rocketdyne propulsion & power corrective action problem solving john degiovanni quality...
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Rocketdyne Propulsion & Power
Corrective ActionCorrective Action
Problem SolvingProblem Solving
John DeGiovanni
Quality Leadership Forum
Johnson Space Center
Sept 25, 2002
Quality DirectorSpace Shuttle Main Engine Program
Boeing Canoga Park
Rocketdyne Propulsion & Power
• Improving Product
• Decreasing Cost
• Improving Delivery
• Adding Value
The Purpose of Corrective Action?
?
Learning to Treat Corrective Action as a Business CaseLearning to Treat Corrective Action as a Business CaseLearning to Treat Corrective Action as a Business CaseLearning to Treat Corrective Action as a Business Case
Rocketdyne Propulsion & Power
Considerations• Timeliness• Depth• Generic Implications • Effectiveness• Interrelationship of
Causes & Effects• Consistency
• Problem Solving Tool Selection
Weighing the Factors…
NASA Code Q Suggestion to Try New Problem Solving ToolNASA Code Q Suggestion to Try New Problem Solving ToolNASA Code Q Suggestion to Try New Problem Solving ToolNASA Code Q Suggestion to Try New Problem Solving Tool
Rocketdyne Propulsion & Power
Every Toolbox has a First Tool
The Problem Solving Tool• Checklist-oriented• Developed by Government and Industry• System / Process Structured
22 Categories22 Categories22 Categories22 Categories
Failure CodesFailure CodesFailure CodesFailure Codes
PossibilitiesPossibilitiesPossibilitiesPossibilities
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The Problem Solving Tool
Sample PageSample PageSample PageSample Page
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Application & Evaluation
Application
• Problem Solving Tool Applied to Over 20 SSME Corrective Actions
• Assessed for:
– Usefulness – Accuracy
– Timeliness – Integration Ability
– Direction
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• Easy to Use• Time Saving/Efficient• Covers Wide Array of Process
Failures & Causes– “Human Performance Factors– “Systemic” Contributors
• Structure Identifies Factors Not Previously Considered
• Easy to Categorize Factors• Structured Approach• Consistent• Programmable/Accessible• System Approach• Adaptable as a Comprehensive
Audit Tool
• Initial Selection of Categories
• Adaptive Reasoning– Can Require Tailoring
• Checklist Culture
• Paper-based / Cumbersome
Pro and Cons
ConsConsConsConsProsProsProsPros
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Enhancing Implementation
Adopted Tool for Web Access
• Accessibility • User Friendly, On-line
• Edited Text
• Added Document Reference• Ref. to NC, UCR, PR, etc
• Trending Availability
• Paperless
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Status• Several Tools being Incorporated Into our CA Toolbox
– Different Tools for Different Applications• Consortium Checklist• Cause Chains• Reason & Other Software Tools• Apollo Methodology
– i.e., “One Tool Does Not Fit All”
The Corrective Action Toolbox
Developing Our Corrective Action ToolboxDeveloping Our Corrective Action ToolboxDeveloping Our Corrective Action ToolboxDeveloping Our Corrective Action Toolbox
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Cause Chain Value Line“The Theory”
Form Team
Immediate Cause
Facts
Relationship
Root Cause
Action Plan
ValueValue
Va
lue
Va
lue
TasksTasks
Cause Chain Designed To:Cause Chain Designed To:Cause Chain Designed To:Cause Chain Designed To:
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Cause Chain 101 Analysis“Value Line Biorhythm”
Va
lue
Va
lue
““Value” Changes Over Time, Given Certain EventsValue” Changes Over Time, Given Certain Events““Value” Changes Over Time, Given Certain EventsValue” Changes Over Time, Given Certain Events
Trouble Signs:Trouble Signs:3 cause chain meetings3 cause chain meetingsProtests on causeProtests on causeRefuse to attendRefuse to attendPush to a CAB deadlinePush to a CAB deadlineProblem weeks old - no actionProblem weeks old - no action
Trouble Signs:Trouble Signs:3 cause chain meetings3 cause chain meetingsProtests on causeProtests on causeRefuse to attendRefuse to attendPush to a CAB deadlinePush to a CAB deadlineProblem weeks old - no actionProblem weeks old - no action
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Corrective Action Factors
SoftwareSoftware““Tools”Tools”
HardwareHardware““Product”Product”
LivewareLiveware““People”People”
Environment
Outcomes depend on: • Mindsets• Priorities• Values• Knowledge• Issues
Environment is Critical…Environment is Critical…Environment is Critical…Environment is Critical…
Interrelationships Create the Corrective Action ResultsInterrelationships Create the Corrective Action ResultsInterrelationships Create the Corrective Action ResultsInterrelationships Create the Corrective Action Results
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What Is Necessary for Better CA?
Team wantsto do it
Team wantsto do it
Excellent C&CA effort
Team understands what to do
Team understands what to do
Team knows how to do it
Team knows how to do it
Team is capable of doing it
Team is capable of doing it
No obstacles interfereNo obstacles interfere
Existing undesirable effects requiring C&CA effort
Existing undesirable effects requiring C&CA effort
• Priorities• Schedule• Budget• Mind sets
C & CA Network Logic DiagramC & CA Network Logic DiagramC & CA Network Logic DiagramC & CA Network Logic Diagram
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Criteria that Influences the Tool Selection• Ease of Use • Interactions Among Causes• Probability of First Time Through (F.T.T.) Success• Business Case for Intervention • Immediate Applicability• Accessibility• Software Compatibility• CA Effectiveness Measures • Supplier Usefulness
How Should the Tool Help?
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• MORT• Human Factors MORT• S.O.U.R.C.E
• Seeking Out the Underlying Root Causes
• Fault Tree Analysis• Logic Tree Analysis• Apollo• Reason• IAT-M
• Incident Analysis Tool - Modified
• Cause Chain• 5 Why’s• Fishbone Diagram
Existing Tools
Does One Size Fit All?
Events
More Complex CasesMore Complex Cases
Medium ComplexityMedium ComplexityCasesCases
Fairly Simple CasesFairly Simple Cases
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Understanding and The Capability of People
What We Are Doing?
• Studying the C&CA Network Logic• Reviewing Tools• Assessing Structure• Investigating Training Options• ENVIRONMENT Changes
(From (From Apollo Root Cause Analysis)Apollo Root Cause Analysis)
“ “ Only 2 or 3 out of 10 People Can Apply the Logic Effectively”Only 2 or 3 out of 10 People Can Apply the Logic Effectively”(From (From Apollo Root Cause Analysis)Apollo Root Cause Analysis)
“ “ Only 2 or 3 out of 10 People Can Apply the Logic Effectively”Only 2 or 3 out of 10 People Can Apply the Logic Effectively”
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Environment ChallengesPossible Environment
Modifying Actions
Real “People” Build Hardware(They Don’t Do C&CA)
Fault-finding More Habitual Than Fact-finding
C&CA Perceived As a “Nice-to-have” vs “Must Have”
Group Interaction (Exercise)
• • •
• • •
• • •
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Moving Out
How Are We Proceeding?• Mentoring/Facilitation Mode• Expanding our Tools• Raising Visibility of System Performance
• Trends• Timeliness / Status
• Accountability Shifting• CABs: Review Mode Action Mode• Investigating Restructuring of Relationships
Developing a Plan to Address The EnvironmentDeveloping a Plan to Address The EnvironmentDeveloping a Plan to Address The EnvironmentDeveloping a Plan to Address The Environment