5Why 解决问题工具.docx

5Why 解决问题工具.docx

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5Why解决问题工具

U.S.StandardRailroadGauge

TheU.S.standardrailroadgauge（widthbetweenthetworails）is4feet,8.5inches.Onemightsaythat'sanexceedinglyoddnumber.

Whywasthatgaugeused?

Becausethat'sthewaytheybuilttheminEngland,andEnglishexpatriatesbuilttheUSrailroads.

WhydidtheEnglishbuildthemlikethat?

Becausethefirstraillineswerebuiltbythesamepeoplewhobuiltthepre-railroadtramways,andthat'sthegaugetheyused.

Whywasthatgaugeused?

Becausethepeoplewhobuiltthetramwaysusedthesamejigsandtoolsthattheyusedforbuildingwagons,whichusedthatwheelspacing.

Whydidthewagonshavethatparticularoddwheelspacing?

Well,iftheytriedtouseanyotherspacing,thewagonwheelswouldbreakonsomeoftheold,longdistanceroadsinEngland,becausethat'sthespacingofthewheelruts.Whobuiltthoseoldruttedroads?

ImperialRomebuiltthefirstlongdistanceroadsinEurope（includingEngland）fortheLegions.Theroadshavebeenusedeversince.Whatdoweknowabouttherutsintheroads?

Romanwarchariotsformedtheinitialruts,whicheveryoneelsehadtomatchforfearofdestroyingtheirwagonwheels.Sincethechariotsweremadefor（orby）ImperialRome,theywereallalikeinthematterofwheelspacing.

Thereyouhaveit!

TheUnitedStatesstandardrailroadgaugeof4feet,8.5inchesderivesfromtheoriginalspecificationforanImperialRomanwarchariot.Specificationsandbureaucraciesliveforever.Sothenexttimeyouarehandedaspecificationandwonderwhathorse'srearcameupwithit,youmaybeexactlyright,becausetheImperialRomanwarchariotsweremadejustwideenoughtoaccommodatethebackendsoftwowarhorses.

There'saninterestingextensiontothestoryaboutrailroadgaugesandhorses'behinds.WhenweseeSpaceShuttleColumbiasittingonitslaunchpad,therearetwobigboosterrocketsattachedtothesidesofthemainfueltank.Thesearesolidrocketboosters,or"SRB's".ThiokolmakestheSRB’sattheirfactoryatUtah.TheengineerswhodesignedtheSRB'smighthavepreferredtomakethemabitfatter,buttheSRB'shadtobeshippedbytrainfromthefactorytothelaunchsitebecauseoftheirsizeandweight.Therailroadlinefromthefactoryhastorunthroughatunnelinthemountains,andtheSRB'shadtofitthroughthattunnel.Thetunnelisslightlywiderthantherailroadtrack,andtherailroadtrackisaboutaswideastwohorses'behinds.

So,themajordesignfeatureofwhatisarguablytheworld'smostadvancedtransportationsystemwasdeterminedovertwothousandyearsagobythewidthofahorse'srearend!

PRACTICALPROBLEMSOLVING

Introduction

IntheDelphiorganization,acommon5-whyproblemsolvingprocessisusedtoanalyzeandsolvequalityproblems.

Therearefourmajorpartsoftheprocess:

∙UnderstandtheSituation

∙CauseInvestigation

∙ProblemCorrection

∙PreventionthroughErrorProofing

♦UnderstandtheSituation

Duringthefirstpartoftheprocess,you:

∙IdentifytheProblem

∙ClarifytheProblem

∙BreakdowntheProblem

∙LocatethePointofCause（PoC）

∙Graspthesignificanceoftheproblem

♦CauseInvestigation

Inthesecondpartoftheprocess,you:

∙Conducta“5-Why”investigationtoidentifytherootcause

▪forthespecificproblem

▪forwhytheproblemwasnotdetected

▪forwhythe“system”allowedtheproblemtooccur

♦ProblemCorrection

Inthethirdpartoftheprocess,you:

∙Takespecificactiontocorrecttheproblem（s）.Ataminimum,short-termtemporarymeasuresarerequiredtoprotectthecustomer.

♦PreventionThroughErrorProofing

Inthefourthpartoftheprocess,you:

∙Takespecificactiontomakesuretheproblemcannotrecur,typicallythrougherrorproofing

∙CaptureandcommunicateLessonsLearned

PRACTICALPROBLEMSOLVINGMODEL

5WhyFunnel

BASICSTEPSOF

PRACTICALPROBLEMSOLVING

PartI–UnderstandtheSituation

♦Step1:

IdentifytheProblem

Inthefirststepoftheprocess,youbecomeawareofaproblemthatmaybelarge,vague,orcomplicated.Youhavesomeinformation,butdonothavedetailedfacts.Ask:

▪WhatdoIknow?

♦Step2:

ClarifytheProblem

Thenextstepintheprocessistoclarifytheproblem.Togainamoreclearunderstanding,ask:

▪Whatisactuallyhappening?

▪Whatshouldbehappening?

♦Step3:

BreakDowntheProblem

Atthispoint,breaktheproblemdownintosmaller,individualelements,ifnecessary.

▪WhatelsedoIknowabouttheproblem?

▪Arethereothersub-problems?

♦Step4:

LocatethePointofCause（PoC）

Now,thefocusisonlocatingtheactualpointofcauseoftheproblem.Whereintheprocessistheproblemoccurring?

Youneedtotrackbacktoseethepointofcausefirst-hand.Ask:

▪WheredoIneedtogo?

▪WhatdoIneedtosee?

▪Whomighthaveinformationabouttheproblem?

♦Step5:

GrasptheSignificanceoftheProblem

Tograspthesignificanceoftheproblem,ask:

▪When?

▪Where?

▪Which?

▪Howoften?

▪Howmuch?

Itisimportanttoaskthesequestionsbeforeasking“Why?

”

PartII:

CauseInvestigation

♦Step6:

Identifyandconfirmthedirectcauseoftheabnormaloccurrence.

Ifthecauseisvisible,verifyit.Ifthecauseisnotvisible,considerpotentialcausesandcheckthemostlikelycauses.Confirmthedirectcausebasedonfact.Ask:

▪Whyistheproblemoccurring?

▪CanIseethedirectcauseoftheproblem?

▪Ifnot,whatdoIsuspectaspotentialcauses?

▪HowcanIcheckthemostlikelypotentialcauses?

▪HowcanIconfirmthedirectcause?

♦Step7:

Use5-Whyinvestigationtobuildachainofcause/effectrelationshipsthatleadtotherootcause.Ask:

▪Willaddressingthedirectcausepreventrecurrence?

▪Ifnot,canIseethenextlevelofcause?

▪Ifnot,whatdoIsuspectasthenextlevelofcause?

▪HowcanIcheckandconfirmthenextlevelofcause?

▪Willaddressingthislevelofcausepreventrecurrence?

Ifnot,continueasking“Why?

”untilyoufindtherootcause.

Stopatthecausethatmustbeaddressedtopreventrecurrence.Ask:

▪HaveIfoundtherootcauseoftheproblem?

▪CanIpreventrecurrencebyaddressingthiscause?

▪Isthiscauselinkedtotheproblembyachainofcause/effectrelationshipsthatarebasedonfact?

▪Doesthechainpassthe“therefore”test?

▪IfIask“Why?

”again,willIbeintoanotherproblem?

Besureyouhaveused5-WhyInvestigationtoanswerthesequestions:

▪Whydidwehavethespecificproblem?

▪Whydidtheproblemgettothecustomer?

▪Whydidour“system”allowtheproblemtooccur?

5WHYCAUSEINVESTIGATION

Step8:

ProblemCorrection

TakeSpecificActiontoAddresstheProblem

Usetemporarymeasurestoeliminatetheabnormaloccurrenceuntiltherootcausecanbeaddressed.Ask:

▪Doesitcontaintheproblemuntilapermanentsolutioncanbeimplemented?

Step9:

PreventionthroughErrorProofing

Implementcorrectiveactionstoaddresstherootcause:

-Forthespecificproblem

-Forwhytheproblemwasnotdetected

-Forwhythe“system”allowedtheproblemtooccur

Ask:

▪Doesitpreventtheproblemfromhappeningagain?

Follow-upandcheckresults.Ask:

▪Isthesolutionworking?

▪HowdoIknow?

Captureandcommunicatelessonslearned.

PRACTICALPROBLEMSOLVINGCHECKLIST

Tobesureyouhavefollowedtheproblemsolvingmodel,usethischecklistasyoucompletetheproblemsolvingprocess.

Understandthesituation

___Identifytheproblem.

___Clarifytheproblem.

___Breakdowntheproblem.

___LocatethePointofCause（PoC）.

___Graspthesignificanceoftheproblem.

CauseInvestigation

___Identify/confirmthedirectcause.

___Ask5Why'stoidentifytherootcause.

___Ask5Why'sfor“Whytheproblemwasnotdetectedandreachedthecustomer?

”

___Ask5Why'sfor“Whythesystemallowtheproblemtooccur?

”

ProblemCorrection

___Implementcorrectiveaction;ataminimum,implementtemporarymeasures

ProblemPrevention

___ErrorProoftherootcause.

___Verifyforeffectiveness.

___CaptureLessonsLearned.

ACTIVITY:

FLEXINDUSTRIESCASESTUDY

Directions:

▪UsetheDelphi5-WhyProblemSolvingProcesstoevaluatetheFlexIndustriesCaseStudybelowandonthefollowingpages.Reviewthe5-Whyanalysistemplateonpage12torecordyourinformation.

▪Useonlytheinformationprovidedinthecasestudytocompletethe5-Why.

▪Donottrytore-engineertherivetsorsolvethetechnicalproblemsinthecasestudy.Thepurposeofthisactivityistousethe5-whyProblemSolvingtemplatetoorganizethegivendataanduncoverthetruerootcause（s）.

FLEXINDUSTRIESCASESTUDY

KeyPlayers

JakeQualityManager

JanetCSE,WindingRiverPlant

SamTeamLeader,EastLine

JudyQAAuditor,EastLine

BenMachineOperator

Background

JakeRyanistheQualityManageratFlexIndustries.Flexisacomponentsupplierthatmanufacturesmetalstampingsandlightassemblyproducts.Thecompanyhasareputationforsupplyinghighqualitypartsonaconsistentbasis.Seldomhastherebeenacustomercomplaint.FlexhasQualityrepresentativescalledCustomerSupportEngineers（CSE’s）ateverycustomerassemblyplant.TheCSE’sreportanyproblemstoJakeforinvestigationandfollow-up.

At7:

00a.m.thismorning,JakereceivedacallfromJanet,CSEattheWindingRiverAssemblyPlant.Janetinformedhimthatthecustomerhadfoundfivedefectivestabilizingbracketsonsecondshiftlastnight.Shecheckedtheremaininginventoryandtherewerenodefectsintheremaining326pieces.Themanufacturingstickeronthebackofthebracketsindicatedthattheyweremadebythesecondshiftoperator.Normally,thestabilizingbracketisfastenedtotheregulatormotorwiththreerivets.Thefivedefectivebracketshadonlytworivetsinthem.Thelowersetofrive