Here is a simple presentation on the basics of a corrective action system

1. Corrective Action and Root Cause Analysis
By Sam Lines, Concrete Sealants

2. Agenda Overview
• Nonconformances
• Corrective Action Process
• Root Cause Analysis
• Cost of quality

3. Opener
LEAKING JOINT

4. Opener
PROBLEM SOLVED! RIGHT?

5. NONCONFORMANCES

6. Nonconformances
• What are non-conformances?
– Product does not match specification
• Discovered by inspection
– Pre-pour
– Post pour
– Final
• Discovered by an external source
– NPCA Plant Certification Audit
– DOT Inspector
• Discovered by the customer
– Product’s form, fit, or function has been altered

7. Bad Forms = Bad Product

8. Enough Steel?

9. Leaking at Honeycomb

10. Poor Consolidation?

11. Insufficient Cover
Reba
r

12. Where’s My Hammer?

13. Nonconformances
• Formwork
• Concrete
• Blockouts and cast in items
• Drawings
• Sales Order
• Other?

14. Nonconformances
• Material from supplier
– Incoming inspection
– Setup and installation
– Mill Certificates
• Traceability Question:
What products might contain material from
nonconforming lot? Do you know?

15. Nonconformances
• Where is the product?
• Is the product quarantined?
• Are any other products affected?
• Are bad products still being produced?
• Were nonconforming products shipped?
Don’t spend your time determining
who was at fault.

16. Now, let’s solve the problem.

17. Traditional Problem Solving
YES NO
Is It Working?
Don’t Mess With It!
YES Did You Mess
YOU IDIOT!
With It?
NO
YES
You’re SCREWED!
Anyone Else
Knows?
NO
Look The Other Way
NO
Can You Blame
Hide It Someone Else?
Yes
NO PROBLEM!

18. The Traditional Way
Event
(Problem)
Form Team
Identify Problem
Gather Data
Analyze Data
Determine Causes
Determine Corrective Action
Implement
(fix It)

19. A Better Way:
The Corrective Action
Process

20. Corrective Action Process
• What is it?
• Why is it needed?
• When is it used?
• Who performs it?
• How is it performed?
• What documentation is needed?
• Correction vs. Corrective Action

21. Corrective Action Process
THE STEPS WITHIN THE
PROCESS

22. Corrective Action Process
• Problem Identification
– Who, what, where, when, why, and how
– Is the problem isolated?
• Problems with significant risk need corrective action
– Has this happened before? Recently?
STEP 1
• Reoccurring problems need corrective action
– Use statistics to evaluate trends
• Trends will show a process which is out of control where
corrective action is needed
• Document the corrective action on a form.
• Assign responsibility for the activity.
• Track corrective actions using a master list.

23. Document the Problem

27. Corrective Action Process
• Short term remedy (immediate fix)
– Repair product
– Quarantine bad product(s)
STEP 2
– Stop producing bad product
– Evaluate extent of problem
– Has any bad product been shipped?
– Notify customers as necessary

28. Corrective Action Process
• Root Cause Analysis
– A process of determining what
underlying cause or causes are
responsible
STEP 3
– Tools: We will learn more about how to
perform a root cause analysis in
• Fishbone Diagram later slides.
• 5 Whys
• Flowchart
• Pareto Diagram
– Document the Analysis

30. Corrective Action Process
• Implementation of the action
– Eliminate root cause
• Training
•
STEP 4
Procedures
• Work instructions
• Visual indicators
• Mistake proof
– Document actions taken
– Evaluate the effectiveness of the actions

32. Corrective Action Process
ROOT CAUSE ANALYSIS

33. Definition
• What is root cause analysis?
“Root cause analysis is the process of
defining all of the major and minor causation
factors, and then determining the one or ones
that, if eliminated, would prevent a future
nonconformance.”

34. The Problem Solving Funnel

35. Tools
• Cause and Effect Diagram, Ishikawa
Diagram, Fishbone Diagram

36. Why is my toast burnt?
• Effect: Burnt Toast
• Main Cause
Categories:
– People
– Equipment
– Methods
– Materials

37. People
• I don’t usually make the toast
– My wife is out of town
– I was not trained on this toaster
• My wife assumed I was smarter than the toaster
– Assumptions are bad!

38. Equipment
• The toaster is old
– The toaster is full of bread crumbs
• The toaster is not maintained
– I didn’t know it mattered
– My wife wasn’t complaining about it
» She knows what she’s doing
• The settings were changed
– A different material was used last time
– There are no instructions

39. Methods
• There are no work instructions
– I thought it seemed easy
• I am smarter than a toaster
– Re-evaluate my self worth
• I didn’t adjust the settings
– Don’t know what setting it
should be
• Lack of instructions

40. Materials
• The bread is stale.
– Didn’t use it fast enough
• Not home for breakfast
– Leave early for work
» Working on a special project
• The bread is thinner than usual
– We change brands
• Save money

41. Cause and Effect: Burnt Toast
Equipment People
I don’t usually
Material is
The toaster is old make the toast
different Bad
I didn’t know
assumption
it mattered My wife assumed I
The settings
She knows what was smarter than
were changed
she’s doing the toaster
The toaster is full I was not
No instructions of bread crumbs trained on this
My wife hadn’t
toaster
complained Burnt
Toast
No instructions Thinner bread
Didn’t
Lack of change the Save Stale bread
knowledge settings money
Not home for
Need
No instructions breakfast
training
Leave early
Don’t know what Changed
Thought it was easy for work
setting to use brand Special project
Didn’t use it fast
Methods Materials enough

42. 5 Why’s
• Ask “Why” 5 times
• Best used when people are involved
• Great for auditing a process to gain
understanding
• Can be 4 or 6 why’s Why?

43. 5 Why’s
Problem Statement: You are on your way home from
work and your engine dies.
1. Why did your engine die?
- Because your car ran out of gas.
2. Why did your car run out of gas?
- Because I didn't buy any gas on my way to work.
3. Why didn't you buy any gas this morning?
- Because I didn't have any money.
4. Why didn't you have any money?
- Because I lost it all last night in a poker game.
5. Why did you lose your money in last night's poker game?
- Because I'm not very good at "bluffing“.

44. Solution
• Good solution:
Stop bluffing
• Better solution:
Set a dollar limit
• Best solution:
Stop playing poker for money

45. Other Problem Solving Tools
• 8D Method
– Developed by Ford in the 80’s
• A3 Format
– Uses A3 Size paper (11” x 17”)
– Used extensively by Toyota
• Process Cause and Effect
– Follows the process to find out where
mistakes can happen.

46. Example of an A3

47. Example of Process Cause and Effect
What can What can What can
go wrong go wrong go wrong
Inputs Process Outputs
What can What can What can
go wrong go wrong go wrong

48. Eliminate the Root Cause
• Implement action based on root cause
analysis
– Creation of instruction
– Training of operator(s)
• Verify effectiveness
– Increase inspection (temporary or long term)
– Create a metric for evaluation
– Audit the process in 1, 3, and 6 months

49. Mistake Proofing
– Poka yoke:
the Japanese work for mistake proofing
• Go / no-go gauge
• Warning lights
• Color coding
– Proportionate to the risk and/or cost of a
future failure

50. Examples of Poka-Yoke
Lights and gauges
Tethers and holders

51. Posted Signs and Instructions

52. • Stop lights
• Spell Cheker
• “Lights on” warning buzzer
• “Auto-off” on coffee maker
• Pictures and signs
• Color coded bins and instructions

53. Poka Yoke Rules

54. Corrective Action Process
THE VALUE OF QUALITY

55. “Quality is free. It’s not a gift, but it is free.
What costs money are the unquality things
– all the actions that involve not doing the
job right the first time.”
Phillip Crosby

56. Defect Escalation Cost
COSTS
$6,000
$5,000
$4,000
$3,000
COSTS
$2,000
$1,000
$1,000
$1 $10 $100
$-
Order Design Pre-pour Post-pour Delivery
Entry Inspection Inspection

57. Cost of Quality
Prevention Costs
Appraisal Costs
+ Failure Costs
Total Quality Costs

58. Cost of Quality
Prevention Costs: The costs of all activities
specifically designed to prevent poor quality in
products or services.
Examples:
– New product review
– Quality planning
– Supplier capability surveys
– Process capability evaluations
– Quality improvement team activities
– Quality improvement projects
– Quality education and training

59. Cost of Quality
Appraisal Costs: The costs associated with
measuring, evaluating or auditing products or
services to assure conformance to quality
standards and performance requirements.
Examples:
– Incoming and source inspection/test of purchased material
– In-process and final inspection/test
– Product, process or service audits
– Calibration of measuring and test equipment
– Associated supplies and materials

60. Cost of Quality
Failure Costs: The costs resulting from products
or services not conforming to requirements or
customer/user needs.
• Internal Failure Costs:
Failure costs occurring prior to delivery or shipment of the
product, or the furnishing of a service, to the customer. Examples:
– Scrap
– Rework
– Re-inspection
– Re-testing
– Material review
– Downgrading

61. Cost of Quality
• External Failure Costs:
Failure costs occurring after delivery or shipment of the product; and
during or after furnishing of a service to the customer. Examples:
– Processing customer complaints
– Customer returns
– Warranty claims
– Product recalls

62. Cost of Quality - Optimized
High
Total Cost of Quality
Where you want to be
Cost
Minimum
Cost of Quality
Cost of Cost of Quality
Service Defects Management
Optimum Level
of Service Quality
Low
Low High
Quality

63. Cost of Quality – Trifecta
Investment in a quality strategy will yield:
– Lower defects
– Reduce cycle time to delivery
– Improve customer satisfaction
– Higher employee morale

64. Value of Quality
• Save 10% (or more) from:
– Reduction of waste, scrap, and repairs
– Less variability in processes
– Less time fixing, more time producing
– Reduced incoming material problems
– Reduced overtime
– Reduced warranty and service calls

65. Conclusion
• A corrective action program is simple to
implement and easy to use.
• Eliminating the root cause is essential in
preventing future nonconformances.
• Preventing problems saves money.

66. Questions