Root Cause Analysis – Digging Deep!

1. Root Cause Analysis – Digging Deep! Tom Land

2. Who is the best manager? A) “I ask ‘why’ five times.” B) “I ask ‘why’ seven times.” C) “I ask ‘why’ nine times.”

3. Two possible root causes BANG!

4. Who is the best manager? A) “I ask ‘why’ five times.” B) “I ask ‘why’ seven times.” C) “I ask ‘why’ nine times.” D) “I ask ‘why’ thirty times.”

5. Root cause, how deep is enough? • Symptom • Why? – Cause • Why? - Deeper Cause • Why? – Deeper Cause • Why? – Deeper Cause • Why? – Deeper Cause • Why? – Deeper Cause • Why? – Deeper Cause • Why? – Deeper Cause • Why? -Big Bang/ Forbidden Fruit

6. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits

7. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching

8. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned

9. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned • Deeper Cause – operator failed to follow instructions “looked clean”

10. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned • Deeper Cause – operator failed to follow instructions “looked clean” • Deeper Cause – insufficient training

11. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned • Deeper Cause – operator failed to follow instructions “looked clean” • Deeper Cause – insufficient training • Deeper Cause – 1st day on job

12. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned • Deeper Cause – operator failed to follow instructions “looked clean” • Deeper Cause – insufficient training • Deeper Cause – 1st day on job • Deeper Cause – supervisor desperate for help

13. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned • Deeper Cause – operator failed to follow instructions “looked clean” • Deeper Cause – insufficient training • Deeper Cause – 1st day on job • Deeper Cause – supervisor desperate for help • Deeper Cause – too much product/too few employees

14. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned • Deeper Cause – operator failed to follow instructions “looked clean” • Deeper Cause – insufficient training • Deeper Cause – 1st day on job • Deeper Cause – supervisor desperate for help • Deeper Cause – too much product/too few employees • Deeper Cause – management trying to run “lean”

15. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned • Deeper Cause – operator failed to follow instructions “looked clean” • Deeper Cause – insufficient training • Deeper Cause – 1st day on job • Deeper Cause – supervisor desperate for help • Deeper Cause – too much product/too few employees • Deeper Cause – management trying to run “lean” • Deeper Cause – profitability pressure

16. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned • Deeper Cause – operator failed to follow instructions “looked clean” • Deeper Cause – insufficient training • Deeper Cause – 1st day on job • Deeper Cause – supervisor desperate for help • Deeper Cause – too much product/too few employees • Deeper Cause – management trying to run “lean” • Deeper Cause – profitability pressure • Deeper Cause – investors want larger return

17. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits • Cause – insufficient rinsing of resist residue before etching • Deeper Cause – machine not sufficiently cleaned • Deeper Cause – operator failed to follow instructions “looked clean” • Deeper Cause – insufficient training • Deeper Cause – 1st day on job • Deeper Cause – supervisor desperate for help • Deeper Cause – too much product/too few employees • Deeper Cause – management trying to run “lean” • Deeper Cause – profitability pressure • Deeper Cause – investors want larger return • Root Cause – Big Bang/Forbidden Fruit

18. Root Cause vs. Actionable Cause • Can I turn the problem on/off or up/down? – YES • Is the solution less expensive than the problem? – YES • Is this the deepest actionable cause? - YES

19. Root Cause Analysis - Short on a Circuit Board • Symptom – extraneous copper between circuits – No, No, No • Cause – insufficient rinsing of resist residue before etching – Yes, No, No • Deeper Cause – resist remover not sufficiently cleaned - Yes, Yes, No • Deeper Cause – operator failed to follow instructions - Yes, Yes, No • Deeper Cause – insufficient training – Yes, Yes, Yes • Deeper Cause – 1st day on job – NOT ACTIONABLE! • Deeper Cause – supervisor desperate for help • Deeper Cause – too much product/too few employees • Deeper Cause – management trying to run “lean” • Deeper Cause – profitability pressure • Deeper Cause – investors want larger return • …. Root Cause: Big Bang/Forbidden Fruit • a) On/Off or Up/Down -YES b) Cost OK – YES c) Deepest Actionable - YES

20. Difficulty entering road from my house to highway • 1) Why?: Increased traffic on that road • 2) Why?: Several new subdivisions that funnel onto the road • 3) Why?: Many people want to buy houses there • 4) Why?: Better house for money than elsewhere • 5) Why?: Market driven economy • 6) Why? Capitalist economy • 7) Why? Communism doesn’t work • 8) Why? Goes against human nature • 9) Why? Big Bang/Forbidden Fruit

21. DMAIC Process • Define • Measure symptoms • Analyze • Create Theories of “root” cause • Test Theories of “root” cause • Improve – Remedy the “root” cause • Control – Standardize the remedy

22. DMAIC Process • Define – Extraneous copper causing shorts • Measure symptoms – was 1.0% now is 5.0% • Analyze – insufficient cleaning by new operator • Improve – thoroughly clean machine • Control – change training instructions for new & experienced operators

23. Chronic Problems Too many shorts on circuit boards It takes too long to get to work Fiber breaks too much Shipping performance too low Sporadic Problems More shorts than there used to be Takes longer to get to work than before Increase in fiber break rate Shipping performance getting worse Sporadic vs. Chronic Problems

24. Define Current commute requires more than 50 minutes ~50% of the time. This is longer than the goal of less than 50 minutes 97% of the time.

25. Pareto Chart

26. Measure

27. Analysis – Theory CreationSymptom: It takes too long to get to work • Why? – too much traffic • Why? – too many others going at same time • Why? – most businesses on similar schedule • Why? – use traditional stop/start times • Why? – daylight requirement before electricity • Why? – planet rotates every 24 hrs

28. Symptom: It takes too long to get to work • Why? – too much traffic NOT ACTIONABLE • Why? – too many others going at same timeACTIONABLE • Why? – most businesses on similar scheduleACTIONABLE • Why? – use traditional stop/start timesACTIONABLE • Why? – daylight requirement before electricity NOT ACTIONABLE • Why? – planet rotates every 24 hrs NOT ACTIONABLE

29. Symptom: It takes too long to get to work • Why? – too much traffic – NOT ACTIONABLE • Why? – bottleneck at key intersection –ACTIONABLE • Why? – design error 20 years ago – NOT ACTIONABLE • Why? – forecast of population growth too low – NOT ACTIONABLE • Why? – forecaster failed to predict future – NOT ACTIONABLE • Why? – forecaster not omnipotent – NOT ACTIONABLE • Why? – forecaster is human – NOT ACTIONABLE • Why? – no plant/animal/divinity available – NOT ACTIONABLE • Why? -

30. Symptom: It takes too long to get to work • Why? – live too far away -ACTIONABLE • Why? – better schools near home- NOT ACTIONABLE • Why? – better funding – NOT ACTIONABLE • Why? – parents in that area wealthier – NOT ACTIONABLE • Why? – capitalist economy – NOT ACTIONABLE • Why? – communism yet to work anywhere – NOT ACTIONABLE • Why? – goes against human nature – NOT ACTIONABLE • Why?

31. Drill Down on multiple causes Commute too long Too much traffic No alternative means Others at same time bottlenecks Live too far No public means Many Businesses- similar schedules Design error Better schools Most people Going another way Wrong forecast Traditional times More funding Fail to predict future Daylight Requirement (historical) Live near me Work elsewhere Work near me Live elsewhere Wealthier parents Not omnipotent Capitalist economy More jobs downtown Less expensive housing Human error Planet’s rotation Failures of communism Divinity not available More difficult To get downtown City began there Human nature Fewer roads Railroad yard location Less clout in legislature

32. What are the odds of striking it rich?

33. Brainstormed Theories people material environment cost schools Wrong turn Too far away Cell phone CD/radio pedestrians Synthetic oil bottlenecks scenery Time of day wrecks School buses 87 octane gas distractions Too much traffic Too long to work Not using alternatives Clock too slow Slow car Inaccurate start time breakdowns bicycle helicopter Inaccurate finish time Bus/train walk battery Flat tire danger Too far methods measures machines

34. After collective judgment process environment cost schools Too far away bottlenecks Time of day wrecks Too much traffic Too long to work Not using alternatives bicycle helicopter Bus/train walk danger Too far methods

35. Theory Testing Proposal – What’s Wrong with This? • Too far – Move, measure time from new house • Schools • Cost • Too much traffic – Purchase M1 tank, plow through traffic, measure time • Time of Day • Bottlenecks • Wrecks • Not using alternatives • Walk – start off on foot (18 miles), measure time • Bike – hop on bike, ride 18 miles in metro Atlanta, measure time • Bus/Train – hop on train..see if goes near office, measure time • Helicopter – purchase helicopter and fly to office, measure time

36. Theory Testing • Too far – leave early, drive there, wait a while, drive to work • Schools - research • Cost - research • Too much traffic – • Time of Day – leave early • Bottlenecks – try another route • Wrecks – record elapsed time each day and wreck/no wreck • No alternatives • Walk – 18 miles, divide by 4 miles/hr – 4.5 hours • Bike – no bike lanes, big hills, out of shape • Bus/Train – Office inconvenient to train, research schedules • Helicopter – no place to land it near office, no license

37. Use of Locational Data <$300k 2 $300k-$400k $400k-$500k house $500k+ work 1 3

38. Time-To-Time Analysis

39. Use of Flowcharting Route “A” Leave Neigh- borhood (2 min) Stop light (2 min) Wait to Merge (7 min) Drive to US78 (3 min) Drive to I-285 (5 min) Drive to I-85 (6 min) Stop light (4 min) Grind way across Peachtree (6 min) Park (1 min) Wait to Merge (5 min) Drive to I-75 Merge (2 min) Wait to Merge (5 min) Wait to Merge (8 min) Drive to 10th St (5 min) Drive to 400 Merge (10 min)

40. Stream-to-Stream Analysis-Time to Work

41. Use of Flowcharting Leave Neigh- borhood (2 min) Stop light (2 min) Wait to Merge (7 min) Drive to US78 (3 min) Drive to I-285 (5 min) Drive to I-85 (6 min) Route “D” N. Druid (20 min) Route “B” Ponce (30 min) Stop light (4 min) Grind way Across Peachtree (6 min) Park (1 min) Route “C” Claremont Rd (25 min) Wait to Merge (5 min) Drive to I-75 Merge (2 min) Wait to Merge (5 min) Wait to Merge (8 min) Drive to 10th St (5 min) Drive to 400 Merge (10 min)

42. Theory Testing • Too far – leave early, drive there, wait a while, drive to work • 3 areas where schools OK & can afford house • area 1: 40 min, area 2: 45 min, area 3: 85 min • Too much traffic – • Time of Day (Route A) – 5:00-6:00 takes 30 min, 6:30 takes 40 min, 7:00-8:30 50 min, 9:00+ 30 min • Bottlenecks – (at 7:30) route B: 40 min, route C: 60 min, route D: 55 min • Wrecks – Days with wrecks (route A): 85 min, 65 min, no wrecks other days • No alternatives • Bus/Train – MARTA estimates 75 min via train&bus after 30 min drive to rail station

43. 42 3.5 0 53 5.8 0 42 3.5 1 48 4.5 0 39 4.0 1 38 3.0 0 40 3.4 0 39 3.3 0 mean St dev wrecks Route B Route A 7:00 6:45 7:15 6:30

44. Can We Answer Yes to the Three Questions? • Can I turn the problem on/off or up/down? - Yes • Yes mean = 53 min with standard route and time • Mean = ~40 min by moving or by adjusting time or route • Is this the solution less expensive than the problem? • Is this the deepest actionable cause? - Yes • Live too far – better schools, better funding, capitalist economy, human nature • Time of Day – traditional hours, daylight (before electricity), rotation of the planet • Bottlenecks – design error, wrong forecast, human error (in the distant past)

45. Save 11 min/day @ $25/hr = $1100/yr

46. Summary of Tested Theories

47. Remeasure Symptoms

48. DMAIC Process • Define – Takes too long to get to work • Measure symptoms – longer than 50 min half the time • Analyze – bottlenecks on primary route 7:00 and 8:30 • Improve – travel on alternate route during that timeslot • Control – leave a reminder on steering wheel I don’t need to know why there are bottlenecks. I just need to avoid them!

49. Have I dug down far enough? • Do I know root cause? – NO • Can I turn the problem on/off or up/down? – YES • Is the solution less expensive than the problem? – YES • Is this the deepest actionable cause? - YES

50. Theory Testing Techniques- ref: Juran’s Quality Handbook • Pareto • Flowcharting • Process Capability Analysis • Design of Experiment (DOE) • Math/Science/Logic/Research • Locational analysis • Multi-vari charts – Is variation • Within piece? • Piece to piece? • Time to time within shift? • Between shifts? • Process Dissection • Test at intermediate steps • Stream-to-stream analysis (look for immunities-full or partial) • Time-to-time analysis • Cutting New Windows