belief that problems
are permanently solved by addressing the root cause,
rather than addressing obvious symptoms. Counter
measures directed at the root cause are more likely to
prevent problem reoccurrence.

4D-RCA
• There may be several effective measures that address
the root causes of a problem. Due to this fact, RCA is
often performed iteratively and is frequently used as a
continuous improvement tool. RCA is reactive,
identifying events or causes, revealing problems and
solving them. Analysis is done after a problem has
occurred. FMEA (Failure Mode and Effects Analysis) is
the usage of RCA to forecast or predict probability of
events before they occur. RCA and FMEA are related
and similar but separated by their place in the Product
or Process life cycle. FMEA is used prior to product or
process launch whereas RCA is used after.

D4-RCA
• The root cause of any problem is found at the
point of creation. The root cause is never an
operator error or a broken tool. The specifics of a
root cause occur at the conversion of a product
or service from one state to a new desired state.
This conversion must be measurable and typically
require proper energy usage. Examples of energy
include, but are not limited to force, temperature
or motion. The incorrect application of energy is
the point at which the root cause can be found.
The root cause can only be known if it can be
turned on and off at will.

D4-RCA
• The RCA process is selected depending upon
many factors such as culture and knowledge
of problem solving tools. Quality-One has
decades of experience in determining the
proper tools and techniques for problem
solving suited to your specific needs. Q-1 is
the leader in Training and Facilitating the most
effective RCA techniques available. We
specialize in 8D (Eight Disciplines of Problem
Solving), 5 Why and Six Sigma.

4D-RCA
• User / Operator Safety-based RCA
• Accident Analysis
• Occupational Safety and Health
• Production-based RCA
• Quality Control
• Manufacturing

4D-RCA
• Process-based RCA
• Business Processes
• Failure-based RCA
• Failure Analysis in Engineering and Maintenance
• Systems-based RCA
• Change Management
• Risk Management
• Systems Analysis

4D-Risk Based Inspection
• Risk Based Inspection could establish through
complex quantitative analysis the principal
causes of the nonconformity.
• RIB is an American based inspection method
developed by API (American Petroleum
Industry)

• An inspection strategy based on risk avoids the
inadequacies of the traditional approach. The
concept of risk takes into account, not only the
probability of failure, but also the consequences
of failure. These may encompass consequences in
terms of lost profits, repair and re-justification
costs, human casualties and environmental clean
up costs. Such a strategy ensures that inspection
effort is targeted appropriately to optimize costs
and benefits, and provides an auditable
demonstration that this has been done with due
diligence.

• In some cases, initial turnaround inspection planning is
based on qualitative risk ranking (QRR). Whereas,
quantitative risk assessment attempts to perform a
precise numerical evaluation of the risk exposure
represented by equipment, qualitative risk-based
inspection (RBI) planning provides a means of making a
risk categorization. Therefore, qualitative RBI planning
provides a useful methodology for correctly targeting
inspection expenditure to components of the plant
where it will be most effective in maximizing the safety
of plant personnel and minimizing the cost exposure to
failure.

• A qualitative RBI methodology presents, to an expert study team,
each of the factors influencing the likelihood of equipment failure
and each of the factors influencing the consequences of that failure
in the event it were to occur. Based on the study team’s combined
expertise, judgments are then made as to the magnitude of each
factor, for each item, according to a pre-determined scheme. The
result of such an assessment is an evaluation of risk category (or
ranking) for each item, the severity of which then dictates the
appropriate required effectiveness of the inspection response.
• In cases where the assessment procedure for determining the
magnitude of any of the factors influencing either likelihood or
consequences of failure, replace expert judgment by numerical
rules, the approach is termed ‘semi-quantitative’.

• Risk Based Inspection:
– is a consequent development of traditional
maintenance strategies that minimizes maintenance
expenses,
– belongs to the knowledge based methodologies
focussing on safety and plant availability on demand
by increasing on-stream time due to less turn-around
time and a consequent reduction of unexpected
failures,
– is a systematic tool that helps users to make informed
business decisions regarding inspection and
maintenance expenses,

• Risk Based Inspection:
– identifies “Weak Points” and “Bad Actors”,
– enables evolution from a “Bandage Approach” to a
sustaining reliability culture,
– is a recognized way towards “Best In Class Performance”
and “Operational Excellence”,
– means fostering replacement strategy,
– is measuring risk as a key performance indicator,
– implies prioritization in maintenance efforts,
– extends inspection intervals where local authorities
recognize Risk Based Inspection (RBI), and
– allows determination of external alternative inspection
methods to avoid internal entry

• Obtainable effects:
– Identification of Weak Points
– Asset Policies
– Replacement Strategy
– Less internal inspections:
– Increased Inspection Intervals
– Alternative Inspection Methods
– Up-front On-Line Inspections

• Short description of methodology
• Step 1:Define probability of failure
• Failure probability rules have been developed such that data
requirements are minimized as much as possible. Generally,
data required can be obtained from P&ID and PFD drawings,
piping and valve specifications, process mass balance data
etc., with only minimal requirement to reference design
drawings, piping isometrics etc. The principle is that such
detailed data should only need to be reviewed for more
detailed analysis if deemed appropriate following risk ranking
using the standard easily applied rules. Major features
include:

• Step 1:Define probability of failure
– Two probabilities of failure are derived for pressure vessels and pipework,
probabilities of failure due to internal damage and due to external damage.
– Where appropriate failure probabilities are defined in terms of remaining life
where the life is calculated according to an assessed or measured
degradation rate, a life in service, and a degradation tolerance.
– For damage mechanisms for which a remaining life is not appropriate, such as
Stress Corrosion Cracking, a failure probability score is derived
according to how the actual process conditions compare with
permissible process conditions for the materials in question.
– Failure probability rules address a wide variety of degradation mechanisms
grouped under the following:
• Wall thinning mechanisms e.g. Corrosion
• Cracking mechanisms e.g. Stress Corrosion Cracking
• Mechanical damage e.g. Fatigue
• Metallurgical Damage e.g. Embrittlement

• Step 2:Define consequence of failure
• Three categories of failure consequence are assessed.
• Safety: toxic, fire, explosion, pressure and temperature
hazards
• Environment: pollution hazard to surrounding population or
landscape
• Business: instant and longer term effects on production

• Step 3:Define maintenance/inspection effectiveness
• RBI/RBM rules allow for inspection effectiveness in apportioning
confidence grades to each equipment item. In the first instance
these grades are taken to be the same as the plant’s existing
inspection grades. In effect the grading represents confidence in
the current and future condition of an item, confidence is lowest if
there is no inspection evidence and highest if there is lots of
appropriate inspection evidence or well behaved degradation.
Major features include:
– For any given risk ranking, items graded high will be allocated longer
inspection intervals than items graded low confidence.
– Probabilities of detection are not used in the standard methodology but
can be taken account of in Inspection Value Analyses.

• Step 4:Risk mitigation methodology
• Inspection alone is not sufficient to mitigate risk, action
arising out of inspection is also required.
• Through use of Confidence Grading and remaining wall
thickness measurements etc., allows for information on
known condition of items and this is then used to influence
‘perceived’ risk. For example, a wall thickness measurement
can be used to refine judgments on historical corrosion, this is
refinement of perceived risk.

• Step 5:Fitness for purpose and remaining life evaluation
• Within ESR Technology’s RBI/RBM methodology ‘fitness for
purpose’ is represented by either remaining life or failure
susceptibility. Remaining lives in the first instance are calculated
according to assessed or measured corrosion rates, design
corrosion allowances, time in service, and presence and condition
of any protective coatings. In almost all instances such a basic
remaining life can be extended through use of improved
determination of corrosion allowance e.g. through more detailed
application of design codes, finite element analysis etc, or through
more in depth corrosion assessment, or through better corrosion
rate trending from wall thickness measurements.

• Step 6:Inspection strategy
• Inspection activities are assigned in terms of damage needing
to be checked for as follows:
– Wall thinning inspection.
– Cracking inspection.
– Mechanical damage inspection.
– Metallurgical damage inspection.
– Internal visual inspection (an activity intended to check for more than
one type of damage category and assigned in instances of either low
confidence and/or high risk).

• Inspection frequencies are assigned for each of the above
activities as the soonest of two calculated dates as follows:
– A frequency obtained from a lookup table according to risk
rank and confidence grade (where the risk is defined by
the overall failure consequences and the failure likelihood
rank for the type of damage).
– A percentage of the remaining life calculated for the type
of damage, where the percentage is obtained from a look
up table according to the derived overall failure
consequence ranking.

• Cost and benefit analysis
• Field experience reports that good quality and thorough
RBI/RBM will result in more efficient inspection scheduling
through which high risk items can be concentrated on using
better inspection whilst inspection requirements are relaxed
on lower risk items. ESR Technology has experience of
calculating the impact of RBI/RBM programmes, the results
can be dramatic. In practice the success of any cost benefit
analysis depends very much on the data that can be obtained
from the plant.

• Short description of methodology- PROBABILITY- CONSEQUENCE
MATRIX

• Short description of methodology-Inspection schedule

• Short description of methodology- API RBI matrix

5D
• Verify Corrective Actions
• Confirm that the selected corrective actions
will resolve the problem for the customer and
will not cause undesirable side effects. Define
other actions, if necessary, based on potential
severity of problem.

5D
• Choose, Verify and Implement CA objective:
• Through pre-production test programs
quantitatively confirm that the selected
corrective actions will resolve the problem for
the customer, and will not cause any
undesirable side effects.
• Define contingency actions, if necessary,
based upon Risk Assessment.

5D
• Choose, Implement & Verify Corrective Actions-1
– By far the most critical step in the problem-solving process is to verify
that the solution will in fact eliminate the problem. In addition, it is
often the most difficult step. The most common method to evaluate a
problem solution is to wait for implementation of the solution, then
see if the problem goes away. However, too much time may be lost
before conclusive information is available. Verification, where ever
possible, should come before implementation.
– Several approaches to verification are available. In engineering, design
verification and production validation testing provides significant
information. In the short term, a bench/lab test can be used to verify.
In some cases dynamometer testing can provide verification. Long
term one can monitor fleet response. For manufacturing, verification
is by in-plant indicators. SPC can verify the elimination of the problem.
Sometimes scrap rate reports and conformance audits provide
information. Sometimes a designed experiment is part of verification.

5D
• Choose, Implement and Verify Corrective Actions-2
– Whatever verifications you choose, a detailed verification / action plan
is required to outline who will be taking what actions by when. The
action plan should show what data or statistics will be collected and
analyzed, who is responsible and must track actual progress and
scheduled completion. The action plan is the detailed Dynamic record
of all phases of the problem solving process.
– Good problem solution verifies the customer is satisfied with the
solution. If possible, involve the customer in choosing solutions.
– All verification of the problem solution will require decision analysis.
Decision analysis is part of the cost and timing consideration of the
solution. Decisions affecting cost must include effects on quality,
future problem recurrence and complete elimination of the problem.
In addition, management and operating procedures may be involved
when choosing the solution. Evaluation of any adverse effects caused
by the solution are important. The FMEA will most surely be affected.

5D
• Choose, Verify and Implement Corrective
Actions-3
– Run Pilot Tests
– Artificially simulate the solution to allow actual
process or field variation.
– Field test the solution using pilot customer groups.
– Verify carefully that another problem is not
generated by the solution.
– Monitor Results
– Quantify changes in key indicators.
– Stress the customer / user evaluation.

5D-Case Study
• -Please define a Pilot Test in order to verify the
reparation of a fractured distilation collumn or
other equipment. The fracture was due to the
fatigue of the material .

5D
• Permanent Corrective Action
• Acceptance Criteria
• Risk Assessment / FMEA (Failure Mode and
Effects Analysis)
• Balanced Choice
• Control Point Improvement
• Verification of Effectiveness

5D-FMEA
• FMEA (Failure Mode and Effects Analysis) is an analytical
methodology used to ensure that potential problems have
been considered and addressed throughout the product
and process development cycle. Examples of common
development cycles are APQP (Advanced Product Quality
Planning), CPPD (Collaborative Product Process Design)
and NPI (New Product Introduction).
• A DFMEA (Design FMEA) is performed prior to the
completion of the design of the product. A PFMEA (Process
FMEA) is performed prior to the release of the design for
the process. It is critical that a FMEA be performed with
sufficient time to take counter measures against the risk
and still capture the changes within the design before its
release.

5D-FMEA
• The primary reason for doing a FMEA is taking
action to prevent a failure, improve design
control through testing or evaluation, or
process control through inspection. In a FMEA,
risk is the substitute for failure. This risk is
treated as if the failure had already occurred
and corrective action is required. The reversal
of this principle is the 8D (Eight Disciplines of
Problem Solving). A FMEA is an 8D before an
8D is necessary.

5D-FMEA
• The RPN (Risk Priority Number) is the product
of Severity, Occurrence and Detection (RPN =
S∗O∗D), and is often used to determine the
relative risk of a FMEA line item. In the past,
RPN has been used to determine when to take
action. RPN should not be used this way.
Actions are determined by Criticality.
Criticality is the combination of Severity and
Occurrence as displayed in the Criticality
Matrix shown in the next slide.

5D-FMEA
• How is a FMEA done ?
• FMEA Development Methodology follows a Three
Path Model. With the combination of pre-work
documentation, evolving team structure and
action closure, a FMEA becomes the road map for
improvement in the design of products or
processes. Severity for each Effect of Failure is
defined in Path 1 by a core team; Occurrence is
selected in Path 2 by an expanded team of SMEs
(Subject Matter Experts); and Detection is chosen
in Path 3 with testing or inspection personnel.

6D
• Implement Permanent Corrective
Actions(PCA)
• Define and implement the permanent
corrective actions needed. Choose on-going
controls to insure the root cause is eliminated.
Once in production, monitor the long-term
effects and implement additional controls as
necessary.

6D
• IMPLEMENT PERMANENT CA OBJECTIVE
– Define and implement the best permanent
corrective actions. Choose on-going controls to
ensure the root cause is eliminated. Once in
production, monitor the long-term effects and
implement contingency actions, if necessary.
– Identify Alternative Solutions
– Evaluate how other groups solved similar
problems.

6D
• IMPLEMENT PERMANENT CA OBJECTIVE
– Use brainstorming to generate Alternate Solution C&E
diagram.
– Consider redesign of the part or process to eliminate
the problem.
– Anticipate failure of the solution. Develop contingency
action(s).
– Implement Solution
– Use an action plan approach to implement the
solution.
– Test and verify contingency actions, if possible

6D
• Implement PCA-1
• Define and implement the ”appropriate”
corrective action(s).
• Choose on-going controls to ensure the root
cause is eliminated.
• Once in production, monitor the long term
effects and implement contingency actions (if
necessary).

6D
• Implement PCA-2
– Once the root cause(s) have been identified, the team
establishes an action plan on the permanent actions
to be taken. Again, the action plan includes who will
do what by when. The permanent actions are
implemented to solve the problem. The question
”Why did this occur?” must be answered.
– Establish ongoing controls on the process to ensure
the process remains in control. Once the permanent
corrective actions are in place, the ongoing controls
will verify the effects of the actions.

6D
• Implement PCA-2
– To forecast reduction of the problem, indicators such
as scrap reports, etc., can be used. A statistical plan
will verify the effectiveness of the actions. A
systematic approach involves a plan to establish the
facts using data or evidence as a requirement for
making decisions. Data is obtained by investigations
and experiments to test assumptions. These
assumptions are identified by translating the
customer concerns into understandable definitions of
what the problem is and relating these definitions of
the problem to product and processes. These
definitions and data are used to verify solutions.

6D
• Implement PCA-3
– Once permanent solutions are in place, document the
changes. In addition, all customers need to be
informed about what actions were taken. In most
cases, some type of training is required to institute
permanent corrective actions. Training may be
required to implement a product design or process
change. In addition, implementation of the
permanent actions may need to include the effect on
design or process issues. In manufacturing,
maintenance personnel often need to be informed of
the changes.

6D
• Implement PCA-3
– Another important part is to correct the obvious. This includes
correcting defective parts already produced, changing product
design, changing tooling, reworking defective machines and/or
equipment, revising ineffective operating systems or working
with and/or replacing suppliers.
– Contingency actions should be identified if for some reason the
permanent actions cannot be implemented. For example, in
manufacturing a recommendation to single source a part may
be recommended. But, if one vendor is unable to meet the
increased productivity alternate action is necessary.
Contingency actions based upon risk assessment are essential to
the success of permanent corrective actions for customer
protection and problem solution.

6D
• CA Questions
• Do the actions represent the best possible long-
term solution from the customers viewpoint?
• Do the actions make sense in relation to the cycle
plan for the products?
• Has an action plan been defined?
– Have responsibilities been assigned?
– Has timing been established?
– Has required support been defined?
– What indicators will be used to verify the outcome of
the actions, both short-term and long-term?

6D-Case Study
• Please describe the permanent corrective
action you ll take if there are systemic errors
on the products which were lathed. You
should take into connsideration the eventual
problems with the machine and the operator.

6D
• Implement and Validate
• Project Plan
• Validation of Improvements

7D
• Prevent Recurrence
• Modify specifications, update training, review
work flow, improve practices and procedures
to prevent recurrence of this and all similar
problems.

7D
• Prevent Recurrence Objective
• Modify those management systems, operating
systems, practices and procedures to prevent
recurrence of this problem and all similar problems.
• Prepare a process flow diagram of the management /
operating system that should have prevented the
problem and all similar problems.
• Make needed changes to the system. Address system
follow-up responsibilities.
• Standardize practices.
• Use action plan to coordinate required actions.

7D
• Prevent Recurrence-1
• Modify the management systems, operating
systems, practices, and procedures to prevent
recurrence of this and all similar problems.

7D
– This next step in the Problem-Solving Process is the seventh
step. It is important to understand what in the process allowed
the problem to occur. A cause-and-effect diagram can be used
to outline the reasons the problem occurred. By asking
”Because?” the C&E diagram can be constructed.
– Another effective tool is a process flow diagram. The process
flow of the manufacturing or engineering process can be
effective in identifying where in the process the problem could
have been prevented. To prevent recurrence of the problem,
most of the time a change to the management system will be
required. Managers must understand why their system allowed
a problem develop. The same system will allow future problems
to occur.

7D
– Management systems, practices and procedures
need to be fully understood to be effective. Most
of them are carry-overs from previous model
years and organized structures. Some are
outdated and need to be revised. Understanding
the elements of a management system can be
achieved by maintaining an up-to-date flow
diagram of the system and process. Also, there
should be easy to follow instructions for those
who are part of the system.

7D
– Management systems, practices and procedures
should provide management support for ”Never
ending improvement” in all areas and activities. The
system should encourage individuals to participate
freely in the problem solving process. It should help to
understand more about their job and how each
individuals effort affects the outcome of the final
product on customer satisfaction. The system should
encourage everyone to learn something new. And it
should recognize individual and team effort when
these new skills are applied.

7D
– Changes in the management system can require documenting
new standard procedures, streamlining to remove obsolete
procedures and revising previous standards. Changes in the
management system need to be communicated clearly to all
customers.
– To prevent recurrence additional training is often required.
Training may be needed in statistical techniques and
methodologies, new engineering or manufacturing technologies
or disciplines, better process and/or project management.
– If concerns develop regarding changes to the system, these
issues will be addressed. A new team may need to be assigned
with the authority to address the management system.

7D
• Prevention
• Similar Products and Process Prevention
• Systems Prevention
• Standard Work or Practice
• Procedures / Policy Updates

8D
• Congratulate Your Team
• Recognize the collective efforts of your team.
Publicize your achievement. Share your
knowledge and learning.

8D
• The final step in a team oriented problem solving effort is
to recognize the team s collective efforts in solving the
problem and show gratitude by applauding individual
contributions. Management will need to determine the
best way to recognize the team s contribution to the
origination. In addition, individual effort and talents need
to be highlighted and rewarded.
• Team oriented problem solving involves risk taking, some
conflict, hard work and participation by everyone. It
includes a free exchange of ideas,, individual talent, skill,
experience and leadership. The team approach, when led
effectively, produces a driving force of individuals
motivated and committed to solving a specific problem.

8D
• Closure and Team Celebration
• Archive Documents
• Team Lessons Learned
• Before and After Comparison
• Celebrate Successful Completion

8D and the Is/Is Not Approach
• 8D is a counterintuitive approach to problem solving. As a problem
is encountered, it is intuitive to try solutions to uncover what the
root cause Is. 8D takes the opposite approach by removing possible
causes that are not contributors. The Is Not approach limits the
number of trial and error attempts at fixing the problem. 8D
achieves this by defining the problem with increasing detail based
on facts as they are available.
• The problem description is the result of a scientific study of; what,
where, when and how much. The method develops theories with
collected facts after removing possible causes not agreeing with the
problem description. These root cause theories are compared to
the problem description prior to physical verification. Trial and error
is not permitted in 8D.

8D and FMEA
• FMEA is a tool used in the planning of product or process design. The
Failure Modes in a FMEA are equivalent to the problem statement or
description in an 8D. Causes in a FMEA are equivalent to potential causes
in an 8D. Effects of failure in a FMEA are problem symptoms in an 8D. The
relationships between 8D and FMEA are outlined below:
• The problem statements and descriptions can be linked between both
documents. An 8D can be completed faster by utilizing easy to locate, pre-
brainstormed information from a FMEA to solve problems.
• Possible causes in a FMEA can immediately be used to jump start 8D
Fishbone or Ishikawa diagrams. Brainstorming information that is already
known is not a good use of time or resources.
• Data and brainstorming collected during an 8D can be placed into a FMEA
for future planning of new product or process quality. This allows a FMEA
to consider actual failures, occurring as failure modes and causes,
becoming more effective and complete.
• The design or process controls in a FMEA can be used in verifying the root
cause and Permanent Corrective Action in an 8D

How to solve problems (or at least try) with 8D

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Similar a How to solve problems (or at least try) with 8D

Similar a How to solve problems (or at least try) with 8D (20)

Más de Stefan Kovacs

Más de Stefan Kovacs (19)

Último

Último (20)

How to solve problems (or at least try) with 8D