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Corrective Action Problem Solving John DeGiovanni Quality Leadership Forum Johnson Space Center

Corrective Action Problem Solving John DeGiovanni Quality Leadership Forum Johnson Space Center Sept 25, 2002. Quality Director Space Shuttle Main Engine Program Boeing Canoga Park. The Purpose of Corrective Action?. ?. Improving Product Decreasing Cost Improving Delivery

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Corrective Action Problem Solving John DeGiovanni Quality Leadership Forum Johnson Space Center

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  1. Corrective Action Problem Solving John DeGiovanni Quality Leadership Forum Johnson Space Center Sept 25, 2002 Quality Director Space Shuttle Main Engine Program Boeing Canoga Park

  2. The Purpose of Corrective Action? ? • Improving Product • Decreasing Cost • Improving Delivery • Adding Value Learning to Treat Corrective Action as a Business Case

  3. Weighing the Factors… Considerations • Timeliness • Depth • Generic Implications • Effectiveness • Interrelationship of Causes & Effects • Consistency • Problem Solving Tool Selection NASA Code Q Suggestion to Try New Problem Solving Tool

  4. Every Toolbox has a First Tool The Problem Solving Tool • Checklist-oriented • Developed by Government and Industry • System / Process Structured 22 Categories Failure Codes Possibilities

  5. The Problem Solving Tool Sample Page

  6. Application & Evaluation Application • Problem Solving Tool Applied to Over 20 SSME Corrective Actions • Assessed for: • Usefulness • Accuracy • Timeliness • Integration Ability • Direction

  7. 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 Pros Cons

  8. 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

  9. The Corrective Action Toolbox 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” Developing Our Corrective Action Toolbox

  10. Cause Chain Value Line “The Theory” Cause Chain Designed To: Value Form Team Facts Root Cause Value Immediate Cause Relationship Action Plan Tasks

  11. Cause Chain 101 Analysis “Value Line Biorhythm” Trouble Signs: 3 cause chain meetings Protests on cause Refuse to attend Push to a CAB deadline Problem weeks old - no action Value “Value” Changes Over Time, Given Certain Events

  12. Environment Hardware “Product” Software “Tools” Liveware “People” Corrective Action Factors • Outcomes depend on: • Mindsets • Priorities • Values • Knowledge • Issues Environment is Critical… Interrelationships Create the Corrective Action Results

  13. What Is Necessary for Better CA? Excellent C&CA effort Existing undesirable effects requiring C&CA effort Team wants to do it Team understands what to do Team is capable of doing it Team knows how to do it No obstacles interfere • Priorities • Schedule • Budget • Mind sets Tools Environment C & CA Network Logic Diagram

  14. How Should the Tool Help? • 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

  15. More Complex Cases Medium Complexity Cases Fairly Simple Cases Does One Size Fit All? Events Existing Tools • 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

  16. 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 Apollo Root Cause Analysis) “ Only 2 or 3 out of 10 People Can Apply the Logic Effectively”

  17. Group Interaction (Exercise) Possible Environment Modifying Actions Environment Challenges 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”

  18. 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 Environment

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