Problem solving 101

1. Problem Solving
Robert Graham

2. What is a Problem?
A problem is a discrepancy
between an existing standard or
expectation and the present or
actual condition.

3. What is problem solving?
 A systematic approach to improve a deviation to a standard
or expectation.
 It can be done individually, however a team approach is
recommended.
 The problem solving goal for any organization: to have all
people participating in problem solving in all aspects of their
work.

4. Why Support and Encourage Problem
Solving?
=
Problem
Solving
Improvement

5. Traditional Reactions to Problems
CAN YOU
BLAME
ANYBODY ELSE
DOES THE
DARN THING
WORK
WILL YOU
CATCH HECK
DOES
ANYBODY
KNOW
DID YOU
MESS WITH IT
DON’T MESS
WITH IT
FOUL-UPS
HAPPEN
YOU’RE IN
TROUBLE
DUMP IT
HIDE IT
NO PROBLEM
Yes
Yes
No
No
Yes
No
No
Yes
No
Yes

6. When Can an Organization Say It Has Effective Problem
Solving Throughout It’s Ranks
 When It Has Total Participation in
Problem Solving !
 When People Have a Feeling of Control
Over Their Problem !
 When 100% of the People Have Been
Trained in Problem Solving !
 When Problem Solving Is a Habit !
 When an Organization Has a Culture of
Empowerment !
 When an Organization Utilizes Problem
Solving and Other Lean Tools to Be Best
in Quality, Lowest in Cost and Best in
Productivity !

7. Creativity Exercise
Instructions:
You must draw three lines.
A to A
B to B
C to C
Rules:
The lines can not touch.
Can not go through the blocks.
Can not go outside the main box.

8. Creativity Exercise
C
C
A
B
A
B
Instructions:
You must draw three lines.
A to A
B to B
C to C
Rules:
The lines can not touch.
Can not go through the blocks.
Can not go outside the main box.
5 Minutes

9. Typical Problem Solving Funnel (Solution Unknown)
Large Vague
Problem
Observation
5Why 3
legged / 8D
Fishbone
Point of Cause
Standardize
Evaluate
Implement
5 Why’s
1) Problem
Identification
2) Find Point Of
Cause
3) Find the Root
Cause (5 Why RCA)
4) Implement
Corrective Actions
5) Evaluate Corrective
Actions
6) Standardize
6 Steps of
Problem
Solving

10. • Stop & Notify
– Understanding if we have a problem
• Highlight problems (Visual Management)
• Pareto Analysis of Issues
• Do we need to Protect the Customer?
– Never send defective product to your customer
– Fix & eliminate the problem quickly to meet your customers
needs
• Is the Solution / Point of Cause Known?
– Yes:
• Rapid Problem Solving…fix it now!
– No:
• 5 Why Root Cause Analysis
Problem
Identification
Find Point
Of Cause
Find the
Root Cause
Implement
Corrective
Actions
Evaluate
Corrective
Actions
Standardize
Problem Identification
Problem Identification

11. Understanding we have a Problem:
• Problems Identified through the
basics:
– Good 5S
– Daily Management
– Visual Management
– Problem Analysis…Pareto
Charts, Control Charts, etc…
Unplanned Maint. DT: 4.0 hrs
THROUGH PUT GOAL:
100,000spd
A MR GOAL: 4.0 hrs
B MR GOAL: 1.9 hrs
C MR GOAL: 1.5 hrs
PRODUCTIVITY
Record of # good sheets/total
production hours
Record total hours for MR
Record total hours for
Unplanned Maint. DT 1 2 3
6 7
9 10
12
15 17
25
5
8
11
20 22
13
16
21
4
18
23
14
19
24
31
30
29
28
27
26
1 2 3 4 5 6
7 10
8 9 11 12
MONTH
What
caused
this?
Productivity Pareto
0
10
20
30
40
50
60
Unplanned D/T MR Time Scrap Jams Planned D/T
Large Vague Problem

12. Identify large vague problem
 collect data based on fact
 determine biggest problem
Grasp the Facts!
VS.
0
5
10
15
20
Dust
Drip
Black
Skin
Scratch/
Hit
0
5
10
15
20
Scratch/
Hit
Dust
Black
Skin
Drip
GO &
SEE

13. Find Point of Cause
Problem
Identification
Find Point
Of Cause
Find the
Root Cause
Implement
Corrective
Actions
Evaluate
Corrective
Actions
Standardize
• Grasp the facts
– “Go and See” (see with your own eyes)
– Understand and be able to describe what happened
– Observe the Process and ask questions
– Use all of your senses
• Understand the process where the problem occurred
– Sketch out the problem area…understand the flow
• Use Flip Charts in the area of the problem
• 2 Suggested Methods to find point of cause
– Cause and Effect Analysis—6M’s (Fishbone – good for 5 Why RCA)
– 5 W’s and 1 H (good for rapid problem solving)
• Who, What, When, Where, Why and How

14. 5W’s and 1H
Who
Who saw it happen?
Who was involved/affected with the issue?
What
What happened/What type of problem?
What occurred?
What has the problem?
When
When did it occur?
When in the sequence of the process?
Where
Where did it occur?
Is it only happening in 1 area/product?
Why
Why did it happen?
Why is it a problem?
How
How did it occur?
How many?
How often?
5W1H
 What is it?
 Method of asking questions in the “Grasp the facts”
phase of understanding the problem that occurred.
 Why is it useful?
 5W1H are the typical questions that need to be
answered to better understand the problem.
 When is it used?
 It useful at the beginning of the problem solving
process in the initial data gathering process.
 How is it done?
 By asking the questions: Who, What, When,
Where, Why and How.

15. 6M Analysis ( Fish Bone)
• Use 6M analysis to better understand the problem:
– Man – human variation: person to person, shift to shift
– Machine – machine warm-up, shutdown, settings
– Material – age of material, dimensions
– Method – standard work, work instructions
– Mother Nature – environmental factors, humidity, etc.
– Measurement System – are we measuring it correctly?
Material
Man Machine
Mother Nature
Method Measurement System

16. 6M Analysis
• What is it?
– The 6M Analysis (also known as Fishbone, Ishikawa or Cause & Effect Diagram) is a technique
to graphically identify and organize many possible causes of a problem (effect).
• Why is it useful?
– 6M Analysis helps identify the most likely Root CauseS of a problem. They can also help teach
a team to reach a common understanding of the problem. This tool can help focus problem
solving and reduce subjective decision making.
• When is it used?
– When the need exists to display and explore many possible causes of a specific problem or
condition. This diagram allows the team to systematically analyze cause & effect relationships.
This tool is typically used with the 5 Why Root Cause Analysis, as it will highlight many potential
points of cause which can then be driven to root cause with the 5 Why RCA tool.
• How is it done?
– Assemble your brainstorming team and using the 6M analysis form, document the problem
(effect) on the right side of the diagram. Brainstorm all possible causes of the problem and
categorize them under the appropriate heading. Once complete, review all the possible causes
and select the most likely causes of the problem and then utilize 5 Why Root Cause Analysis to
solve for root cause.

17. Rapid Problem Solving Fishbone Diagram/Template
Problem
Statement
Measurement
Material
Method
Mother Nature
Machine
Man
Variation
Variation
Availability
Quality
In Spec.
Capability
Speed
Availability
Condition
Set-Up / Program
Troubleshooting
Training
Std. Work
Procedure / Visuals
Skills
Training
Attitude / Fatigue
Sense of Urgency
Attendance
Accuracy
Frequency
What to Measure
Standards
Set-Up / Calibration
Environment
Utilities
Humidity
Temp.
Tooling
Mistake Proofing
Process Changed?

18. Find the Root Cause
• 5 Why Root Cause Analysis
– Not always a single path to the true root cause
– Possibility of multiple root causes
• For part/product quality defects, it is critical to find the root cause of 2
issues:
– Why made?
– Why missed?
• When to use the Root Cause Analysis report
– Delivery Miss, Part Shortages, Engineering Issue, Quality Problem,
Productivity (Downtime), Supplier Defects, Scrap, Safety, etc…
– Performance Metrics not being met (Inventory, Workmanship Errors, etc…)
– Process problems, Countermeasure Sheets, etc…
– Order to Cash cycle interruptions
Problem
Identification
Find Point
Of Cause
Find the
Root Cause
Implement
Corrective
Actions
Evaluate
Corrective
Actions
Standardize
These 2 Root Causes
are NEVER the same

19. 5 Why’s: The Process
• Driving to root cause using the 5 Why technique.
– Perhaps the simplest of problem solving and creativity tools, the 5
Whys can easily be taught and used by everyone in the
organization.
– Simply start the process from the “Point of Cause” determined
through the other problem solving tools (Go & See, 5H1W,
Fishbone, etc…).
– Then ask why it is so, for up to 5 successive iterations, until the true
root cause has been identified.
– If performed correctly and the correct point of cause found then you
will have found the true Root Cause.

20. Root Cause
Root Cause: The fundamental breakdown
or failure of a process
When you fix Root Cause, the problem goes
away & doesn’t come back!

21. 5 Why Form

22. The National Park Service asked the 5 Why’s to attack a crumbling stone problem on
and within the Jefferson Memorial.
Point of Cause
Crumbling caused by excessive washing.
5 WHY’s
Why does the stone need regular washing?
Because a large amount of bird droppings on the stone. WHY?
Because of the large number of birds inside the memorial. WHY?
Because there is a large food supply (spiders) inside the memorial. WHY?
Because a large number of midges are inside and around the memorial. WHY?
ROOT CAUSE
The lights that illuminate the memorial attract mating midges at dusk.
COUNTERMEASURE
The memorial lights were not needed at dusk – there was still enough light to see the memorial, so
they were delayed to illuminate 1 hour after dusk.
RESULTS
The result was a 90% reduction in midges, fewer spiders, fewer birds, and far fewer washings.
The Jefferson Memorial – 5 Why Example

23. A short lesson in technology
• Why #1: Why are space shuttle booster rockets the size they are?
– Answer - Because they are limited by tunnel widths when being transported by rail during
assembly.
• Why #2: Why are tunnel widths as wide apart as they are?
– Answer - Because that was the typical width of rail road tracks.
• Why #3: Why are railroad track as wide apart as they are?
– Answer - Because that was the typical width of wagon wheels.
• Why #4: Why are wagon wheels as wide apart as they are?
– Answer - So they could fit in Roman chariot wheel ruts left in ancient roads across Europe.
• Why #5: Why are Roman chariot wheels as wide as apart as they are?
– Answer - Because that was the typical width of two horses' hind ends.
5 Why’s: Extra Example
Lesson to be Learned
• Even the most complex technology is ultimately driven by a pair of
horses' rear ends.

24. 5 Why Exercise
• Let’s work together to solve the following problem for root cause…
– “My car would not start this morning”

25. Typical Problem Solving Funnel (Solution Unknown)
Large Vague Problem:
“Car won’t start”
2) Observation:
- Check battery cables for
corrosion
- Check fluid in battery cells
- Check alternator belt
- Check battery voltage
3) 5W1H: (Grasp the facts)
-Who: I saw it & was impacted by it.
- What: Car wouldn’t start, no sign of elec.
- When: When I turned the key.
- Where: At home
- Why: I can’t get to work
- How: 1st time for occurring
4) Fishbone:
“See next Slide” Point of Cause:
-“Dead Battery”…Findings:
- Battery won’t hold charge
- Low fluid in cells
Standardize
Evaluate
Implement
5 Why’s
5) 5 Why’s:
- Why 1: Why was the fluid low in the battery?
- Owner didn’t add fluid to battery
- Why 2: Why was fluid not added?
- Owner not aware of need to add fluid
-Solutions:
- Create/Implement P.M. Schedule for battery
- Purchase “No Maintenance” Battery
- Why 3: Why was the owner unaware of
maintenance?
- Didn’t read manual on battery
- Why 4: Why didn’t owner read manual?
- Didn’t have time…
- Why 5: etc…

26. Car won’t start
Measurement
Material
Method
Mother Nature
Machine
Man
Training on how to start a car
Error: Leaving lights on
Poor Assembly
Maintenance of car
Voltage of battery
Alternator output
Continuity of wiring
Bad Alternator
Bad Switch
Bad Cables
Dead Battery
How to turn on car
How to shut down car
How to maintain car
Corrosion
Too cold to start car
Car is old
Car draws too much current
Short in wiring
Fishbone Exercise

27. Root Cause Analysis
Common mistakes in root cause analysis
1. Confusing the symptoms with the root causes
Symptoms are defined as the observable effects of a problem (example: car won’t
start)
Root Causes are defined as the reason for the existence of the symptoms (example:
dead battery)
2. Assuming that the true root cause of the problem is known without
adequately testing or verifying the theory.
3. Assuming there was only one root cause.
For example: Why did the Titanic sink?
The rudder was too small to turn in time
The night watchman did not have binoculars
The rivets used to assemble to boat were bad quality

28. Root Cause Analysis
Common mistakes in root cause analysis
4. Focusing on filling out a problem solving form rather than on solving a
problem
5. Jumping to conclusions without data, without “Go & See”
6. Not digging deep enough to find point of cause
7. Documenting 5 Why’s, just because it’s called 5 Why Analysis
8. Brainstorming to get 5 un-related answers to “Why”

29. Implement and Evaluate Corrective Actions
• Don’t be a “Fire Fighter”
• Fix all possible root causes (if more than 1)
• Evaluate the corrective actions
– Confirm that the problem has been eliminated
– Audit system (Leadership Standardized Work)
Problem
Identification
Find Point
Of Cause
Find the
Root Cause
Implement
Corrective
Actions
Evaluate
Corrective
Actions
Standardize

30. Standardize
Prevent Re-Occurrence
Change process documentation to new, improved process:
Standardized work
Work instructions
Etc.
Share the improved process as a best practice (Knowledge Sharing)
Problem
Identification
Find Point
Of Cause
Find the
Root Cause
Implement
Corrective
Actions
Evaluate
Corrective
Actions
Standardize

31. Problem Solving Summary
Follow the process.
Go see! Observe the process.
Find the “point of cause” – where is the defect occurring,
when is it occurring, etc.
After point of cause is found, do root cause analysis.
Think deeply. You are not done just because you filled out a
form answering “why?” 5 times. Did you go deep
enough? Did you go broad enough?
Correct the problem, standardize the solution to prevent
future similar problems from occurring.

32. Knowledge Check
1. What is a problem?
2. What should your first action be when dealing with a problem?
3. What are the 5Ws and 1H? When are they used?
4. What are the 6Ms? What is another name for this form?
5. When do you use the 5 Whys Process? If performed correctly, what
will the 5 Why Process lead you to?
Knowledge Check
1. What is a problem?
2. What should your first action be when dealing with a problem?
3. What are the 5Ws and 1H? When are they used?
4. What are the 6Ms? What is another name for this form?
5. When do you use the 5 Whys Process? If performed correctly, what
will the 5 Why Process lead you to?

33. Questions?
Questions?