3x5 Why-why Analysis
- A new approach for root cause analysis
1st Supplier Quality Day * 27NOV09 ST Shenzhen Plant
3x5 Why Why Analysis Content
A. B. C. D.
The 3x5 Why Project Background The 3x5 Why Method The 3 x 5Why Focus Templates
ST target is to share with our suppliers a common approach for problem solving methods especially for 3x5 Why why tool , to get complete, exhaustive FA report and to avoid any recurrence.
Naze-Naze / 3x5Why-Analysis Project Background
A. The Naze-Naze Project Background
* Naze = Why in Japanese
Naze-Naze / 3x5Why-Analysis Project Background The Situation
[Link] Need of our Customers * To understand each 8D-Report from semiconductor and passive suppliers in depth * To understand if the problems are solved in a way that they never reoccur
Remark: Having reached ppm-level, our customer fails enable ST and their customers / suppliers to look at each 8D-Report in depth.
2. Improvement of 8D-Quality by Why-Why-RCA (Root Cause Analysis) In 2009, ST takes the next step and has started a project with our key suppliers. Focus on: * Implementing Why-Why-Analysis for non-conformance and non-detection aspects including system root causes * Getting a common understanding of a sustainable problem solving process * Having a comprehensive documentation of each failure which is understandable on a general technical knowledge level for our customers & management.
Hint: This project is part of the 8D improvement initiative which is measured acc. Toyota scoring methodology
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Naze-Naze / 3x5Why-Analysis Project Background Motivation
ST is the Top 3 automotive electronics supplier. All automotive customer request is ZERO FAILURE However, ST devices didnt reach the target : some failure were reoccurrences, special caused by quality excursions material. quality level is improving very slowly. requires systematic application of lessons learned prerequisite: full understanding of real root causes (technical and non-technical)
there is a strong need for persistent improvement
=> method: 5 why analysis (naze naze), from Toyota
Naze-Naze / 3x5Why-Analysis Project Background Role of Naze-Naze Champions
Internal and Suppliers 5Why-Champion Name: - Reviewed and Agreed by STM management Task: - Leading of internal 5Why project, roll-out to all divisions and plants, Develop to all key suppliers. - Encourage and support 8D-Engineers in applying the 5Why problem solving method - Assure that technical & systemic root cause is analyzed and eliminated for prevent and escape aspect=> avoidance of recurrence. - To be trained and evaluated by ST QA. - Involving management team into Naze-Naze Method.
B. The Naze-Naze Method
Naze-Naze / 5Why-Analysis Method
Historical Background
Although the 5-Why problem solving technique has been popularized by the Japanese, this common-sense concept has been around for quite some time. For want of a nail a shoe (hoof) was lost, for want of a shoe a horse was lost, for want of a horse a rider was lost, for want of a rider an army was lost, for want of an army a battle was lost, for want of a battle the war was lost, for want of the war the kingdom was lost, and all for the want of a little horseshoe nail.
John Gowers <Confessio Amantis> dated approximately 1390 AD. The earliest known written version of the rhyme above (often taught to British children)
Naze-Naze / 5Why-Analysis Method
Historical Background (cont.)
One of Ohnos habits was to repeat asking 1. why the problem happened 2. why the problem was not prevented -whywhy-why-why.. until the real root cause was found. This habit has been preached to overseas transplants of Toyota. All Toyota employees are trained through their daily jobs to find out problems, root causes, countermeasures in this way. His habit became a Toyotas culture. This culture is one of the keys of Toyotas success today, that is realized by enthusiastic problem finding skill of every employee.
Ohno ([Link] Taiichi Ohno (1912-1990) Former executive vice president of Toyota who established Toyota-ProductionSystem, which is known by Kanban. His philosophy is still alive in today's Toyota way.
"Ask why five times about every matter."
1. "Why did the robot stop?" The circuit has overloaded, causing a fuse to blow. 2. "Why is the circuit overloaded?" There was insufficient lubrication on the bearings, so they locked up. 3. "Why was there insufficient lubrication on the bearings?" The oil pump on the robot is not circulating sufficient oil. 4. "Why is the pump not circulating sufficient oil?" The pump intake is clogged with metal shavings. 5. "Why is the intake clogged with metal shavings?" Because there is no filter on the pump.
Link to the information source: [Link] [Link]
Having no problems is the biggest problem of all
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Naze-Naze /5Why-Analysis Method
Purpose of Naze Naze Analysis (5 x Why) Question: How are you sure that your Naze-Naze Analysis is performed properly? Answer: When real root causes are identified, there should be no reoccurrence of failures! The purpose of Naze-Naze Analysis: To prevent reoccurrence of failures by implementing correct countermeasures on real root causes
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Naze-Naze / 5Why-Analysis Method
What does Problem mean?
Problem is defined as a gap between the way it should be and the way it is.
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Naze-Naze / 5Why-Analysis Method
Problem description First step of problem solving!
If a problem is described wrongly, the result of problem solving will be also wrong. Example of wrong description
This is not a joke! Real example from a workshop with engineering colleagues
Customer give us feedback very late when a delivered sample was out of spec., and we can not make improvement timely.
An out-of-spec. sample was produced and delivered to customer.
Then, describe standard and actual in comparison
Think from customers view
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Naze-Naze / 5Why-Analysis Method
Basics of Naze-Naze Analysis
What to do Analyze with GENCHI-GENBUTSU
1. Organize & narrow down the problem A complex problem 2. Localize the problem Perform GENCHI-GENBUTSU 3. Evaluate the situation of occurrence plural individual problems
Grasp the situation Pursue root causes Implement effective C/M
Why to do
Grasp the pattern
Fix the real root cause and never let it reoccur
1. Shift from reactive firefighting to preventive countermeasure
C/M to prevent a reoccurrence
Firefighting will result in reoccurrence 2. Master the key points of Naze-Naze to pursue real root causes Grasp every factor of the failure regularly, orderly
No reoccurrence should happen when the real root cause is fixed
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Naze-Naze / 5Why-Analysis Method
Grasp the situation accurately Shortcut to real root causes!
Initial Problem Perception (large, vague or unclear) Clarify the problem Locate the Point of cause
Preparation for 5 x Why
3 elements to grasp the situation Organize and narrow down the problem Localize the problem Evaluate the situation, how the problem happened
Locate the Point of cause
to clarify what when where who how in GENCHI GENBUTSU
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Naze-Naze / 5Why-Analysis Method
GRASP THE SITUATION
Initial Problem Perception (large, vague or unclear)
1 2 2 3
5 x Why is a key step in the problem solving
Clarify the problem Locate the Point of cause
Point of cause
Basic Cause/Effect Investigation
Direct Cause
4 5 6
5 Why investigation
Root Cause Countermeasure Follow Up and Check
Source: TMUK PPS
CAUSE INVESTIGATION
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Naze-Naze / 5Why-Analysis Method
Grasp the situation accurately 1. Organize and narrow down the problem
Often a detected failure is a combination of complex problems Example Contamination on a product
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Naze-Naze / 5Why-Analysis Method
Grasp the situation accurately 2. Localize the problem
Go back the processes from where the problem was detected Example Iron ball particle on a product
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Naze-Naze / 5Why-Analysis Method
Grasp the situation accurately Localize the problem in the history
If different direct causes were set in different timing or many persons were involved, list up all the events chronologically with evidences.
Evaluate each action if it was correct or not. Email, letter, documents, etc
Example
ple rt m Exa y cha r sto Hi
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Naze-Naze / 5Why-Analysis Method
Grasp the situation accurately 3. Evaluate the situation, how the problem happened
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Naze-Naze / 5Why-Analysis Method
Fact analysis find important factors Compare no problem time and problem time If not yet clarified, use Ishikawa diagram Always consider with 5M1E
5M1E Man Machine Material Method Measurement Environment
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Naze-Naze / 5Why-Analysis Method
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Naze-Naze / 5Why-Analysis Method
For your successful Naze-Naze analysis
Understand the function and construction of the object well
Product: understand the function and construction with parts, drawings, etc Management: confirm the process and function with working process flow, rules, documents, etc Search in two dimensions of Produced and Delivered Non-conformance Non-detection
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Naze-Naze / 5Why-Analysis Method
Drill for important factors deeper with Naze-Naze analysis
Do not jump immediately to investigate countermeasures. Do Naze-Naze analysis to search real root causes.
Direct Cause 5 Why Investigation
Root Cause
Repeat asking why at least 5 times. However this does not mean to repeat asking meaninglessly why just 5 times, but to find the real root causes.
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Naze-Naze / 5Why-Analysis Method
Difference between containment and preventive measures Example Machine stop
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Naze-Naze / 5Why-Analysis Method
Difference between Technical and System root cause Example Machine stop
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Naze-Naze / 5Why-Analysis Method
Example entered into excel-template
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Naze-Naze / 5Why-Analysis Method
How Yokoten works in Toyota
*Depending on the severity, escalation level is decided.
Horizontal Deployment
C/M should be implemented not only in technical aspect, but also system aspect**.
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Naze-Naze / 5Why-Analysis Method
Key Points
Define 1st Why from principle Describe only things differing from normal state Verify the hypothesis as soon as a hypothesis is made Do not diffuse the problem (avoid subjective issues) Avoid searching for causes under psychological ( )aspects Describe simply (not two facts in one sentence) Avoid ambiguity (unclear expression like bad or insufficient) Clarify the comparative object when an adjective is used Repeat why until a cause which can lead to a preventive countermeasure is found to avoid a reoccurrence Read backwards and confirm if Naze-Naze story is correct
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Naze-Naze / 5Why-Analysis Method
Define 1st Why from principle Principle: something very basic Focus on the problem phenomenon and define 1st Why upon the principle of the problem Problem 1st Why 2nd Why
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Naze-Naze / 5Why-Analysis Method
Thoroughly Pre-Investigation first
These 2 causes are to be found through thoroughly pre investigation. They are not necessarily part of 5Why.
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Naze-Naze / 5Why-Analysis Method
Describe only things differing from normal state
< Bad example > Dust level increased in clean room Machines are operated with full capacity Production volume is big
Machines create dust
Demand increased
No business can be continued with this root cause !
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Naze-Naze / 5Why-Analysis Method
Verify the hypothesis as soon as a hypothesis is made
Verify the hypothesis immediately if possible, even during NazeNaze analysis. Verify by facts based on: SANGEN-SHUGI (Genba , Genbutsu Genjitsu interview, reproduction test, etc , ), Principle of the three Gens real place, real thing and reality.
Two methodologies:
my eyes and my legs.
These are all I need to see, to judge, to consider, to decide.
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Naze-Naze / 5Why-Analysis Method
Do not diffuse the problem
< Bad example >
Motor overheate d Insufficient lubricant The story was diffused due to missing description of what insufficient is Lubricant forgotten Insufficient maintenance managemen t Avoid subjective issues, i.e. Bad example personal skills Manager does not know GENBA Wrong manager at the post
Avoid searching for causes under psychological aspects
It is difficult to make effective countermeasures against mental < aspects to prevent reoccurrence Bad example >
Why
Mr.A got his head injured Mr.A hit his head at the edge of the ceiling
Why
Mr.A did not pay attention
Why
Mr.A was careless
C/M
Be careful when walking
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Naze-Naze / 5Why-Analysis Method
Describe simply
+ when, where, how, etc
Describe simply with subject + verb
Do not describe two facts in one sentence
risk to miss other causes) < Bad example >
Only 1 subject in one sentence
Be careful with and, or, therefore, because, thus
The battery has not been replaced for long time and the pointer cannot be turned on.
Separate into 2 sentences
The battery has not been replaced for long time
Problem
The pointer cannot be turned on
The pointer cannot be turned on Problem
The battery has run down The battery has run down The spring lost contact with the bulb
More potential causes are successfully found!
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Naze-Naze / 5Why-Analysis Method
Avoid ambiguity
Describe concretely
Examples of inappropriate texts (to be avoided) XX is bad XX is insufficient XX shortage XX not thoroughly done
Operator not enough experienced
Operator did not remember the changeover procedure
Describe concretely
Operator did not know where the stop switch located Inexperienced operator was disposed at this process
Clarify the comparative object when an adjective is used
XX is too big for YY XX is bigger than YY XX is longer than YY
The bolt diameter is big
X
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Bolt diameter is too big for the hole diameter The hole diameter is too small for the bolt diameter
Naze-Naze / 5Why-Analysis Method
Repeat why until a cause which can lead to a preventive countermeasure is found to avoid reoccurrence
A containment measure cannot prevent a reoccurrence. See Page 4Considering the daily operation, stop why when a preventive measure which we can maintain is found.
Read backward and confirm if Naze-Naze story is correct
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Naze-Naze / 5Why-Analysis Method
Practical hints for your problem solving workshop*
Team member selections: Expert team + the persons who were directly involved in the problem. This is not to punish the individual faults, but is to perform grasp the situation with facts. Manager Question technique: During grasp the situation, avoid questioning based on assumptions and concentrate on gathering facts. Otherwise this might guide the team into a wrong direction. Managers attitude: Think about why the problem was not predicted nor discovered by manager. Is there anything to improve?
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Naze-Naze / 5Why-Analysis Method
Last but not least:
It is necessary to keep on learning in your daily work in order to improve your Naze-Naze skills.
Is it a reoccurrence? Product B was mixed in product A After a measure was implemented Product C was mixed in product A
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Naze-Naze / 5Why-Analysis Method
Practical hints for successful Yokoten*
For a successful Yokoten, the key point is in receiver side. If the product or process is different, it is easy to excuse not applicable. Instead of saying not applicable quickly, think how the Yokoten case can be interpreted to your own processes. Every case is an opportunity of On the Job Training.
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Naze-Naze / 5Why-Analysis Method
Before you sign on a problem solving report:
Go back with therefore
Is 5 x Why logically done till system aspect? Are you convinced that the problem will not happen again? Is the report easy-to-understand from customers view? Can you present it to your customer?
Mindset of coach
The reason that students (my colleagues) are not learning is because the teacher (I) is not teaching.
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C. The 3 x 5Why-Focus
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Naze-Naze / 3x5Why-Analysis Focus
What is the 3x5Why-Root Cause Analysis? General:
The 5-Why Root Cause Analysis technique is a practical and proven tool for elimination of root causes. Failing to address the deeply rooted seed of the problem means it will likely recur.
The Method:
The problem-solver simply asks a Why-question approximately five times in series to analyze a certain aspect.
Because Why
Through the 3x5Why-method the root cause can be discovered 1. 2. 3. in the Manufacturing process to PREVENT failures (non-conformance) in the Quality test inspection process, in order to PROTECT the customer from test escapes (non-detection), and to identify/PREDICT weaknesses in the (Quality) Management or System, in order to exclude recurrence (-> learning organization towards zero defect).
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Naze-Naze / 3x5Why-Analysis Focus
Avoid this Pattern
The following sequence of Questions should not be followed:
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Naze-Naze / 3x5Why-Analysis Focus
Basic Solution Pattern
The following sequence of Questions is recommended:
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Naze-Naze / 3x5Why-Analysis Focus
Identification of System-Rootcause
Purpose of 5Why-Analysis: Identification of the individual (1) Technical and (2) System Root Cause Drill Deep
Definition System Root Cause: Organizational causes, that lead to a deviation. Example: Missing work flows, unclear descriptions and/or responsibilities not defined Solution or definition of measures is up to the management System Root Cause Recommendation: In the Fishbone-branch for methods organizational weaknesses can be considered.
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Naze-Naze / 3x5Why-Analysis Focus
Summary Why-Why Analysis
Ask for system root causes for each technical root cause
non-detection: same as above!
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D. Templates
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Naze-Naze / 3x5Why-Analysis Template Naze-Naze / 5Why-Basic Word-Template
Corrective Action with Responsibility 1 x 5Why : Define Problem NONCONFORMANCE (PREVENT) ASPECT: Use this path for the specific nonconformance being investigated A Date
[Link]
2 x 5Why :
[Link]
C1 3 x 5Why : C2
[Link]
[Link]
WHY?
NON-DETECTION (PROTECT) ASPECT: Use this path to Investigate why the problem was not detected
WHY?
Technical Root Causes
System Root Causes
PREDICT ASPECT : Use these fields to investigate the systemic root cause
WHY?
WHY?
WHY?
WHY?
WHY?
WHY?
WHY?
C1
The template (word
Ref. No. (RMA, DMR, etc)
or excel file) can be used as a Date
[Link] summary sheet for root cause investigation. Product / Process Location Content Latest Rev Date
WHY?
WHY?
It is not mandatory City/ Country exactly to use Electrical component [Link]
WHY?
Communicate this form, but Resolution Complete be a helpProcess Changeto Customer Date: [Link] it might in tracing Date: [Link] back Break Point Problem Implement System Change Date: [Link]
C2
Lessons Learned: the systemic root cause for both aspects,
non-conformance and non-detection.
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Naze-Naze / 3x5Why-Analysis Template
Define Problem:
Result Investigation Report:
TECHNICAL ROOT-CAUSE
SYSTEM ROOT-CAUSE
SYSTEM-ROOT CAUSE (PREDICT)
NON-CONFORMANCE (PREVENT): Use this path for the specific non-conformance b eing invested Use these fields to investigate the systemic or Management-Root Cause
...
Why? Why? Why? Why? Why?
NON-DETECTION (PROTECT): Use this path to investigate why the prob lem was not detected
xce E
tem l
late p
Why?
Why?
Why?
Why?
Why?
Why?
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Naze-Naze / 3x5Why-Analysis Template Example: Processability due to bad solderability
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Naze-Naze / 3x5Why-Analysis Template Example: Weak Processability due to bad solderability (cont.)
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Naze-Naze / 3x5Why-Analysis
Thank you for your time.
Questions / Feedback: Mail to: [Link]@[Link] [Link]@[Link] [Link]@[Link] [Link]@[Link]
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