First Time Completing a 5 Why/RootCause Failure Analysis

love02eat

Involved In Discussions
#1
Please any and all feed back is appreciated I am struggling with it. Know one here is trained and my manager was placed into QA roll. Please review and let me know what verbiage and how it should really be . its been along week and a half.:bonk:
 

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Jim Wynne

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#2
Re: First Time Completing a 5 Why/RootCause

You posted the same question twice. I deleted the other post to avoid confusion.
 

Marc

Hunkered Down for the Duration
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#3
Re: First Time Completing a 5 Why/RootCause

Any takers on this one? TIA
 

yodon

Staff member
Super Moderator
#4
Re: First Time Completing a 5 Why/RootCause

Well, I'll throw in a couple of cents...

I'm not sure I followed your approach. The 5-whys (and 5 is just a number, not a mandatory count) are intended to help you drive to the root causes (and do note there can be more than 1). So the last sentence in your 'Root Cause' statement is probably close to *a* root cause, but I would ask why isn't there 100% inspection to detect undersized parts?

It looks like you did the work in isolation. You need the stakeholders involved. Your recommendations may be fine but without stakeholder agreement, they're likely to not be implemented.

I would sit down with the manufacturing folks and go back through the process.

Ask them their view on why 1 in 50 were short. Take the questioning from there (continue asking why - without sounding like a 2-year-old!) to try to isolate root causes (and remember there may be more than 1 so you may have to 'branch' the questioning).

Bear in mind that the 5-why method is just one technique at finding root cause. Other methods like fault tree analysis may be better suited to the problem.

For your containment, why was it limited to just that one lot? Note that if other product is run on that same equipment, there may be issues there as well! So consider other lots and other products.

Finally, how will you know if your changes have the desired effect (and don't have any negative effects)? You need a plan on how to verify this and a plan on how to determine effectiveness.

You're to be commended for giving it a good run. You shouldn't have to do it in a vacuum, though! It needs to be a team exercise to ensure that you have identified the problem, put the right fixes in place, and ensure it's all good.
 

love02eat

Involved In Discussions
#5
Re: First Time Completing a 5 Why/RootCause

Well, I'll throw in a couple of cents...

I'm not sure I followed your approach. The 5-whys (and 5 is just a number, not a mandatory count) are intended to help you drive to the root causes (and do note there can be more than 1). So the last sentence in your 'Root Cause' statement is probably close to *a* root cause, but I would ask why isn't there 100% inspection to detect undersized parts?

It looks like you did the work in isolation. You need the stakeholders involved. Your recommendations may be fine but without stakeholder agreement, they're likely to not be implemented.

I would sit down with the manufacturing folks and go back through the process.

Ask them their view on why 1 in 50 were short. Take the questioning from there (continue asking why - without sounding like a 2-year-old!) to try to isolate root causes (and remember there may be more than 1 so you may have to 'branch' the questioning).

Bear in mind that the 5-why method is just one technique at finding root cause. Other methods like fault tree analysis may be better suited to the problem.

For your containment, why was it limited to just that one lot? Note that if other product is run on that same equipment, there may be issues there as well! So consider other lots and other products.

Finally, how will you know if your changes have the desired effect (and don't have any negative effects)? You need a plan on how to verify this and a plan on how to determine effectiveness.

You're to be commended for giving it a good run. You shouldn't have to do it in a vacuum, though! It needs to be a team exercise to ensure that you have identified the problem, put the right fixes in place, and ensure it's all good.




Thanks for your feed back on this. But I don't have a team to sit down with because the manager who doesn't know how to do corrective actions simply stated that operator error. I know the customer doesn't want to hear that... The containment is done. There was no product running and there was none in stock. so should I state that differently? The 100 % isn't done because we make plastic tubing device we are not the finished product so we follow a AQL or we would never get it out. We are not automated. all QC final inspection is done manually by inspectors. 1 lot could be a 80,000pc order so this is why we follow a AQL percentage. Anything else. Do you use a different form for corrective action? Also do you think you could share a sample of a completed corrective action?
 

hogheavenfarm

Quite Involved in Discussions
#6
Re: First Time Completing a 5 Why/RootCause

We break our 5-Y down into three areas, this puts us further into the issue than we would get just working in one area. First area - defect itself, Second area - defect escape reasons, third area, Quality system deficiency that allowed the escape.
Each area gets 5-Y and all RC's are viewed together.
 

Michael_M

Trusted Information Resource
#7
Re: First Time Completing a 5 Why/RootCause

Thanks for your feed back on this. But I don't have a team to sit down with because the manager who doesn't know how to do corrective actions simply stated that operator error. I know the customer doesn't want to hear that... The containment is done. There was no product running and there was none in stock. so should I state that differently? The 100 % isn't done because we make plastic tubing device we are not the finished product so we follow a AQL or we would never get it out. We are not automated. all QC final inspection is done manually by inspectors. 1 lot could be a 80,000pc order so this is why we follow a AQL percentage. Anything else. Do you use a different form for corrective action? Also do you think you could share a sample of a completed corrective action?
I have to ask the following question based on your comments:

Does Management want you to perform root cause/corrective action or do they want you to close the customer CA and make it go away?

Note, this should not be an either/or question as there can be many shades between, but if given the two options, which one does management want?

If they want a root cause/corrective action then the areas where you say "I recommend xxx does this", get with the person and ask them what/how and will it be effective. I have had to train (and train and train--then I had to train again) supervisors what is desired with corrective actions.

If management just wants the CA closed, then you had additional concerns because you will not have the support to be able to train properly, and this becomes an issue.
 

Candi1024

Quite Involved in Discussions
#8
Re: First Time Completing a 5 Why/RootCause

Thanks for your feed back on this. But I don't have a team to sit down with because the manager who doesn't know how to do corrective actions simply stated that operator error. I know the customer doesn't want to hear that... The containment is done. There was no product running and there was none in stock. so should I state that differently? The 100 % isn't done because we make plastic tubing device we are not the finished product so we follow a AQL or we would never get it out. We are not automated. all QC final inspection is done manually by inspectors. 1 lot could be a 80,000pc order so this is why we follow a AQL percentage. Anything else. Do you use a different form for corrective action? Also do you think you could share a sample of a completed corrective action?
If I were the customer I would at least want to see the final action to avoid future operator error. Training could be at the top of that list. Other potential things would be a written warning, signs made to remind operators to check things, a secondary check for the operations and settings to be signed off for each batch, more inspections, ect.

To me the first why would be, Why did this short part get out? (I believe because it fell onto the passing tray??)
The second why would be - why did it fall onto the passing tray?
 

Jim Wynne

Staff member
Admin
#9
Re: First Time Completing a 5 Why/RootCause

If I were the customer I would at least want to see the final action to avoid future operator error. Training could be at the top of that list. Other potential things would be a written warning, signs made to remind operators to check things, a secondary check for the operations and settings to be signed off for each batch, more inspections, ect.

To me the first why would be, Why did this short part get out? (I believe because it fell onto the passing tray??)
The second why would be - why did it fall onto the passing tray?
I think the first "why" (if more than one is necessary) is "Why did this short part get made?"
 
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