Currently
We don’t always follow the same steps or directions.
Too often we attempt to solve problems without really understanding
them and all of the contributary factors.
By not identifying the real owner we do not arrive at the real root
cause and are left with permanent containments (extra work).
We often think we have cured a problem only for it to resurface at
a later date.
PROBLEM SOLVING
Verify the basics first:
is the standardised work process being used?
is the tooling standardised and correctly applied?
are the right parts being used?
Confirm the process (if we can make one right, why not all?)
Understand the impact of variation in the process
Is the process running out of control?
Is the process capable?
Can the process be changed to prevent the problem/defect?
ONLY when we have ensured these items can we;
Involve Engineering to apply more technical investigative methods
If the manufacturing process is NOT being managed to design intent, then it must be corrected and validated, before we can consider asking for Engineering assistance.
Engineering referral only occurs when the manufacturing process does meet design intent and the problem still exists.
3 – Verify/Correct Parts
4a/b – Investigate Parts
(1) ‘Central’ PCBs
Issued by Plant QA for GCA Audit Factor 50, 10 and repetitive Factor 1.0 defects found on Audit vehicles. Repetitive defects found at the ‘Squeak and Rattle’ test, Water Test, C.A.T audit and Electrical Systems audit also generate PCBs.
(2) Local/Internal PCBs
These are issued by the Unit Manager through the Unit PRT Team for repetitive Quality defects, DRL repeats, BIW Audit defects and high cost or repeat Scrap parts and assemblies.
On completion all PCBs are returned to the PRT Team to update the tracking system and forward completed ‘central’ PCBs back to Plant QA.
PCB – Escalation to Diamond 4a
If after completing each stage of Diamond 1-3 on the PCB form the cause is not apparent or it is clear the problem belongs to another department the PCB is returned to the Unit PRT Team who will decide whether to refer the PCB elsewhere or progress the PCB to Diamonds 4a and/or 4b.
LH SIDE LOAD DOOR LOCK LOCATION
AVE 2 PER WEEK (FROM STABS DATA)
ALL + LH S/L DOOR
N/A
PROBLEM DESCRIPTION/DATA
AB/CD/EF
01/01/99
YES
100% CHECK ON SUB ASSEMBLIES PRIOR TO LOADING TO S/L/D CELL
100% CHECK OF SUPPLIED PARTS IN 001 STORES
SUPPLEMENTARY CHECK BY QA AT END OF BIW SIP STATION
AB/CD/EF
SQA DEPT
GH/IJ/KL
01/01/99
01/01/99
01/01/99
YES
YES
YES
CONTAINMENT
To generate the possible causes we use a simple but effective technique known as ‘brainstorming’ which is used to help create as many ideas in as short a time as possible.
BRAINSTORMING
Ensure all group members are aware of the nature of the problem/defect e.g. missing part, damage, wrong part etc.
Next, ask each person to think of as many possible causes for the defect (however likely or unlikely they may seem).
Get each person to briefly explain their ideas and note down EVERY idea clearly on a flipchart/paper.
As a group discuss each idea and agree on the most likely causes.
Where possible ask group members to verify/investigate the most likely causes and suggest suitable countermeasures
DO – record and discuss every idea – however extreme they may appear (quite often even the strangest ideas prove to contain some benefits)
DON’T – never dismiss or ridicule any ideas. This is likely to switch that person off and refrain from any further positive input.
DO – try to ensure that all ideas are fully understood – ask individuals to explain them and ask questions to ensure there are no misunderstandings.
DON’T – be influenced by any previous history of a particular problem or defect – always start with a blank sheet of paper!
DO – ensure whenever an idea is discarded, that the individual who came up with it fully understands why it will not be pursued.
Following SOS/JES correctly?
Operator checking for part present?
Operator unable to see if part is present?
Faulty part location pins/clamps?
BRAINSTORMING - CHECK LIST
2
Are the guns/tools being used correctly?
3
Are all shifts using the same guns/tools?
4
Are the welding tips worn or misaligned?
5
Are all spot welds in the specified locations?
6
Is sealer applied to the specified quantity and location?
7
Are any location pins or clamps loose, worn or missing?
8
Are the guns/tools/fixtures protected where required?
9
Are power tools set for the specified torque and properly calibrated?
10
Are any tool bits or sockets worn?
11
Does the workstation contain any error proofing/ Poke-Yoke devices?
12
Have the Poke-Yoke devices been verified - Maint records?
13
Has Preventative Maintenance (or TPM) been done? (check log)
14
Does the workstation allow the operator to work effectively?
You can drag these symbols
into the fishbone
Step 3
Cross Through
Unlikely Causes
Step 4
Circle Probable
Causes
Step 5
Mark Most Likely
Cause with Star
Team Leader A Shift
Supervisor A Shift
Step 1
Brainstorm all
possible causes
Step 2
Complete Checklist
Sign Off for Diamonds 1-3
and Checklist Complete
Fault or
Problem
1 - Man
4 - Material (Specification)
2 - Machine
3 - Method
Cause and Effect Analysis and Investigation:
Missed operation?
Operator not trained?
Operator not working to SOS/JES?
Welds missed?
Welds failed?
Poke –Yoke not working?
Following SOS/JES correctly?
Operator checking for part present?
Operator unable to see if part is present?
Faulty part location pins/clamps?
Supplier part?
COMPLETING THE FISHBONE (2)
Yes
No
Can the Problem Occur Elsewhere
Yes
No
Trend Analysis (from Containment)
Problem Closed (15 Shifts Clear):
Final Solutions for Root-Cause
Complete
Who
When
(Root Cause):
If Standardised, Where is it
Documented:
Why?
Why?
Why?
Why?
Why?
Date & Sign-Off
Team Leader
Supervisor
Shift Manager
Quality Insp
Unit Manager
A - Shift
B - Shift
C - Shift
Front sheet
Back sheet
NO THREADED BOSS IN LH S/L DOOR TO FIT BOLT
WELD NUT MISSING FROM LH S/L DOOR
WELD NUT MISSED FROM LH S/L DOOR REINFORCEMENT SUB ASSEMBLY
SUPPLIER PART – SQA & QE TO INVESTIGATE SUPPLIER PROCESS AND TAKE NECESSARY ACTIONS
MISSED OPERATION FROM OUTSIDE SUPPLIER OF ASSEMBLY
MISSED OPERATION FROM OUTSIDE SUPPLIER OF ASSEMBLY – SUPPLIER QUALITY PROCESS NOK
Yes
No
Can the Problem Occur Elsewhere
Yes
No
Trend Analysis (from Containment)
Problem Closed (15 Shifts Clear):
Final Solutions for Root-Cause
Complete
Who
When
(Root Cause):
If Standardised, Where is it
Documented:
Why?
Why?
Why?
Why?
Why?
Date & Sign-Off
Team Leader
Supervisor
Shift Manager
Quality Insp
Unit Manager
A - Shift
B - Shift
C - Shift
Front sheet
Back sheet
CHECK JES/SOS FOR QUALITY CHECK POINT
UPDATE SOS/JES TO INCLUDE QUALITY CHECK FOR WELD NUT
CHECK ALL STOCK IN STORES, IN TRANSIT & AT SUPPLIER
INVESTIGATE SUPPLIER ASSEMBLY & INSPECTION PROCESSES
ALL OPERATORS INSTRUCTED ON ALL SHIFTS, VISUAL AIDS POSTED IN STATION
AB/CD/EF
01/01/99
YES
NO REFERENCE TO CHECK FOR THIS ISSUE
AB/CD/EF
01/01/99
YES
SOS/JES UPDATED OK
AB/CD/EF
02/01/99
YES
ALL IN HOUSE STOCK CHECKED – CHECK AT SUPPLIER ONGOING
SQA QE
02/01/99
NO
IN PROGRESS WITH SUPPLIER
QE
06/01/99
NO
DIAMONDS 1 - 3
DIAMOND 4b
RECORD ALL ACTIONS/STATUS
Yes
No
Can the Problem Occur Elsewhere
Yes
No
Trend Analysis (from Containment)
Problem Closed (15 Shifts Clear):
Final Solutions for Root-Cause
Complete
Who
When
(Root Cause):
If Standardised, Where is it
Documented:
Why?
Why?
Why?
Why?
Why?
Date & Sign-Off
Team Leader
Supervisor
Shift Manager
Quality Insp
Unit Manager
A - Shift
B - Shift
C - Shift
Front sheet
Back sheet
SUPPLIER TO 100% CHECK FOR WELD NUT PRIOR TO SHIPPING TO IBC
BODY MAINTENANCE & ME TO INVESTIGATE POSSIBILITY OF POKE-YOKE DEVICE IN SIDE LOAD DOOR TOOLING
Who
When
Complete
AB/CD/ EF
QE/ SUPPLIER
ME/ MAINT
02/01/99
05/01/99
T.B.D
YES
YES
NO
SUPPLIER TO INVESTIGATE AND IMPROVE QUALITY SYSTEMS TO ASSURE OK PARTS TO IBC
QE/ SUPPLIER
T.B.D
NO
Yes
No
Can the Problem Occur Elsewhere
Yes
No
Trend Analysis (from Containment)
Problem Closed (15 Shifts Clear):
Final Solutions for Root-Cause
Complete
Who
When
(Root Cause):
If Standardised, Where is it
Documented:
Why?
Why?
Why?
Why?
Why?
Date & Sign-Off
Team Leader
Supervisor
Shift Manager
Quality Insp
Unit Manager
A - Shift
B - Shift
C - Shift
Front sheet
Back sheet
Problem Closed (15 Shifts Clear):
If Standardised, Where is it
Documented:
Date & Sign-Off
Team Leader
Supervisor
Shift Manager
Quality Insp
Unit Manager
A - Shift
B - Shift
C - Shift
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1
2
3
4
5
6
7
8
Use appropriate scale
JES/SOS SHEETS
This part of the PCB MUST be filled in by hand.
PROBLEM SOLVING
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