KR Mohan Ananthanarayanan

Vice-chairman, NIQR Trivandrum Branch

Member ASQ
 If I had an hour to solve a
problem I’d spend 55
minutes thinking about
the problem and 5 minutes
thinking about solutions.

Give me six hours to chop

down a tree and I will
spend the first four
sharpening the axe
Background
 Inspection and control versus Prevention

 Increased customer awareness and demands

 Concepts of customer delight more than satisfaction alone

 Principles of Lean management

 Growth of Aerospace and Automobile industries uptrend in the turn of the

century.

 Supply chain environment

 Story on Root Cause Analysis

“Fred” complaining to Ford Headquarters

that his car won’t start whenever he buys
vanilla ice cream
Ford asked Fed to repeat his ice cream visits
but to carefully capture data concerning
time of day, type of gas used, outside
temperature, time it takes to purchase,
flavor selected and whether the car started
or not.
Data provided a clue: It always took Fred
less time to buy vanilla then any other flavor.
Once time became the key variable– not the
flavor of ice cream – the solution became
apparent: vapor lock.
When a car was shut off, it needed time to
cool down before it would restart
Importance of formal Fred got vanilla more quickly, the engine was
recording - Forms still too hot for the vapor lock to dissipate.
SUPPLY CHAIN ENIVRONMENT
Aerospace and Automobile supply chain environment

The need
for in
depth
Root
cause
Analysis

Failure progression

Complex sub-systems in aerospace can have scenario like this –

surprises after delivery and during mission
Problem Solving – Root Cause
Analysis - Models
 Drill Down Technique

 The Four Frame Model

 The Cynefin Framework

 Eight Disciplines of Problem Solving -8D

These methods use tools like 5 why; brain storming,

cause and effect diagram etc
The term ‘drill down’ is frequently used in business to highlight any
process that narrows something down from bigger components into
smaller pieces. That is exactly what is going to happen within
the Drill Down Technique of problem solving –
Moving down layers of data – IT industries
 Four Frame Model –
To understand organizational problems and
change management
Cynefin Framework helps you figure out how you should be thinking
about a problem in the first place. It is more a decision making tool.
Cynefin a Welsh word meaning habitat – from IBM
8 D Model
 The eight disciplines (8D) model is a problem solving approach evolved over the
periods by different techniques like QC circles, 7 steps of solution

 Its purpose is to identify, correct, and eliminate recurring problems, and it is useful
in product and process improvement

 Developed in Ford company and used widely in automotive and aerospace

industries.

 It follows PDCA and is similar to DMAIC

 It is more customer driven than QC circles and provides containment / mitigation

measures.

 It is mandatory to carry out 8D analysis for aerospace as per AS13000 standard.

Aerospace standards – Problem
solving and Resolution
 AS13000: Problem Solving Requirements for Suppliers

 AS13001: Supplier Self Release

 AS13002: Requirements for Developing and Qualifying

Alternate Inspection Frequency Plans

 AS13003: Measurement Systems Analysis Requirements

for the Aero Engine Supply Chain

• AS13004: Process Risk Mitigation – Publication planned

• AS 13005 : Quality Audit Requirements

• AS 13006:Process control
Why 8D
 Chronic process and product problems- Better customer focus – Eg. Tyre
scratches - export products feedback

 Involvement of the concerned to improve the processes. Better

accountability

 Containment before major harm is done. Flow down in supplier chain.

 It is mandatory requirement for aerospace industries as per AS13000

 Helps in benchmarking
Steps in 8D approach
D0 - Prepare for the 8D Process

We call this step D0 because it precedes the formal steps D1–D8. In this
phase, a customer or internal management indicates they have a specific
problem that needs to be addressed.

At this time a quality alert is generated and vigorous containment effort is

started to isolate the problem from the customer(s).

Management will decide whether it is significant enough to launch an 8D

problem-solving team. The 8D effort requires significant time and
resources, management support allocating time, and team authorization,
all of which are essential for the success of the team.
Provide awareness for all concerned.
Steps in 8D approach
 D1- Establish Team- Knowledge of process, function, assessment
 D2 - Define and Describe the Problem- IS/ IS Not, Recurring, Multiple
process
 D3 - Develop interim containment plan; implement and verify interim
actions
 D4 - Define and Verify Root Cause and Escape Point (Why it was not
detected)
 D5 - Choose and Verify Permanent Corrective Actions (PCAs) for Root
Cause and Escape Point
 D6 - Implement and Validate Permanent Corrective Actions (PCAs)
 D7 - Prevent Recurrence
 D8 - Recognize Team and Individual Contributions
Establish the Team
 Establish a small group of people with the process and/or
product knowledge, allocated time, authority, and skill in
the required technical disciplines to solve the problem and
implement corrective actions. Review boards are similar
to this but may not involve the shop floor personnel.

 The group must have a designated Champion and Team

Leader. The group begins the team building process

 Four phases of Team development –

form,norm,storm,perform
Define and Describe the problem
 Is/Is not , recurring, where ,when it occurs – Scope
Is – Is not Analysis – making clear boundaries for the issue
 Who cares about this?
 What will happen if we do nothing about it?
 Do we have the authority to work on this?
 What do I know about this already?
 Do we care about this?
 Will we actually do something about this?
 Whose problem it is not?
 Reporting form for incidents
Define and Describe the problem
 Who? Who is complaining?
 • What? What are they complaining about?
 • When? When did it start?
 • Where? Where is the problem occurring?
 • Why? Why is this problem occurring (an educated
guess)?
 • How? How did this problem occur (an educated guess)?
 • How? How many problems (measurable and magnitude)?

Document the findings in a form

8D details- Containment
 What action can be taken immediately?

 Are we still manufacturing parts with the problem?

 Will the actions that we take cause other problems?

 Written instruction to be issued and verified for implementation of

containment
Every effort is taken to isolate the problem from the customer. It may
involve 100% inspection of the product in house and in the customer’s
warehouse and additional steps in the process to ensure that the
integrity of the product being produced is maintained. It is the team’s
responsibility to review whether the containment action taken already
is appropriate and to modify the action plan if needed
Containment- Band Aid
 Emergency Response Action: (ERA) Actions applied to stop
the internal or external customer from receiving the problem
(i.e. quarantine, tagging, segregating, Call back etc,.) Also
known as Containment.

 Interim Containment Action: (ICA) A temporary solution to

protect the customer from the problem. ICAs usually add cost
to the process (100% inspection, etc.) and is used to "buy time"
until the ROOT CAUSE can be identified and corrected.
 The containment action plan must be documented on the
8D form and reviewed periodically.
8D details- RCA and Escape point
 Is and Is not can be used to eliminate trivial many and to focus
vital few.

 5 why; brainstorming, fish bone, flowcharting etc

 Does it relate to FEMA

 Escape Point: The earliest location in the process, closest to the

root cause, where the problem should have been detected, but
was not. Why it escaped? Understanding and awareness on
operation and inspection
8D -Details
 Isolate and verify the Root Cause by testing each possible
cause against the problem description and test data. Also
isolate and verify the place in the process where the effect of
the Root Cause should have been detected and contained
(Escape Point).

 If the problem is change-induced, the root cause must be the

result of a change relative to one or more of the identified
changes.

 The root cause must explain all known data.

Verification of Root cause
 Once you've determined the most likely cause(s), verify that it
actually causes the problem.

 Passive verification is done by observation

 Active verification is done by manipulating the root cause

variable

 Determine and identify escape point – Operator inspection/ QC

Corrective action
 Choose the corrective action for eliminating the root cause .

 Ensure CA is not creating other undesirable effects.

 Verify implementation of CA and validate

 Prevent Recurrence- Modify the necessary systems including

policies, practices, and procedures to Prevent Recurrence of
this problem and similar ones. Make Recommendations for
systemic improvements as necessary.
Congratulate the team
 Steps for Recognition:

 Select key documents and provide for their retention.

 Review the team's process and document team Lessons Learned.

 Recognize the entire team's collective efforts in solving the problem.

 Mutually recognize all contributions to the problem solving process.

 Celebrate completion.
Case studies
 8d report sample
Points to Remember

 Perfection is a continuous journey. Products and services can

always be improved. If one process has been optimized, others
can be enhanced.

 Change is not always good. Looking for opportunity to make

improvements does not mean looking to change everything.
Think of the reason for change.

 What is adequate today will not be tomorrow. Change never

ceases, especially our industry. Even if we have reached the
top in our field, tomorrow someone will redefine “the top”.
Points to Remember
 What works and what seems logical are different. For each
theory that works, 99 others do not. Ideas deserve to be tested.
They must be before they are accepted.

 Realize that each new idea may create new problems. Watch
for the potential repercussions of each quality improvement
you make. Check your finished product against a list of quality
objectives.
THANK YOU
AS13000: Problem Solving Requirements for Suppliers As previously briefed in
NTS368 & NTS389, AS13000 adopts the eight disciplines (8D) approach that is
widely recognised across industry. It is supported globally through existing
external training and consultancy organisations. SABRe already allows the use
of 8D and a number of suppliers currently use this tool.
AS13001: Supplier Self Release AS13001 was written to standardise the Delegated
Product Release (Self-Release) training requirements that each Original
Equipment Manufacturer requires in order to ship product to the delegating
organisation, without additional oversight by a representative of that
organisation. Prior to AS13001, a supplier would have to attend training from
each delegating organisation in order to be approved to ship products on behalf
of that organisation. With AS13001 a supplier can attend a single training class
conducted by SAE international at an independent location.
AS13002: Requirements for Developing and Qualifying Alternate Inspection
Frequency Plans AS13002 defines requirements for moving from 100%
inspection to a reduced or sample method. AS13002 recognises a number of
possible control methods which are suited to a broad range of manufactured
product: Statistical process control Software numerical Control Die/Mold
and form tool control (including methods for complex structural castings)
Process parameter control
Approaches to problem solving
 Suppliers when they encounter a non-conformity, consult
with the customer who analyse the impact and provide the
actions required to rectify and proceed with production.
Focus is on certain functionality. Many a times the bigger
picture is not seen leading issues later.

During hard Chrome plating of Cylinder– high variation in

thickness is cleared based on available grinding allowance.
Later it is found during grinding that some portions the
plating is fully ground off.

 Suppliers themselves, based on their experience, correct

and proceed
AS13003: Measurement Systems Analysis Requirements for the Aero
Engine Supply Chain As previously briefed in NTS377, AS13003 adopts
best-practice from other industries, including the Automotive Industry
Action Group’s (AIAG) Measurement Systems Analysis Manual, and
describes the acceptance criteria that suppliers are expected to
demonstrate.

AS13004: Process Risk Mitigation This standard is currently in the final

stages of drafting and has been created to establish a common practice
for effective process risk identification, assessment, mitigation and
prevention. It defines a methodology to mitigate risk using process
flow diagrams, Process Failure Mode and Effects Analysis (PFMEA)
and control plans. It is to be used by customers and producers
throughout the life cycle of a product.

AS13006: Process Control This standard is likely to be published in

2017. The use of statistical techniques and other proven methods will
result in improved quality and manufacturing maturity.
Introduction
 Aerospace and Automobile industries concentrate on
prevention of defects to enhance production aiming
right quality ,first time every time.
 In order to achieve this, problems need to be analysed
in depth and solved so that they do not occur again.
 8 Disciplines problem solving is a method applied in
these industries and many others too.
 Supply Chain Challenge

 significant challenge: not just assuring the security and

integrity of the components in the supply chain but, given
the hiatus in space operations, assuring that there is a
viable industrial base at all.
 NASA’s focus has been on creating new tools to assess how
program changes impact the financial liquidity of the
supplier base and map the multi-functional relationships
of the lower-tier suppliers in the supply chain. This
approach helps catalyze a regional innovation cluster
approach to encourage virtual collaboration, advanced
manufacturing, and shared infrastructure in order to
sustain the industrial base for multiple NASA missions.
Problems and its context
 A Non-conformity in system, process or product or a
regulatory requirement is referred to as a problem in
this context.
 All organizations experience unintended variation and
its consequences.
 Recurring problems stand out as “sore thumbs” that
are most in need of prevention efforts and root cause
analysis can be the key.
5 Why?
 Primary Cause: Loss of thrust in one L40

 Why? Turbo pumps stopped -Failure of Gas generator

 Why? High operating pressure and temperature in GG

 Why? Large flow rate of propellants to GG and reduced

cooling

 Why? Regulator hardware malfunction

 Why? Inadvertent error in manufacturing

Brain Storming
 Problem resolution with Participation of all concerned
and out of box thinking

U रे ക