A Summary of Apollo Root Cause Problem Solving

1. A Summary of Apollo Root Cause Problem Solving Holly Duckworth Master Black Belt TRW Automotive 4/16/2008

2. Method Credited to… Based upon the book: “Apollo Root Cause Analysis”, Dean L. Gano, 2nd ed., Apollonian Publications, Yakima, Washington, 2003.

3. Problem Solving Techniques • Problem Resolution -- to help identify and rectify an identified problem – a “special cause” situation • 8-D problem solving • Process Improvement -- to identify and implement improvements proactively – a “common cause” situation • Six Sigma process improvement • 8-D Problems solving can be used within a six sigma project to solve special cause issues

4. PDCA Plan Plan for a change needed to solve the problem/improve the process Act Implement the change, if appropriate. Make all needed systems changes to formalize Plan Act Check Do Do Test change on a small scale. Collect data. Check Check the impacts of the proposed change.

5. We will focus on the unique root cause identification tools in this lecture 8-D Problem Solving The Eight Disciplines* (8-D) are: • Team Formation • Problem Description • Interim Corrective Action • Root Cause Identification • Choosing/Verifying Permanent Corrective Action • Implementing Permanent Corrective Action • Preventing Problem Recurrence • Recognizing the Team *Generally attributed to Ford Motor Company

6. Root Cause Identification • We always start with understanding the EFFECT • However, in each problem there is usually a series of effects and causes • Example: EffectCause Injury Fall Fall Wet Floor Wet Floor Mopping Mopping Mud in Aisle Mud in Aisle No mat at door

7. Action: Match Strike Condition: Ignition Contact Effect: Brush Fire Condition: Fuel-Dry Brush Condition: Oxygen Root Cause Identification • What we also find is that every EFFECT is caused by a combination of CONDITIONS and ACTIONS • Conditions – Causes that exist prior to an action • Actions – Momentary causes that bring the condition and effect together

8. Defect and Systemic Root Cause • The effect is an employee slips and falls • The defect root cause is the employee walking across a wet floor • The condition is the wet floor • The action is the employee walking on the wet floor • The systemic root cause is the employee choosing the at-risk behavior and/or the janitor not marking the wet floor

9. Equipment Materials People Effect Methods Measurement Environment Cause and Effect Diagrams • We might use a “fish bone” diagram, but only to brainstorm possible causes (conditions and actions)

10. Action: Employee chooses to ignore wet floor sign Action: Employee walks on wet floor Condition: “At risk” behavior not corrected Effect: Employee Slips and Falls Action: Janitor mops up mud Action: No mat placed at door Condition: Wet floor Condition: Muddy floor Condition: No side walk to walk on Cause and Effect Diagrams • But the important tool in Apollo Root Cause Problem Solving is the Condition/Action Chart

11. Condition: Battery is dead Effect: Car doesn’t start Condition: Car is out of gas Condition: Starter is defective Action: Ignition switch does not start the car Condition/Action Analysis • Let’s walk through an example…

12. Condition: Battery is dead Evidence: voltmeter shows low Effect: Car doesn’t start Condition: Car is out of gas Gage shows ¾ tank full Condition: Starter is defective New car with no prior starter issues Action: Ignition switch does not start the car Evidence: personal observation Condition/Action Analysis • We must now VERIFY each condition and action with EVIDENCE

13. Condition: Battery beyond warranty life Condition: Battery is dead Evidence: 5yr warranty v. purchase date Evidence: voltmeter shows low Action: Battery not replaced Effect: Car doesn’t start Condition: Car is out of gas Evidence: original batter observed Gage shows ¾ tank full Condition: Starter is defective New car with no prior starter issues Condition: No voltage to starter Action: Ignition switch does not start the car Evidence: observation of voltmeter Action: Repeated trial of ignition switch Evidence: personal observation Evidence: personal observation Condition/Action Analysis • Next, we analyze the next “layer”

14. Condition: Battery beyond warranty life Condition: Battery is dead Evidence: 5yr warranty v. purchase date Evidence: voltmeter shows low Action: Battery not replaced Effect: Car doesn’t start Condition: Car is out of gas Evidence: original batter observed Gage shows ¾ tank full Condition: Starter is defective New car with no prior starter issues Condition: No voltage to starter Action: Ignition switch does not start the car Evidence: observation of voltmeter Action: Repeated trial of ignition switch Evidence: personal observation Evidence: personal observation Condition/Action Analysis • Can we take these causes any further?

15. Condition/Action Analysis Condition: Battery beyond warranty life Condition: Lowest cost objective • These are the systemic root causes Condition: Battery is dead Action: New battery purchase delayed Action: Battery not replaced Effect: Car doesn’t start Condition: Car is out of gas • These are the defect root causes Condition: Starter is defective Condition: No voltage to starter Action: Ignition switch does not start the car Action: Repeated trial of ignition switch

16. Condition/Action Analysis • How do you know when to stop? • Answers are nonsense or repeated • Condition/Action Charting is an iterative process • Once a draft chart is finished, start at the beginning and refine • All Actions and Conditions should be verified with evidence • This may take some time

17. Solutions • The best solutions address CONDITIONS • If we can remove conditions, then it doesn’t matter what actions happen • There may be multiple root causes with multiple conditions • It may be too costly to address CONDITIONS, then ACTIONS should be addressed Systemic Corrective Action on CONDITIONS will prevent recurrence

18. Apollo Root Cause Problem Solving • Condition/Action Charting and Analysis • Another tool in the tool box • Now you’ll try an example.