Archives for category: Root Cause Analysis

My family and I love to go fishing. Most of our weekends are spent fishing somewhere as well as our vacations. We normally go for whatever is available in the ocean, lake or river. Sometimes bass, sometimes walleye or trout or blue fish. We do catch and release fishing so others can enjoy the experience as well. I get several people offering me new techniques and lures to catch the big one. I just like fishing but I do try some of the lures. Below is an image of some of the different types lures.

Frogs for lily pads. Crank baits, spinner baits, rooster tails, shad raps which are not pictured below and others that are used in specific conditions. It is amazing how many options there are. And this is just for bass let alone saltwater blue fish or drum or any other species. With these lures comes the technique to use them. Some you just crank them in, some you just float and have them “hop” on the top of the water, some you let them sink and crank a turn and then repeat. Are these techniques and lures statistically significant in catching fish? I don’t know but I am working with others on that question. One thing I do know is that it gets you into the store and gives you options on the water when what you are currently using is not working.

Bass Fishing Lures

 

Then there is catfish. I am sure there is just as much variation and subtleties to catfish fishing as there is to bass or any other species. What I will say, in my families experience, is that a bass hook, a 1/2 to 1 ounce sinker and a hot dog will bust you some serious hogs!

Hot Dogs

We have caught catfish in several lakes and ponds with this “rig” and have never needed to go back to the bait tackle store for something else. We just go to the local grocery store and buy the doggers. We usually by double so that we can eat some over the fire after the fishing day is done.

I have friends and family that have been fishing for decades longer than I have and have all the experience needed to bring in what ever fish they want to catch. What I find interesting is that when someone gives me the inside scoop on a lure / technique combination and they give me some bright lure with an instruction manual ala Ikea, I feel funny handing over an 8 pack of Ball Park Franks and telling them just drop them on the bottom and relax until they hit. But whether they are impressed or not, it works. That’s what I find sometimes when I am working on a project that I could have some great tools that wows the crowd during a presentation and show them how smart the team is but I would rather just show them how easy it can be to accomplish their goals. Sometimes it takes ANOVA analysis to get to the bottom of an issue. Sometimes it takes going out into the field and watching the process and giving some suggestions or using what the employee feels as pain points to resolve and issue. Just because you have the statistical hammer doesn’t mean everything has to be a complicated nail.

 

 

 

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From time to time I have worked with companies that bring in a team to work at a site and fix a process or productivity or just improve the performance. What I have found is that we rarely have the right team assembled. They have individuals with experience with the process and the company as well as solid knowledge of processes, management, and engineering. All good but not enough.

When going into a site to better understand and fix major issues, the first individuals to show up should be HR not Process engineers. This is because 80% of the time, the leadership has issues and engineers or continuous improvement professionals do not have the skill set to deal with these issues nor do they have the authority. This is first. The HR audit should drive the next step.

Step 2 is engineering. This is to ensure that the equipment and processes can perform what is being asked of the site. Engineering should be used to protect / improve the plant for the future. Even if this is their main role, there are still limits to what the engineering team can do in real time. This review of the site can determine what is possible, what is out of the site’s hands and what resources are needed if there is a gap.

The final step is bringing in the CI / process improvement team. From HR and Engineering perspective it will be very clear the role of the CI team, the scope and timing of the project and the goal of the intervention.

Though, I showed this sequentially, this could happen simultaneously. One other item that I did not mention is related to the corporate leadership that is bringing the team in. they have to be open to any direction that improves the overall performance and no pre-conceived notions about what is wrong and how to fix it. I have had teams that were undermined by a leadership that already had the answer or was unable to remove themselves from the root causes and solutions to the problems at the site.

The team approach to improve a site or process is definitely the way to go as long as it is the right time focused on the right issues with the freedom to fix and perform their role.

On a previous post, I mentioned that I couldn’t find a situation that Continuous Improvement didn’t help but I looked back at some of my notes from other companies and sites and did come up with one area where CI has limited impact. This is when there is a dysfunctional team running a site or process. I have run into these environments a few times and I think I need to be more specific when I mention a dysfunctional team. This is related to trust, leadership and ownership.

A trust issue is when process / site leadership does not trust the front employees or vice versa. This environment creates inefficiencies due to Auditing for “wrong” behavior, Stand up meetings turning to blame games and holding things back for both parties. I have seen this in union, non-union and “High Performance Work Teams” as well. This also turns supervisors and the middle team into a confused mess and ultimately short term employees

Leadership means that one will lead the team. The whole team. All the time. I have found the biggest issues around this are when the site / process leadership start thinking they are CEO’s instead of team leaders. This can be witnessed when leaders are in their offices instead of the processes. Meetings in conference rooms instead of production floors. Talk about why we can’t get something done instead of what can be done. It is subtle and sometimes needs outsiders to see how bad it is.

Ownership is that the team is together and knows that the team determines the results. The term team isn’t leadership or supervision or front line. It is and. This means the blame is shared just as much as the glory. It is recognizing individuals and turning that performance into subprocesses so that everyone can be a hero. It stops the excuses and supports standard work. If Tony fails, we all fail. It is the responsibility to state that Tony and John and Jenny all work together to find the one best way and they all do it the same way – Their way. Not managements way, not Tony’s way, the way.

In these type of environments, CI work can be very challenging and the basic ideas of 5S and standard work don’t have a foundation to work from. When I have been confronted with this type of environment my recommendation is to step back and reassess what the site or process really needs. That can be hard because it may be as simple as a mirror.

“The Line always goes down at the X!”. Fill in the blank. How often do you hear this? That the piece of equipment that goes down on a line or in a process is blamed for the downtime or quality issue. This can sometimes turn into a belief or perception instead of actual information. The equipment is a piece of junk or we have a rebuild coming up or its always been this way are some comments I have heard. What I find interesting is that some organizations at one time or another think this is okay or that this response will satisfy customer demand, employees frustrations or shareholders needs for returns.

I look back at my career and wonder if I have had the reaction to things. I probably have, though I can’t think of it. I am the kind of person that focuses on a few items and then I don’t even look at anything else. I have multiple blind spots and maybe that is why I don’t have too many memories of this type of issue. My real concern is how do we get root cause and deeper thought at the level of manifestation to drive to causation and countermeasure. How do we get this type of analysis of the situation at the very level of incident?

What if we give employees the basic knowledge of their job and then 3 more actions:

  1. If your work becomes harder, notice it
  2. Look where the issue is occurring
  3. Is the problem before or during the process

With these actions, they will at least be able to find out if the issue is internal or external to the process. From that, the lead should be able to do the same 3 steps at their level.

This should at least start the conversation on causation.

Examples:

Waitress at a restaurant notices that the meals are coming out late and the customers are getting frustrated. Is their job harder? Yes. Okay, I have noticed this. Instead of going back to the cook and yelling, is there something else that I can notice? Are other people getting their food late? Yes or no or don’t know. Am I picking up my food when it is ready? Am I putting my orders in the right process? May be the ordering process is broken or someone called in sick.

You are at your piece of equipment and jams start occurring. Where are they occurring? They are at the end of the process. What is causing it?

Are there areas where continuous improvement / Lean Six Sigma do not need to be used or shouldn’t be used?

What about a known solution? Is there no risk related to this change? Is everyone aware of the changes? Even if there is a known solution, if it crosses process owners and potential unintended consequences, it is wise to at least review the process, look at an FMEA, Change Management and Control plan.

What about CapEx or buying equipment? Would that need LSS help? Let me ask you, in your experience, how many of these projects have been on-budget, on-time, and SLA’s, service level agreements, are satisfied? I have found that is not the case. Early management, Risk assessment, Widening the options for what to purchase and when are all items that continuous improvement could help with. This doesn’t even include the CapEx process that most companies struggle with.

I started thinking about this idea based on the belief that there are some items and topics that continuous improvement. I now think that there is always a better way and that CI tools can help in any situation. I have had multiple discussions in the companies that I have worked with and almost all of them have had what they perceived as “A players.” They are very capable and smart and know their business but I have rarely seen one of these teams put together a project that produces better results or less unintended consequences than a good process. Great teams have a hard time beating a great process.

There is an increase drive to eliminate reports in large organizations. So much time spent putting them together and who is looking at them let alone is there anything actionable being address or even triggered. It goes without saying that as systems gain the ability to track more, the more is usually noise not signal. I have been in meetings and discussions about rationalizing reports but I find that the discussion looks at quantity and who receives it. All good stuff but I think there are other questions that need to be asked.

What are the metrics and information that drive the business? This is a different question than do you use this report and, if so, what do you look at. Driving the business and the risks to that business are the only items that should be tracked. This type of discussion, across the organization, will create metrics that everyone shares and needs to be focused on. This takes longer and multiple parts of the organization need to be at the table but this will create a discussion and understanding across the organization. Total Landed Cost is one that can unite multiple parts of the team. This will create better meetings and better decisions across the supply chain. This will eliminate 50% of the reporting requirements and streamline discussions.

How much time and/or resources are required to generate these reports? This is better than discussing the number of reports or different types. This recognizes the fact that reports aren’t free and that making them “personalized” for each “leader” is a waste. How many times have you experienced someone stating that they focus on this set of metrics or I like mine in columns versus rows? Does the leader have to defend this to the wider organization? Do they work with their peers to find the format that works? Rarely. What work does this eliminate? This is a question I ask before I put together any report. If it is going to be business as usual, I recommend that the report does not get developed.

What are you going to do with the information? What is actionable? This is better than what do you do this report. So many reports are related to FYI reports or nice to know. I know there are reports that leaders think are actionable. “Johnny, this number stinks. Fix it.” That is not actionable. Actionable means that you having triggers that once they are reached, there are corrective actions and countermeasures as well as root cause analysis that need to set up to support the report.

The report problem needs to be solved but not by making them easier or doing fewer of them. You need to decide what is important, track it and develop improvements when needed.

 

I have been performing and reviewing some BDA’s (Break Down Analysis) events at sites and their RCA’s, Root Cause Analysis, are starting to be much better. What I have seen is that some of the countermeasures have failed to be implemented or once you walk the process, the countermeasure isn’t fulfilling the need. What I have suggested when this comes up is another RCA but on behavior or the process not the equipment. This takes some out of their element and doesn’t always come naturally to them.

Root Cause Analysis should be used for why the countermeasure didn’t work, why the employees aren’t using the centerlines, and why the supervisors don’t audit or use checklists. Same process. Different use.

The first key difference is looking at the critical behaviors that are causing the issue. This is similar to finding the failure mode of the component in the BDA process. This does not give you all the information that a FMEA would but you have a direction. It could be that when a Supervisor is supposed to do an audit, they have quality and safety documentation that takes up the time. A centerline isn’t followed because the employee doesn’t believe that it is correct, the countermeasure didn’t work because when setting up for the next run, the sequence is wrong and it isn’t set up correctly.

The next step is related to finding what is behind the behavior. This can be workload – What to say no to. This can be a process that was not fully understood when it was changed and implemented. It could be the set-up of equipment that did not have buy-in from operators or the informal leadership. This is really the root cause of the problem. But now what? Carrots and sticks and a little imagination.

The reason people aren’t following a process or doing what is needed is rarely because of intelligence or someone coming in and saying, I want to do stuff wrong today. There is always a kernel of truth behind deviation and that needs to be addressed and worked on. This becomes the carrot. Centerlines not being used – Is it because this has been tried before and it didn’t work or because the operator expressed their concerns and they were not empowered to move forward or something else. Deal with that small truth to win over the skeptics to the process. Also, if there is too much work to be done, it is your job to clean this up or at least force rank and develop if – then statements so that the individual can be successful without dealing with a 10 pounds of stuff with a 5 pound bag.

The stick is not nearly as fun but still important. This is the penalty if work is not performed correctly. I am all about making the work place a positive environment and that means ensuring that everyone is doing their work correctly and not creating more work for someone else. Didn’t perform centerline review or move them without notification. Retraining / discussion / discipline. Audit sheet not filled out? Retraining / discussion of the issues / discipline. I wish there was a way around this but I have not found one. It can’t be a surprise. This should be well understood what the path is for non-compliance. It should also be very clear and purposeful that the goal is the improved process. Also, it has to be absolute and for all. Not just the “bad” performers but Johnny has been here for 20 years, so let’s give him a pass. Everyone, everytime.

Imagination is for mistake proofing the process so it can’t be performed incorrectly again. This could be a permanent setting instead of a centerline. It could be an audit sheet that is tied directly to the other documentation that is already being performed so it flows the same way as before the process was changed. The process steps are now automated so that at a press of a button the equipment is lined up and ready to go.

Root Cause Analysis is a great tool for troubleshooting, training, and developing a continuous improvement mindset and it is not limited to the equipment but needs to be expanded to HR, QC, Safety and any other point that the business is impacted by.