Hidden Fault lines In Your Organization

1. Hidden FaultlinesIn Your Organization Find them FAST FIX them Forever Dr. Ted Spickler Qualityand Business Services 412-777-2054 ted.spickler.b@bayer.com  Bayer Corporate and Business Services LLC

2. Why Are We Here? • Organizations, like geological features, are subject to earthquakes - sudden upheavals that can later be attributed to hidden, underground faultlines that are sensitive to stresses and can, without warning, let lose with disastrous consequences.

3. Faultlines • Some of us have chronic problems that have defied previous attempts at resolution. • Old problems rear up out of the blackness and bite us again and again. • Meaning we never really fixed them the first time.

4. What Are We Going to Do Today? • Examine techniques for uncovering faultlines. • Practice building logic tree’s, a key tool for uncovering LatentCauses. • Differentiate between Direct Causes, Symptoms, Contributing Causes, and Latent Causes. • Learn to build effective fixes to these problems.

5. When Something Goes Wrong: Typical reaction • Shoot the messenger. • Jump to quick conclusions about why something happened. • Find someone to blame - THEN: Hang ‘em high! • Review procedures with “bad” person. • Re-train and discipline “bad” person. • How about: blame the supplier! • Better yet: “Blame the CUSTOMER”! • Hope it doesn’t happen again.

6. We Need A Better Approach • Find out what really went wrong. • How do the quakes happen? • What can we do to prevent bad things like this from happening again? • Where do you find evidence for the hidden faultlines? • Utilize a systematic approach using tools that avoid simple blaming. • Develop practical solutions that fix it forever.

7. Finding the Faultlines • We have learned to look in these two places: • Customer Complaints • ISO audit Corrective Action Requests (CARS)

8. COMPLAINTS • Individual complaints are like viewing the company using tunnel vision. • You can get trapped in the specific details of any one case. • Instead look at a broad range of similar complaints looking for patterns. • These patterns appear to be “families” of complaints. • The underlying causes of these patterns are what we are looking for. • Doing this is easier if you have a comprehensive customer complaint database.

9. ISO Corrective Action Requests • In a similar manner look into the requests for corrective action that are written as a result of internal ISO audits. • Are there relationships between complaints and CAR’S? • As with complaints, you need a database of CAR’S.

10. Steps in searching for that hidden FaultLine • Work backwards from the visible symptom of a hidden faultline. • The visible symptom is evidence that you have a problem. • The kind of problem we are interested in shows up multiple times and sometimes in varying places with often a variety of symptoms. • You don’t know this at first because you start with visible symptoms. • Sometimes this backwards analysis uncovers just a local issue that hardly counts as a faultline. • In that case you find the cause of the problem and fix it.

11. Variety of Problem-Solving Tools • Fishbone Diagram (Cause and Effect). • The Five Whys. • Systematic Root Cause Diagramming Methods • Commercial systems (see bibliography) • Computer programs and chart-based analyses. • Chronological timeline • Logic Tree • “What’s Different” Analysis, also known as “IS/IS-NOT” • (Kepner & Tragoe) • Be prepared to apply multiple tools as the circumstances dictate

12. Two “Models” for Uncovering Faultlines • Single Investigator • Has a “virtual team” lurking in the background. • Can use all the tools described later. • BUT might be biased or jump too quickly to conclusions. • AND might miss something hidden under the surface. • May fail to come up with a good mix of corrective actions. • Team with Facilitator • Expensive to get everyone together. • Used when a highly visible problem really needs “big-time” attention. • Used when many departments “touch” the problem.

13. If You Need a Team ... • Include people who know something about what happened. • But hold down the size of the team! 5 - 7 seems optimal • Want persons with different expertise and backgrounds. May want a vendor or a customer representative on the team if appropriate. • Some team members might feel guilty! • The guilty-feeling persons should not be “spotlighted” - we need information and not remorse. • Hold “kick-off” meeting - carefully define the problem. • Determine what sorts of information are likely to be needed.

14. Gather Information • Interviews, copies of procedures, copies of logs, charts, test results, reports, photographs, maintenance records, audit reports, process flow charts and diagrams. • Has this happened before? Retrieve reports from earlier investigations. • This is why archiving investigations in databases is useful! • Do not assume anything - fill in the details with facts. • Expect the unexpected - look for the surprise!

15. A Lesson In Assuming Bill owns a company that manufactures and installs car-wash systems. Bill's company installed a car-wash system in Frederick, MD. These are complete systems, that include not only the car wash itself, but also the money-changing machines.

16. A Lesson In Assuming Lots of money turned up missing - was it the manager? Or had someone stolen the key from the manager to make a copy? Bill just couldn't believe that his people would do that, so they set up a camera to catch the thief in action. Well, they caught him on film!

17. It was not just one bird; there were several working together. Once they identified the thieves, they found over $4000 in quarters on the roof of the car wash and more under a nearby tree.

19. A Lesson In Assuming No matter what the circumstantial evidence may be, don’t jump to conclusions until you have all the facts. In this case, the new owner made the assumption that since:a) Money was missing on a regular basis.b) The machines were not being broke into (no damage).c) The only other keys would be the dealer or one of the dealer’s employees. that it must be theft by the dealer or a stolen key. WRONG!!

20. Key Tool for Identification of Hidden Faultlines: The Logic Tree

21. How to Construct a Logic Tree • For training purposes we will play around with a trivially simple case: • First define the PROBLEM by examining symptoms: • “We lost 20 hours of production” • “The customer’s plant had to be shut down” • “An employee broke his leg” • “My son was ticketed for speeding” • Search for the “pain”, where does it hurt? • The problem has a “so what” dimension, check: why do we care? • The cost of a ticket is an “OUCH”! • The possible increase in insurance premiums HURTS! • Your son has run afoul of the LAW [not a good thing].

22. Construct the Sequence of Events and Conditions • Begin with the “bad thing”. • Ask: “How did that bad thing happen?” or “What immediately preceded the problem event to directly cause it to happen?” • EXAMPLE: • “My son was driving his car” AND “His speed was 35” AND “The speed limit was 25” AND “A Police Officer observed him”. • Think in terms of “events” and all of the necessary “conditions” that conspired to cause something bad to happen. In this example, the two events and two conditions had to all be present to lead to the end result.

23. “Speeding” Logic Tree Each box contains a single item. Avoid statements like: “Driving his car at 35”.

24. Building The Logic Tree • The structure looks like a sideways tree. • It spreads out with multiple “limbs”. • Develop each limb of the tree by asking “What caused this tohappen?”. • Capture events and conditions necessary to describe what happened - working backwards. • If you don’t know the “why”, terminate that branch with a “?” mark. You may need to research that limb further. • Eventually each branch ends. • Judgment is required here. Don’t terminate a branch prematurely (you may miss a significant organizational fault, but on the other hand don’t keep going back forever to the “origin of time”.

25. What the Logic Tree Looks Like:

26. “Speeding” Logic Tree ? Need to investigate why he was “Not aware that speed limit was 25”

27. “Speeding” Logic Tree The root cause here might be attributed to “Inattention”. BUT: why the “Inattention”?

28. Try a Simple Example Take these eight statements and identify the symptom of the problem - then draw the events and conditions in a Logic Tree Chart.

29. Eight Statements: • Did not see debris • Driving to work • Left by previous car? • Got a flat tire • Looking backward to pass car • Debris shredded tire • Slow car in front • Debris in road

30. Case of the Shredded Tire Case of the Shredded Tire

31. After The Logic Tree is Constructed ... • Identify Direct Causes. • Key events or conditions (e.g., “ran over debris”) that led directly to the undesirable event. • Appear to the untrained person as the “root cause” but is not. • Identify Contributing Factors. • They have an influence on the problem, but if they were not present, the event could still have occurred. • Example: Talking on the cell phone

32. Now Look Deeper: • Identify Latent Causes. • Affect not only this incident but influence spreads over a wide area and could generate many other similar incidents. • The process of checking for access to the passing lane

33. Definition of Latent: “Present but not visible or Active” “Dormant” “Quiescent”

34. Searching for Latent Causes • One reason for identifying Direct Causes and Contributing Factors is to avoid calling them Latent Causes. • Direct Causes and Contributing Factors affect this particular case. • Fixing these factors is sometimes called “Containment”. • Latent Causes will generate new problems of a similar nature at a later date. • Addressing Latent Causes leads to “sustaining” corrective actions.

35. Finding a Latent Cause • In the speeding example, “Speed was 35” is a Direct Cause to “Ticketed for speeding”, but not the latent cause. • Latent Causes underlie Direct Causes. • Latent Causes are at the end of the cause-and-effect chain yet still within the control of the organization. • Although the Direct Causes lead directly to the problem, the Latent Cause sets up circumstances to bring about the Direct Causes.

36. Test for statements identifying latent causes • If a statement merely summarizes a bit of factual information about something that took place it is not a good latent cause statement. • Example: “Pipe broke” • This is an accurate statement describing what happened. BUT the statement does not “drill deep” enough beyond describing what happened, hence it is not identfying a latent cause.

37. Latent Cause Tests: • Events are not typically latent causes. Latent causes are more likely conditions that allowed events to lead to the (usually) undesired effect . • Think in terms of inadequate systems, processes, and procedures.

38. Other Tests for a Latent Cause Statement • If you were to remove the latent cause, or fix it, or change it so that the influence it had before is gone...the problem should go away permanently. • Sometimes it might take fixing or removing more than one “thing”, in that case you have more than one latent cause. • One of the causes is “necessary” but not “sufficient”. • This shows up as fixing the problem under certain circumstances but not all circumstances.

39. WARNING: Symptoms are not latent causes. • Symptoms partially describe the problem. • Symptoms tell you something about what’s wrong. • BUT Fixing the symptom rarely stops the problem from happening again. • “We are having processing problems at the customer site, and their filters are showing evidence of a solid contaminant in our product.” • The solid contaminant is a only a symptom of the underlying cause. • Ineffective corrective action: “They should switch to larger filters.”

40. Corrective Actions • After the Logic Tree chart is completed: • Check each box and ask if there is anything that can be done about it. • Build a corrective action list from these ideas. • Corrective Actions should: • Be practical and achievable. • Reduce the likelihood of problem repetition. • Be compatible with other departments or functions. • Be accountable in terms of persons and time. • Be sure you have done something about the Latent Causes and the various contributing factors.

41. EXAMPLE The Case of Something That went Wrong?

42. Examples of Actual Investigations

43. EXAMPLE • “For the want of a nail, the shoe was lost; for the want of a shoe the horse was lost; and for the want of a horse the rider was lost, being overtaken and slain by the enemy, all for the want of care about a horse-shoe nail”. Benjamin Franklin, Poor Richards Almanac

44. EXAMPLE OF AN INEFFECTIVE LATENT-CAUSE ANALYSIS • Complaint: “Five skids are misidentified. Labels exhibit code 160200 instead of 160280”. • Latent Cause: “The latent cause of this error is that the label was not generated with the correct code” • IS THIS CORRECT?

45. ANOTHER EXAMPLE OF AN INEFFECTIVE LATENT-CAUSE ANALYSIS • “Customer profiles define shipping requirements. If the shipment arrived at the wrong temperature, it is because the temperature was not in the customer profile”. • HAVE WE FOUND THE LATENT CAUSE?

46. The Case of the Missing Bar-Code Label • Complaint Description Section: • “Missing bar code labels - customer requires bar-code labels on every box showing the part number.” • Investigation Section: • “All messages are in place for customer to receive bar-code labels on their shipments. Order Entry tested a “dummy” order to make sure everything was in place for them to receive them on the next order and the test ran perfectly. We can only conclude this was a system-related problem that should not occur again.” • WAS THIS AN EFFECTIVE INVESTIGATION?

47. A Less than Effective Latent Cause and Corrective Action • Latent Cause Section: • “Isolated incident that may have been a system-related problem. All procedures are in place for customer to get bar-code labels. Test confirmed this.” • IS THIS A LATENT CAUSE? • Corrective Action Section: • “Make sure before printing a bill of lading that bar-code indicator is set to “N” in other words do not bypass bar code labeling. This has been noted on customer profile.” • IS THIS AN EFFECTIVE CORRECTIVE ACTION?

48. The Case of the Scrambled Boxes • Complaint Description • “Customer received sample with two different labels on one box. One label read 248-1050 and the other label read 348-012002. The material ordered was 248-1050.” • Investigation • “There were two orders from the customer scheduled to ship. One order was for 100 pounds of 348-012002 and the other for 100 pounds of 248-1050. As the technician was processing the samples the shipping labels were attached to the wrong boxes. In essence it is inattention on the part ofthe technician which resulted in these orders being labeled inappropriately.”

49. Next Step………….. • Latent Cause Analysis • “The latent cause was human error, affixing address labels on two orders incorrectly.” • “This is also a procedure short coming. We do not, in detail, define the steps that should be taken by the technician to eliminate the potential for mixing sample orders.”

50. Following Step…... • Corrective Action • “We have met with the technician responsible for sample shipments, we reviewed the incident with the technician. This issue will be discussed with all technicians in the next team meetings.” • “The procedure covering the preparation and shipment of sample orders will be reviewed and updated as necessary to address this type of issue.”