Learning to See MUDA Calibrating the Eyes

Muda

Definition

Transactional

Operations

Over-production

Generating more than the customer needs right now

More information than the customer needs

More information than the next process needs

Creating reports no one reads

Making extra copies

Producing product to stock based on sales forecasts

Producing more to avoid set-ups

Batch processing resulting in extra output and delays

Transporting

Unnecessary movement of items that adds no value

Retrieving or storing files

Carrying documents to and from shared equipment

Taking files to another person

Going to get signatures

Moving parts in and out of storage

Moving material from one workstation to another

Moving product to and fro

Motion

Unnecessary movement of people that adds no value

Searching for files/information

Extra clicks or key strokes

Clearing away files on desk

Gathering information

Looking through manuals and catalogs

Handling paperwork

Searching for parts, tools, prints, etc.

Sorting through materials.

Reaching for tools

Lifting boxes of parts

Learning to See MUDA Calibrating the Eyes

Muda

Definition

Transactional

Operations

Waiting

Idle time created when materials, information, people or equipment is not ready

Waiting for..

Faxes

The system to come back up

Copy machine

Customer response

A hand-off file to come back

Waiting for parts

Waiting for prints

Waiting for inspection

Waiting for information

Waiting for machine repair

Over-Processing

Efforts that create no value from the customers viewpoint

Creating reports

Repeated manual entry of data

Use of outdated standard forms

Use of inappropriate/outdated software programs

Multiple cleaning of parts

Paperwork

Over-tight tolerances

Awkward tool or part design

Inventory

More information, project, or material on hand than the customer needs right now

Files waiting to be worked on

Open projects

Office supplies

E-mails waiting to be read

Unused records in a database

Raw materials

Work in process

Finished goods

Consumable supplies

Learning to See MUDA Calibrating the Eyes

Muda

Definition

Transactional

Operations

Defects

Work that contains errors, rework, mistakes or lacks something necessary

Data entry error

Pricing/billing error

Missing information

Misplaced mail

Incorrect customer information

Missed specifications

Lost records

Scrap

Rework

Defects

Correction

Field Failures

Variation

Missing parts/information

Talent

Under-utilization of human skills and knowledge. Not creating a safe environment that promotes employee participation

Chronic/acute injury or illness

Accepting hazardous conditions as status quo

Not sharing company or process performance information

Not working in teams with shared goals

Fostering internal competition between departments/ processes

Chronic/acute injury or illness

Accepting hazardous conditions as status quo

Not sharing company or process performance information

Not working in teams with shared goals

Fostering internal competition between departments/ processes/shifts

Step 2

Step 3

Step 4

Step 5

Step 6

Step 7

Step 8

Step 9

Building World Class Organizations in 9 Simple Steps.. Lack of awareness of Lean Management tools Muda of Transportation Muda of Motion Muda of WaitingHands-onTraining TFM 5S + Muda, Mura, Muri EliminationMuda Of UnusedHuman Talent Muda of Over Production Muda of InventoryMuda of Defects / Rework Muda of Over Processing Kanban,One piece / Small Batch Flow, JIT, Pull Manufacturing Total Human Management (THM) Process Standardization TFM,TPM,TQM, Lean Office TPM, TQM, Lean OfficeIdentifyReduceEliminate MUDAsADD VALUEat each stepUsingLEAN TOOLSStep 1WORLD CLASS Organization

Wastes or MUDA

Lean ProductionThe latest incarnation of JIT

Based on Toyota Production System.

Waste elimination

Widely used in automotive manufacturing & other repetitive mfg.

Its a mindset & commitment to achieve a totally waste-free operation thats focused on your customers success achieved by simplifying and continuously improving all processesIts the elimination of waste Everywhere while adding customer value

DefinitionLean Manufacturing A way to eliminate waste and improve efficiency in a manufacturing environment Lean focuses on flow, the value stream and eliminating muda, the Japanese word for waste

Lean manufacturing is the production of goods using less of everything compared to traditional mass production: less waste, human effort, manufacturing space, investment in tools, inventory, and engineering time to develop a new product

From the operations perspective

Lean production cuts costs & inventories rapidly to free cash, which is critical

It also supports growth by improving productivity & quality, reducing lead times, and freeing huge amounts of resources.

From the operations perspectiveFor example, lean production frees office and plant space and increases capacity so companies can

Add product lines In-source component productionIncrease output of existing products without acquiring new facilities.

Lean Video

Continual Improvement Flow DiagramDefine ProblemIdentify Waste in Current ProcessConduct Gap & Root Cause AnalysisMeasure Current PerformanceDefine Should-BeProcessImprove Current ProcessDevelop Measurements for SuccessStandardize Operating ProceduresDevelop 60 Day Action Plan

Problem Categoriesand Problem Solving Approaches

Types of ProblemsSimple, cause known; Just do it issues

Complex, cause unknown; need to dig deeper issues

Sometimes the financial impact of a problem dictates how it will be classified

Just Do It IssuesTypically isolated, sporadic incidents

Are easily fixed; apparent cause tends to be known

Often recognized during process planning and reflected in PFMEA

Just Do It IssuesAddressed through troubleshooting, (diagnosis and remedy) and reaction plans on control plans, (control of nonconformity)

Can be fixed by process owner; addressed at process levelOccurrence should be monitored ongoing for cost and impact

Dig Deeper Issues-Sometimes referred to as Chronic-Long-term and/or complex issues-Cause is not readily apparent, unknown-Require in-depth investigation to identify root cause-Addressed through root cause analysis, disciplined problem solving and improvement process

Dig Deeper Issues-Source of problem typically unknown-Cross-functional participation needed to solve-Effective resolution requires both process and system solution consideration

-Require management intervention via resource commitment

-When available data re: problem is limited, may be handled as Just do it based on impact and/or risk

Steps in Disciplined Problem Solving1. Establish Team2. Operational Problem Definition3. Containment & Interim Actions, (if needed)4. Root Cause Analysis, (process & system)5. Plan & Implement Solutions6. Results of Solutions7. Verification, (including independent)8. Closure & Congratulate the Team

Problem Type ConsiderationsJust Do ItReflects product or process controls established when planning the processManagement decision to live with such conditions based on acceptable level of riskShould be routinely evaluated for cost and impactCan only be eliminated by applying disciplined problem solving to understand true root cause in order to improve process Dig DeeperUnanticipated conditions which occurMay also be anticipated issues for which actual level of risk is now determined to be unacceptableRequire concentrated investigation to understand source of problem and process factors leading to problem condition to allow appropriate solutions

A Note about Fire-fighting!Fire-fighting is essentially un-prescribed actions taken on a process without understanding the relation of causal factors and process outputFire-fighting is dangerous as these actions tend not to be specifically focused to a particular cause

A Note about Fire-fighting!The resulting impact of fire-fighting is typically not known ahead of timeTherefore, chaos is introduced into the processA very high-risk approach to problem solving!

Problem Type Considerations

Problem TypeProcess of OriginMethodConsidera-tionsJust do itKnownTroubleshooting; reworkSeen before; can live with impact when problem recursDig DeeperUnknownRoot cause analysisData-driven investigation to determine actual factors causing problem conditionUnknownFire-fightingTaking action possibly on wrong process; not using data to confirm root cause

Prioritize ProblemsMost organizations should only be actively working on 3-5 disciplined problem solving efforts, (Dig Deeper issues), at a time to balance the use of resources and get the most effective solutions; (no one person should be working on more than 2 Dig Deeper teams at any given time)

Determining the Root Cause of a Problem

When should root cause analysis be performed?When PROBLEMS occur !!

How does it differ from what we do now?Firefighting! Immediate Containment Action ImplementedProblem IdentifiedImmediate Containment Action ImplementedDefined Root Cause Analysis ProcessSolutions validated with dataSolutions are applied across company and never return!USUAL APPROACH PREFERRED APPROACHProblem IdentifiedProblem reoccurs elsewhere!Find someone to blame!

Why Determine Root Cause?

Prevent problems from recurring

Reduce possible injury to personnel

Reduce rework and scrap

Increase competitiveness

Promote happy customers and stockholders

Ultimately, reduce cost and save money

Look Beyond the Obvious Invariably, the root cause of a problem is not the initial reaction or response.It is not just restating the Finding

Often the Stated Root Causeis the Quick, but Incorrect Answer

For example, a normal response is:Equipment FailureHuman Error

Initial response is usually the symptom, not the root cause of the problem. This is why Root Cause Analysis is a very useful and productive tool.

Most Times Root Cause Turns Out to be Much More

Such as:

Process or program failureSystem or organization failurePoorly written work instructions Lack of training

DefinitionsCause (causal factor): a condition or event that results in an effectDirect Cause: cause that directly resulted in the occurrenceContributing Cause: a cause that contributed to the occurrence, but by itself would not have caused the occurrenceRoot Cause: cause that, if corrected, would prevent recurrence of this and similar occurrences

Why do we need itBenefits of RCA- Real cause of the problem can be found- Problem recurrence will be minimized

What is Root Cause Analysis?

Root Cause Analysis is an in-depth process or technique for identifying the most basic factor(s) underlying a variation in performance (problem).

Focus is on systems and processes Focus is not on individuals

Types of RCA

Safety-based RCA- Investigating Accident and occupational safety and health. - Root causes:- unidentified risks, or inadequate safety engineering, missing safety barriers.

Production-based RCA- Quality control for industrial manufacturing.- Root causes:- non-conformance like, malfunctioning steps in production line.

Types of RCA Process-based RCA- Extension of Production-based RCA.- Includes business processes also.- Root causes:- Individual process failures

System-based RCA- Hybrid of the previous types - New concepts includes:- change management, systems thinking, and risk management.- Root causes:- organizational culture and strategic management

4 Levels of Root Cause

Root Cause Analysis Levels

Level(Deep)Root CauseConsiderationToolsOther(Wide)ProductDefect/Detection causeCondition of controls to detect problemControl Barrier AnalysisWhat other products have similar controls?ProcessDirect process cause, (trigger at process of originFactors at process of origin triggering problem, (5Ms)Fishbone, (cause & effect)What processes have similar trigger cause?PlanActual root cause, (led to trigger cause)Linkage to planning processes that trigger cause5 Why with Hypothesis testingWhat other processes affected?Systemweakness in mgt. policies or practicesLinkage of mgt. system to actual causeSystem Cause AnalysisOther affected mgt. policies

When Should Root Cause Analysis be Performed? Significant or consequential eventsRepetitive human errors are occurring during a specific processRepetitive equipment failures associated with a specific processPerformance is generally below desired standard

How to Determine the Real Root Cause? Assign the task to a person (team if necessary) knowledgeable of the systems and processes involved

Define the problem

Collect and analyze facts and data

Develop theories and possible causes - there may be multiple causes that are interrelated

Systematically reduce the possible theories and possible causes using the facts

How to Determine the Real Root Cause? (continued)Develop possible solutions

Define and implement an action plan (e.g., improve communication, revise processes or procedures or work instructions, perform additional training, etc.)

Monitor and assess results of the action plan for appropriateness and effectiveness

Repeat analysis if problem persists- if it persists, did we get to the root cause?

Useful Tools For Determining Root Cause are:

The 5 WhysPareto Analysis (Vital Few, Trivial Many)BrainstormingFlow Charts / Process MappingCause and Effect Diagram

Common Errors of Root Cause Looking for a single cause- often 2 or 3 which contribute and may be interactingEnding analysis at a symptomatic causeAssigning as the cause of the problem the why event that preceded the real cause

Successful application of the analysis and determination of the Root Cause should result in elimination of the problem

Five Whys PreparationProblemRoot CauseCorrective ActionsRoot Cause analysis Tools: Ishikawa Charts (Fish Bone) Design of Experiments 5 Whys Cause & Effect Diagram. Statistical Data Analysis (Cpk, Paretto Charts, Anova,etc)Five whys is a Root Cause Analysis Tool. Not a problem solving technique. The outcome of a 5 Whys analysis is one or several root causes that ultimately identify the reason why a problem was originated. There are other similar tools as the ones mentioned below that can be used simultaneously with the 5 Whys to enhance the thought process and analysis.

Example #1Identify Problem

Part polarity reversed on circuit board

Immediate ActionAdditional inspection added after this assembly process step to check for reversed part defects

Last 10 lots of printed circuit boards were re-inspected to check for similar errors

Root CausePart reversedWhy?

Root CausePart reversedWorker not sure of correct part orientationWhy?

Part is not marked properlyRoot CausePart reversedWorker not sure of correct part orientationWhy?

Engineering ordered it that way from vendorPart is not marked properlyRoot CausePart reversedWorker not sure of correct part orientationWhy?

Process didnt account for possible manufacturing issuesEngineering ordered it that way from vendorPart is not marked properlyRoot CausePart reversedWorker not sure of correct part orientation

Corrective Action

Permanent Changed part to one that can only be placed in correct direction (Mistake proofed). Found other products with similar problem and made same changes.

Preventive - Required that any new parts selected must have orientation marks on them.

Root Cause Analysis Example #2

Example #2

Identify Problem

A manager walks past the assembly line and notices a puddle of water on the floor. Knowing that the water is a safety hazard, she asks the supervisor to have someone get a mop and clean up the puddle. The manager is proud of herself for fixing a potential safety problem.

Example #2

But What is the Root Cause?

The supervisor looks for a root cause by asking 'why?

Immediate ActionKnowing that the water is a safety hazard, the manager asks the supervisor to have someone get a mop and clean up the puddle.

Root CausePuddle of water on the floorWhy?

Root CausePuddle of water on the floorLeak in overhead pipeWhy?

Water pressure is set too highRoot CausePuddle of water on the floorLeak in overhead pipeWhy?

Water pressure valve is faultyWater pressure is set too highRoot CausePuddle of water on the floorLeak in overhead pipeWhy?

Valve not in preventative maintenance programWater pressure valve is faultyWater pressure is set too highRoot CausePuddle of water on the floorLeak in overhead pipe

Corrective ActionPermanent Water pressure valves placed in preventative maintenance program.

Preventive - Developed checklist form to ensure new equipment is reviewed for possible inclusion in preventative maintenance program.

Example #3Root Cause Analysis Example #3

*Example #3

Identify Problem

Customers are unhappy because they are being shipped products that don't meet their specifications.

*Immediate ActionInspect all finished and in-process product to ensure it meets customer specifications.

Root CauseProduct doesnt meet specificationsWhy?

Root CauseProduct doesnt meet specifications Manufacturing specification is different fromwhat customer and sales person agreed toWhy?

Sales person tries to expedite work by callinghead of manufacturing directlyRoot CauseProduct doesnt meet specificationsManufacturing specification is different fromwhat customer and sales person agreed toWhy?

Manufacturing schedule is not available forsales person to provide realistic delivery dateSales person tries to expedite work by callinghead of manufacturing directlyRoot CauseProduct doesnt meet specificationsManufacturing specification is different from what customer and sales person agreed toWhy?

Confidence in manufacturing schedule is nothigh enough to release/link with order systemManufacturing schedule is not available forsales person to provide realistic delivery date Sales person tries to expedite work by callinghead of manufacturing directlyRoot CauseProduct doesnt meet specificationsManufacturing specification is different fromwhat customer and sales person agreed to

Root CauseConfidence in manufacturing schedule is nothigh enough to release/link with order systemWhy?

Root CauseConfidence in manufacturing schedule is nothigh enough to release/link with order system Parts sometimes not available therebycreating schedule changesWhy?

Expediting and priority changes consumeparts not planned forRoot CauseConfidence in manufacturing schedule is nothigh enough to release/link with order systemParts sometimes not available therebycreating schedule changesWhy?

Manufacturing schedule does not reflectrealistic assembly and test timeExpediting and priority changes consumeparts not planned forRoot CauseConfidence in manufacturing schedule is nothigh enough to release/link with order systemParts sometimes not available therebycreating schedule changesWhy?

No ongoing review of manufacturing standardsManufacturing schedule does not reflectrealistic assembly and test time Expediting and priority changes consumeparts not planned forRoot CauseConfidence in manufacturing schedule is nothigh enough to release/link with order systemParts sometimes not available therebycreating schedule changes

Corrective ActionPermanent Manufacturing standards reviewed and updated.

Preventive - Regular ongoing review of actuals vs standards is implemented.

Root Cause Analysis Example #4

Example #4

Identify Problem

Department didnt complete their project on time

Immediate ActionAdditional resources applied to help get the project team back on schedule No new projects started until Root Cause Analysis completed

Root CauseDidnt complete project on timeWhy?

Cause and EffectDidnt complete project on timeEquipmentMaterialsPersonnelProceduresLack of worker knowledgePoor project mgmt skillsPoor project planInadequate computer programsInadequate computer systemPoor documentationLack of resources

Cause and EffectDidnt complete project on timeEquipmentMaterialsPersonnelProceduresLack of worker knowledgePoor project mgmt skillsPoor project planInadequate computer programsInadequate computer systemPoor documentationLack of resources

Root CauseDidnt complete project on timeResources unavailable when neededWhy?

Took too long to hire Project ManagerRoot CauseDidnt complete project on timeResources unavailable when neededWhy?

Lack of specifics given to Human Resources DeptTook too long to hire Project ManagerRoot CauseDidnt complete project on timeResources unavailable when neededWhy?

No formal process for submitting job openingLack of specifics given to Human Resources DeptTook too long to hire Project ManagerRoot CauseDidnt complete project on timeResources unavailable when needed

Corrective ActionPermanent Hired another worker to meet needs of next project team

Preventive - Developed checklist form with HR for submitting job openings in the future

Cause and Effect Diagram

(C&E, Ishikawa, Fault or Fishbone Diagram)

Cause & Effect DiagramThe Cause and effect diagram is also called: Fishbone Diagram-because of the way it looksIshakawa Diagram for the inventor, Dr. Kaoru Ishakawa.

What is a Cause and Effect Diagram?A visual tool to identify, explore and graphically display, in increasing detail, all of the suspected possible causes related to a problem or condition to discover its root causes.Not a quantitative tool

Why Use Cause & Effect Diagrams?Focuses team on the content of the problemCreates a snapshot of the collective knowledge of teamCreates consensus of the causes of a problemBuilds support for resulting solutionsFocuses the team on causes not symptomsTo discover the most probable causes for further analysisTo visualize possible relationships between causes for any problem current or futureTo pinpoint conditions causing customer complaints, process errors or non-conforming productsTo provide focus for discussion

ManMethodsMachineMaterialsMeasurementFive Key Sources of VariationEnvironment+Use cause and effect diagram to single out variation sources within the 5Ms + EProduct/Manufacturing

7 MsManMachinesMethodsMother NatureManagementMaterialsMeasurement System

PeopleProceduresPoliciesPlaceMeasurementFive Key Sources of VariationEnvironment+Use cause and effect diagram to single out variation sources within the 4Ps + M&ETransactional/Service

CausesEffectShows various influences on a process to identify most likely root causes of problemFishbone - Cause and Effect Diagram

MethodsMaterialsMachineryManpowerMaintenanceProblem/Brainstorm to determine root causes and add those as small branches off major bonesConstructing a C&E Diagram

Fishbone Diagram Example

Same Example More Detail

External Example: Why is your car getting poor gas mileage?No moneyNo awarenessPoor trainingWrong oilNo oil changeHard to inflateImpatienceCant hear engineDrive too fastUse wrong gearsUnder-inflated tiresBad oilPoor driving habitsPoor maintenanceAlways lateRadio too loudPoor hearingPoor designNo $Poor trainingWrong pressureNo manualWrong gasManpowerMaterialsMethodsMachineryWrong fuel mixPoor Gas Mileage

Manjunath VS*

Manjunath VS

*Physical C&E ConstructionC&E Fishbone diagrams can be constructed two ways:Paper and pen Usually more effective when working in a teamMay take multiple sheets of flip chart paperMany teams find it helpful to do the flip chart method first because it lends itself to group dynamics. Everyone can see and participate easier. Minitab softwareVery helpful when sharing diagram with an audience outside of your team

What is Jidoka?Jidoka is providing machines and operators the ability to detect when an abnormal condition has occurred and immediately stop work.

Enables operations to build-in quality at each process and to separate men and machines for more efficient work.

Jidoka is one of the two pillars of the Toyota Production System along with just-in-time.

Jidoka is sometimes called autonomation, meaning automation with human intelligence.

Why Jidoka?Increase qualityLower costsImprove customer serviceReduce lead time

Prevention TechniquesPoka YokeVisual control of qualityPrevents defects from happeningExample: A floppy disk can only be inserted into the drive in one orientation

AndonsCommonly lights to signal production line statusRed: line stoppedYellow: call for helpGreen: all normalAndon signals require immediate attention

Jidoka StepsThe four steps in Jidoka are:

Detect the abnormality. Stop. Fix or correct the immediate condition. Investigate the root cause and install a countermeasure.

SHIGEO SHINGOPOKA-YOKE

Those who are not dissatisfied will never make any progress. - Shingo(1909 1990)

Zero Quality Control (ZQC)An approach to quality management that relies heavily on the use of Poka Yoke devicesSuccessive checksSelf-checksEach method relies on 100% inspection whereas traditional SPC rely on random checks

Poka YokeJapanese for mistake-proofingPoka - inadvertent mistakeYoke preventDeveloped in the 1960sEither prevents a mistake from being made or makes the mistake obvious at a glance

POKA-YOKEFool proofing

Poka-Yoke is an approach for mistake-proofing process using automatic devices or methods to avoid simple human error

All errors like omitted processing, processing errors, setup errors, missing parts, wrong parts, adjustment errors etc are eliminated using poka-yoke

*VSMPOKE-YOKEShingo believes that quality should be controlled at the source of the problem not after the problem has manifested itselfHe recommends that inspection should be incorporated within the process where the problem has been identified and where it should be eliminatedIt is handling errors as they occur

VSM

ERRORSForgetfulness due to lack of attention

Misunderstanding because of the lack of familiarity with a process or procedures

Poor identification associated with lack of attention

Lack of experience

Absentmindedness

Delays in adjustment when process is automated and equipment malfunctioning

PokaYoke Device CategoriesPrevention device - make errors impossible Detection device - Make errors visible to the operator

PRINCIPLES OF POKA-YOKEPrediction, or recognizing that a defect is about to occur and providing a warning

Detection, or recognizing that defect has occurred and stopping the process

EXAMPLESMachines have limit switches connected to warning lights that tell an operator when parts are improperly positioned

Counting devices

Warning messages on a computer

LEVELS OF MISTAKE PROOFINGDesigning for potential errors out of the product or process

Identifying potential defects and stopping a process before the defect is produced

Finding defects that enter or leave process

Characteristics of Good Poka Yoke DevicesThey are simple and cheapThey are part of the process They are placed close to where the mistakes occur

What Is A Failure Mode?A Failure Mode is:The way in which the component, subassembly, product, input, or process could fail to perform its intended functionFailure modes may be the result of upstream operations or may cause downstream operations to failThings that could go wrongWhat Can Go Wrong?

FMEA Procedure1.For each process input (start with high value inputs), determine the ways in which the input can go wrong (failure mode)2.For each failure mode, determine effectsSelect a severity level for each effect3.Identify potential causes of each failure modeSelect an occurrence level for each cause4.List current controls for each causeSelect a detection level for each cause

FMEA Procedure (Cont.)5.Calculate the Risk Priority Number (RPN)6.Develop recommended actions, assign responsible persons, and take actionsGive priority to high RPNsMUST look at severities rated a 107.Assign the predicted severity, occurrence, and detection levels and compare RPNs

FMEA Inputs and OutputsFMEABrainstormingC&E MatrixProcess MapProcess HistoryProceduresKnowledgeExperienceList of actions to prevent causes or detect failure modes

History of actions takenInputsOutputs

Severity, Occurrence, and DetectionSeverityImportance of the effect on customer requirementsOften cant do anything about thisOccurrenceFrequency with which a given cause occurs and creates failure modesDetectionThe ability of the current control scheme to detect or prevent a given cause

Risk Priority Number (RPN)*RPN is the product of the severity, occurrence, and detection scores.SeverityOccurrenceDetectionRPNXX=

FMEA WorksheetSev - Severity of the failure (what impact will it have on our process?)Occ How likely is the event to occur (probability of occurrence)Det How likely can the event be detected in time to do something about itRPN Risk Priority Number (multiply Sev, Occ, and Det)

Process or Product NamePrepared by:Page _____ of ______Person ResponsibleDate (Orig) ___________ Revised __________

Process StepKey Process InputPotential Failure ModePotential Failure EffectSevPotential CausesOccCurrent ControlsDetRPNActions RecommendedSevOccDetRPN

How To Complete the FMEA

General SuggestionsUse large white board or flip chart with a FMEA form drawn on it during the generation phase Focus the team on the specific area of study (product or process). Have process map availableHave all subassemblies and component part of a product.

Process for FMEAProcess to Change Oil in a Car3000 miles drivenDrive caron liftFill withnew oilDrain OilReplaceFilterTake Car off liftProcess Complete

How to Complete the FMEA

Step 1. Complete header information Step 2. Identify steps in the processStep 3. Brainstorm potential ways the area of study could theoretically fail (failure modes)

*FMEA WorksheetSev - Severity of the failure (what impact will it have on our process?)Occ How likely is the event to occur (probability of occurrence)Det How likely can the event be detected in time to do something about itRPN Risk Priority Number (multiply Sev, Occ, and Det)

Process or Product NameChange Oil in CarPrepared by: LeonPage _1____ of __1____Person ResponsibleLeon MechanicDate (Orig) __27 Sep 2007___ Revised __________

Process StepKey Process InputPotential Failure ModePotential Failure EffectSevPotential CausesOccCurrent ControlsDetRPNActions RecommendedSevOccDetRPNFill with new oilNew OilMechanicWrong type of oilEngine wearNo oil addedEngine Failure

*How to Complete a FMEAStep 4 For each failure mode, determine impact or effect on the product or operation using criteria table (next slide) Rate this impact in the column labeled SEV (severity)

*Severity (SEV) Rating

SEVSeverityProduct/Process Criteria1NoneNo effect2Very MinorDefect would be noticed by most discriminating customers. A portion of the product may have to be reworked on line but out of station3MinorDefect would be noticed by average customers. A portion of the product (

*FMEA WorksheetSev - Severity of the failure (what impact will it have on our process?)Occ How likely is the event to occur (probability of occurrence)Det How likely can the event be detected in time to do something about itRPN Risk Priority Number (multiply Sev, Occ, and Det)

Process or Product NameChange Oil in CarPrepared by: LeonPage _____ of ______Person ResponsibleLeon MechanicDate (Orig) __27 Sep 2007___ Revised __________

Process StepKey Process InputPotential Failure ModePotential Failure EffectSevPotential CausesOccCurrent ControlsDetRPNActions RecommendedSevOccDetRPNFill with new oilNew OilMechanicWrong type of oilEngine wear2No oil addedEngine Failure10

*How to Complete a FMEAStep 5For each potential failure mode identify one or more potential causes (Could use Affinity Diagram again to brainstorm ideas) Rate the probability of each potential cause occurring based on criteria table (next slide) Place the rating in the column labeled OCC (occurrence).

FMEA Occurrence (OCC Rating)

OCCOccurrenceCriteria1Remote1 in 1,500,000 Very unlikely to occur2Low1 in 150,0003Low1 in 15,000 Unlikely to occur4Moderate1 in 2,0005Moderate1 in 400 Moderate chance to occur6Moderate1 in 80 7High1 in 20 High probability that the event will occur8High1 in 89Very High1 in 3 Almost certain to occur10Very High> 1 in 2

FMEA WorksheetSev - Severity of the failure (what impact will it have on our process?)Occ How likely is the event to occur (probability of occurrence)Det How likely can the event be detected in time to do something about itRPN Risk Priority Number (multiply Sev, Occ, and Det)

Process or Product NameChange Oil in CarPrepared by: LeonPage _____ of ______Person ResponsibleLeon MechanicDate (Orig) __27 Sep 2007___ Revised __________

Process StepKey Process InputPotential Failure ModePotential Failure EffectSevPotential CausesOccCurrent ControlsDetRPNActions RecommendedSevOccDetRPNFill with new oilNew OilMechanicWrong type of oilEngine wear2Mis-labeled3No oil addedEngine Failure10Hurrying3

How to Complete the FMEAStep 6Identify current controls or detectionRate ability of each current control to prevent or detect the failure mode once it occurs using criteria table (next slide) Place rating in Det column

*FMEA Detection (DET) Rating

DETDetectionCriteria1Almost CertainCurrent Controls are almost certain to detect/prevent the failure mode2Very HighVery high likelihood that current controls will detect/prevent the failure mode3HighHigh Likelihood that current controls will detect/prevent the failure mode4Mod. HighModerately High likelihood that current controls will detect/prevent the failure mode5ModerateHigh Likelihood that current controls will detect/prevent the failure mode6LowLow likelihood that current controls will detect/prevent failure mode7Very LowVery Low likelihood that current controls will detect /prevent the failure mode8RemoteRemote likelihood that current controls will detect/prevent the failure mode9Very RemoteVery remote likelihood that current controls will detect/prevent the failure mode

*FMEA WorksheetSev - Severity of the failure (what impact will it have on our process?)Occ How likely is the event to occur (probability of occurrence)Det How likely can the event be detected in time to do something about itRPN Risk Priority Number (multiply Sev, Occ, and Det)

Process or Product NameChange Oil in CarPrepared by: LeonPage _____ of ______Person ResponsibleLeon MechanicDate (Orig) __27 Sep 2007___ Revised __________

Process StepKey Process InputPotential Failure ModePotential Failure EffectSevPotential CausesOccCurrent ControlsDetRPNActions RecommendedSevOccDetRPNFill with new oilNew Oil from supplierWrong type of oilEngine wear2Misread oil chart for vehicle3None 9No oil addedEngine Failure10Hurrying3Engine light3

*How to Complete the FMEAStep 7 Multiply SEV, OCC and DET ratings and place the value in the RPN (risk priority number) column. The largest RPN numbers should get the greatest focus. For those RPN numbers which warrant corrective action, recommended actions and the person responsible for implementation should be listed.SEV * OCC * DET = RPN( 2 * 3 * 9 = 54 )

Process StepKey Process InputPotential Failure ModePotential Failure EffectSevPotential CausesOccCurrent ControlsDetRPNActions RecommendedSevOccDetRPNFill with new oilNew Oil from supplierWrong type of oilEngine wear2Misread oil chart for vehicle3None 954No oil addedEngine Failure10Hurrying3Engine light390

*FMEA RankingsRating

101HighLow

SeverityOccurrenceDetectionHazardous without warningVery high and almost inevitableCannot detect or detection with very low probabilityLoss of primary functionHigh repeated failuresRemote or low chance of detectionLoss of secondary functionModerate failuresLow detection probabilityMinor defectOccasional failuresModerate detection probabilityNo effectFailure UnlikelyAlmost certain detection

*Action ResultsStep 8

After corrective action has been taken, place summary of the results in the Actions Recommended block Assign new value for: SeverityOccurrenceDetection

Calculate new RPN number

*FMEA WorksheetSev - Severity of the failure (what impact will it have on our process?)Occ How likely is the event to occur (probability of occurrence)Det How likely can the event be detected in time to do something about itRPN Risk Priority Number (multiply Sev, Occ, and Det)

Process or Product NameChange Oil in CarPrepared by: LeonPage _____ of ______Person ResponsibleLeon MechanicDate (Orig) __27 Sep 2007___ Revised __________

Process StepKey Process InputPotential Failure ModePotential Failure EffectSevPotential CausesOccCurrent ControlsDetRPNActions RecommendedSevOccDetRPNFill with new oilNew Oil from supplierWrong type of oilEngine wear2Misread oil chart for vehicle3None 954No oil addedEngine Failure10Hurrying3Engine light390Oil level checked by partner103130

Pareto AnalysisVital FewTrivial Many60 % of Material RejectionsApproved for Public Release

************When should we perform root cause analysis? All the time!When you do not dig deep enough into the detail of these problems, you should expect them to continue to reoccur time and time again

*Here is the usual versus preferred approach to problem solving.In most companies, when a problem surfaces, we firefight and try to put out the fire immediately. This involves some kind of quick fix or work around to keep the process moving. Just as we find an acceptable band aid fix that works, another fire starts somewhere else and we rush to fix it.We never take the time to revisit these fires to figure out why they happened in the first place. We keep dealing with the same problems over and over again.The preferred approach is similar. First, we develop a quick fix for the problem. However, instead of rushing to the next issue of the day, we take some extra time to do root cause analysis so that same problem is not tomorrows big fireWe then implement the process change and check to see that is does not return, we institutionalize the solution so other areas and groups do not have the same problem as well.Which one of these approaches will take longer to complete?Obviously the preferred approach will take much longer, so why should we take the time? We must think in the long term. In six months or a year from now, do we want to be dealing with the same number of problems as we are today, or do we want to have more time available to work on improving the process and other value added activities.

*************We identify the problem as part polarity reversed on a printed circuit board. This may have been one incident, or a recurring problem identified from a pareto chart*The immediate activity implemented after the team gets together*The problem is placed in the first box. We then ask the first why. Why was the part reversed?*The team determines that the factory worker was unsure of the correct part orientation when performing the task. Often times, teams will stop and assume that the problem is due to human error. This is NOT an acceptable root cause. Errors will always be made, so teams must dig deeper to find a way of making the process easier, or find a better way of catching the problem sooner.We again ask why. Why was the worked unsure of the correct orientation?*Continue with the 5 Whys process until they reach a defective process*The 5 Whys implies asking why five times, but it could be more than 5. Asking at least five times forces the team to dig beyond their own knowledge of the process and make certain they dont stop short of the root cause

*The team determines that the engineering process does not adequately account for manufacturing issues during the selection or specification process. Notice that they did not put the blame on the individual engineer.*Here are the permanent and preventive actions. The permanent changes that part for that particular problem. The preventive truly addresses the larger issue of selecting the parts correctly the first time with orientation marks, instead of afterwards when the problem is found.**********************Example #2 is geared towards transactional, or office related processes*The team applies additional resources to get the team back on schedule and no new projects were started until the root cause solutions of this project were completed.**The team uses the Cause and Effect Diagram to identify possible causes of the projects delay. Each cause is placed into the appropriate category*The team decides, based on experience and the available data, to focus on the lack of resources as the major reason for the delay.*The team determines that the appropriate resources were not available when they were most needed to keep the project on schedule. *In this example, the Project Manager was not hired in time, which had a huge impact on the projects schedule.*The team keeps asking why, this time determining that the specifics for the Project Manager position were not clear and caused the Human Resources department to contact and interview some candidates who were not fully qualified*Instead of stopping and blaming the HR department, the team brings a representative from HR into the team to dig further. After some discussion, the team determines that there are some problems with the internal job posting process, which allows the job specifics for the position to be overlooked or not clearly defined.*The permanent action involves adding an additional full time support person to the project.The preventive action addresses the process issue so that the problem does not happen again!******************This is the basic worksheet. **This is the basic worksheet. **After filling in the basic details, determine the Severity Rating. The next slide shows the rating criteria in more detail. *This is the basic worksheet. **Next, determine the occurrence rating (How likely is it to occur). *This is the basic worksheet. **Next determine the Detection rating (How likely is the failure to be discovered before it goes to the customer?). Details are on the next slide. *This is the basic worksheet. *To calculate the total Risk Priority Number (RPN), multiply the severity, occurrence and detection ratings.

The largest RPNs should be worked on first. Identify recommended actions and a person responsible for implementation of a plan to reduce or alleviate the risks. *After you have implemented a correction, report the summary of actions in the Actions Taken block. Then start over again and determine new values and see what you need to address next. *This is the basic worksheet.