or True Story of the Car Which Did Not Like Vanilla Ice Cream

Transcription

or
True Story of the Car
Which Did Not Like
Vanilla Ice Cream
© 1996-2014
Quexx International Ltd.
1-604-728 3373
QUEXX
Operational Excellence Series “ROOT CAUSE”
Presenter
PROFESSIONAL PROFILE
35 years of professional experience
FIAT, TOYOTA, SPECTRUM, MIVI, LEVELTON
QA/QC, TPS/LEAN, SQA, ISO 9001-series
A.W.(Arc) Rajtar M.Eng.
ex
Supplier Quality Supervisor
Quality Assurance Manager
Purchasing Engineering Manager
TOYOTA AUSTRALIA
Quality Assurance Specialist
LEVELTON Consultants Ltd.
Managing Partner
QUEXX International Ltd.
Integrated Quality Management Systems
Supply Chain Optimization
LEAN Techniques
© 1996-2014
1-604-728 3373
Page: 2
QUEXX
ROOT CAUSE
© 1996-2014
1-604-728 3373
Page: 3
QUEXX
Definition
In plain English …
“Root Cause"
is a "cause"
(harmful factor)
that is "root"
(deep, basic, fundamental, etc)
[Wikipedia]
© 1996-2014
1-604-728 3373
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QUEXX
THE STORY
© 1996-2014
1-604-728 3373
Page: 5
QUEXX
… a truly puzzling
story of a car …
© 1996-2014
1-604-728 3373
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QUEXX
The Weird
… which did not
like vanilla
ice cream.
© 1996-2014
1-604-728 3373
Page: 7
QUEXX
OK
© 1996-2014
1-604-728 3373
Page: 8
QUEXX
NOT OK
© 1996-2014
1-604-728 3373
Page: 9
QUEXX
Complaint
“A flavor of ice cream
being transported
affects a car's performance.
Every time vanilla is
the my choice,
the car stalls…
The Owner”
© 1996-2014
1-604-728 3373
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QUEXX
THE INVESTIGATION
© 1996-2014
1-604-728 3373
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QUEXX
WHY #1
WHY?
The engine in my car always stalls
when I buy vanilla ice cream?
BECAUSE:
…the car does not like
the vanilla ice cream.
1 x WHY
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1-604-728 3373
Page: 12
QUEXX
WHY #2
WHY?
The car does not like waiting
for the vanilla ice cream?
BECAUSE:
…it takes long time to get vanilla ice cream
and the car always runs out of fuel,
or… just feels like it...
© 1996-2014
1-604-728 3373
2 x WHY
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QUEXX
WHY #3
WHY?
The car feels like it run out of fuel?
BECAUSE:
…there seems to be no fuel supplied to the engine.
3 x WHY
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1-604-728 3373
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QUEXX
WHY #4
WHY?
No fuel in the the carburetor?
BECAUSE:
…of a “vapor lock” in the fuel line.
4 x WHY
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QUEXX
WHY #5
WHY?
The fuel line develops “vapor lock”?
BECAUSE:
… it overheats.
5 x WHY
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1-604-728 3373
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QUEXX
WHY #6
WHY?
The fuel line overheats?
BECAUSE:
…of the design.
6 x WHY
© 1996-2014
1-604-728 3373
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QUEXX
WHY #7
WHY?
…design is responsible for the overheating…
BECAUSE:
… fuel line close to the exhaust gets hot
… poor airflow = insufficient cooling
…small diameter = small volume
7 x WHY
 = “vapor lock”
© 1996-2014
1-604-728 3373
Countermeasure:
Increase size (diameter)
= eliminate “vapor lock
Page: 18
QUEXX
GOOD EXAMPLES
© 1996-2014
1-604-728 3373
Page: 19
QUEXX
Problem:
Example
1
Car “jumping”
on uneven
pavement
Reason:
Missing rear shock
absorbers
Possible Cause(s):
Not fitted. Stolen.
Root Cause:
Symptom: Shortage of personnel at the assembly line.
Reason: Bleaching of the toilet paper.
Corrective Action:
1) Change toilet paper
2) 2) Double the doublers 3) Implement procedure
© 1996-2014
1-604-728 3373
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QUEXX
Example
Problem:
Police unable
to read
registration
plates
2
Reason:
License plate horizontal
Possible Cause(s):
Fuel inlet cover broken, weak spring
,damaged, purposefully distorted
Root Cause:
Symptom: Swelling of non-fuel-resilient fuel filler cup rubber seal.
Reason: Non-fuel-resistant rubber used.
Corrective Action:
1) Random test the rubber
2) Buffer stock
3) Change supplier
© 1996-2014
1-604-728 3373
Page: 21
QUEXX
Example
Problem:
Vehicle engine
compartment fire
3
Reason:
Freon of A/C
system ignited
Possible Cause(s):
Defective or sub-standard parts,
assembly error, damage during
servicing, excessive flammability
Root Cause:
Symptom: Automatic transmission oil dipstick too short.
Reason: Machine setup not confirmed.
Corrective Action:
1) Use “sealed sample” to verify machine setup
2) Confirm machine setup at the end of production run
© 1996-2014
1-604-728 3373
Page: 22
QUEXX
BAD EXAMPLES
© 1996-2014
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QUEXX
Root Cause?!
Problem:
Misplaced
steel beam.
1
Description:
The subcontractor
has changed the location
of the mounting plate
and embedded it in the concrete
without approval from the Designer.
Root Cause
The plate was shifted without authorization.
Corrective Action:
The contractor to be reminded any changes must be approved by the Designer.
© 1996-2014
1-604-728 3373
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QUEXX
Root Cause?!
Problem:
Deck drainage
installed
incorrectly.
2
Description:
The drain housings
were installed
at the incorrect elevations.
Root Cause
The decision was made in a hurry.
Corrective Action:
The supervisor to take an extra day to review the setup prior to the site QC review.
© 1996-2014
1-604-728 3373
Page: 25
QUEXX
Root Cause?!
Problem:
Unspecified
welds of “fraction
critical” beam.
3
Description:
Additional, not required
welds on 4 different beams
of the same critical component.
Some welds affect one joint,
some two joints, some three.
Vary from beam to beam.
Root Cause
CNC machine performed the wrong operation.
Corrective Action:
Machine has been fixed and adjusted.
© 1996-2014
1-604-728 3373
Page: 26
QUEXX
ADVICE
© 1996-2014
1-604-728 3373
Page: 27
QUEXX
Why?
Ask ”
“
5 - 7x min!
© 1996-2014
1-604-728 3373
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QUEXX
Define and Classify
A B C D
A1
C1
A2
C2
C2
Define
Organize
© 1996-2014
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QUEXX
Organize and Focus
C C2 A
A1
C1
D1
B1
B
D
Define
Organize
© 1996-2014
1-604-728 3373
Page: 30
QUEXX
CAUTION #1
Correction
prevents
the problem recurring.
Correcting of the “true root cause”
may be not economical and/or not practical.
© 1996-2014
1-604-728 3373
Page: 31
QUEXX
CAUTION #2
Complete prevention
by one corrective action
may be not possible.
Multiple corrective actions may need
proper coordination and sequencing.
© 1996-2014
1-604-728 3373
Page: 32
QUEXX
CAUTION #3
Management
and the root cause
are often connected.
© 1996-2014
1-604-728 3373
Page: 33
This presentation was delivered by…
QUEXX International Ltd.
Management Consultants
Integrated Management Systems
Supply Chain Optimization
LEAN Techniques
Cel.:
Ph.:
Fax.:
E-mail:
(604) 728 3373
(604) 469 6002
(604) 469 6070
mail@quexx.com
Web:
www.quexx.com
© 1996-2014
1-604-728 3373
Coming soon from…
QUEXX International Ltd
Management Consultants
www.Cruise-and-Learn.com
http://www.cruiseshipcenters.com/ArcRajtar
© 1996-2014
1-604-728 3373

or True Story of the Car Which Did Not Like Vanilla Ice Cream

Transcription

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