8D Problem Solving

8D
Problem Solving
Learning Outline
• Introduction to 8D
• D1 – Problem Solving Team
• D2 – Problem Description
• D3 – Containment and Short-Term Corrective Actions
• D4 – Root Cause Analysis (Definitions, Fishbone, 5 Why, etc)
• D5 – Long Term Corrective Actions
• D6 – Implementation & Verification of Long-Term Corrective Actions
• D7 – Preventative Actions
• D8 – Congratulate the Team & Conclusion

2
Introduction
“Failure is simply the opportunity to begin again,
this time more intelligently.”
– Henry Ford
There is no method of improvement more effective than good problem solving
A problem is an opportunity for improvement that:

• You have proof is worth addressing
• You can quantify the benefit of addressing
• You can convince others is worth addressing

Introduction 3
Introduction
What to expect from your 8Ds: 8Ds are not about returning to the status quo before the
1. Elimination of the problem problem. They are about improving on the status quo.
improved performance
2. Permanent prevention of the
Performance
problem
3. Prevention of similar problems
4. Overall improvement problem
Time
Introduction 4
Common Misconceptions
8Ds are part of the punishment for 8Ds are only for quality issues.
failures.  No! Problem solving processes can be applied to
 No! 8Ds and Corrective Actions are great any type of problem (cost, quality, delivery).
opportunities to improve.
Problem solving means 8D, 100% of the time.
 No! The 8D is a strong, formal corrective action
8Ds are Quality’s responsibility. process, not the only one.
 No! Problem solving only works when the
experts are involved.
8Ds are only able to prevent recurrence of
the same failures.
 No! 8Ds should also address system weaknesses in
order to prevent related failures.
Introduction 5
8D Form
Two versions of the Oshkosh 8D are available (8D process is the same with both):
Excel spreadsheet on the OSN Reliance SCAR

https://osn.oshkoshcorp.com/gsq-en.htm (issued by Oshkosh Supplier Quality)
Introduction 6
8D Pre-Work (D0)
Before kicking off an 8D, you need to understand:
Who is impacted?
• Customer? Production line? End user? Etc.
How significant is the impact? Is this an emergency? Does it need to be

escalated?
What is the scope of the problem (best guess)?
Has this happened before?
Introduction 7
8D Pre-Work (D0)
Pareto analysis is one Pareto Chart

very effective method to (July 2019)
90
determine what 80
Quantity of Rejects
problem deserves an 8D 70
60
50
40
30
20
10
0
Parts bent - Parts bent Cam locks Missing weld Plate not
short backwards installed installed
incorrectly
Introduction 8
Problem Solving Process
D1 Problem D2 Problem D3 Containment and Short D4 Root Cause
Solving Team Description Term Corrective Actions Analysis
Make short
Identify the Define the Contain the Understand Investigate Analyze
term
team problem problem the process causes causes
correction
Develop long Implement

Develop
Identify root term long term Verify Congratulate
preventative
cause(s) corrective corrective effectiveness the team
actions
actions actions
D4 Root Cause D5 Long Term D6 Implementation and Verification D7 Preventative D8 Congratulate

Analysis Corrective Actions of Long Term Corrective Actions Actions the Team
Introduction 9
D1 – Problem Solving
Team
D1 - Problem Solving Team 10
Identify the Team
Teams are critical to problem solving!

• No individual has the necessary knowledge or
objectivity
• Overcoming initial biases is difficult and

typically requires a team
• Getting buy-in is difficult as an individual
8D Rule 1: If there’s no team, it’s

Rule of thumb: Look for a team of 3 to 5 members. not an 8D.

Identify the Team
Team Champion
• Person of authority in the organization
• Does not actively participate in team

meetings
Contributions:
• Sets expectations
• Is responsible for the culture of problem
solving
• Removes roadblocks (i.e., politics and resources)
The team champion is responsible for the
success of the whole 8D program.
• Guarantees positive recognition for the team
“70% of Why do you think they fail?
Projects or •
•
Adoption of change
Lack of sponsor engagement
Initiatives •
•
Too many priorities going on at same time
History of past failed changes
Fail” •
•
They can’t understand it
They can’t shape or influence
• It attacks things they hold dear
• It lacks direction
McKinsey & Company
• And many more reasons…
13
13
Reference Guide Questions
D1 – Summary
Key Questions – Problem Solving Team:
Does the team champion have the necessary influence? Does the team have a knowledgeable 8D facilitator?
Will the team champion be an active member of the Does the team include the stakeholders?
team?
Is the team cross-functional?

Does the team include the process experts?

Class Exercise – Origami Jumping Frog
Objective: Each person has 10 min to build an Origami Jumping Frog. Frog must
jump at least 12”.
 Instructions are provided at origami.me/jumping-frog
 Materials are not provided. You’ll need to provide your own.
 The time limit for the build campaign is 10 minutes
 Frog must jump at least 12”

15
Team Exercise
Class Exercise – Identify the Team
Objective: Based on the initial problem statement

• Production • Quality Manager
from the customer (instructor), identify the best
problem solving team Manager • Planner
• Operator 1 • Director of Quality
• Operator 2 • Purchasing
Roles: • Operator 3 Manager
• Assembler • Tool Room
1. Team Champion
• QA Manager
2. Team Leader • Process Engineer – • Maintenance Lead
3. Team Members Operations • Director of
• Process Engineer – Operations
Assembly • Sales Engineer
Note: Select from the roles to the right (or similar • Quality Engineer • Company President
roles), not from your team members.

D2 – Problem
Description
D2 - Problem Description 17
Define the Problem
“If I had an hour to solve a problem, I'd spend 55 minutes “If you define the problem correctly, you almost have the
thinking about the problem and 5 minutes thinking about solution.”
solutions.” ― Steve Jobs
― Albert Einstein
“You don’t fix the problem until you define it.”
— John W. Snow
The definition of the problem, rather than its solution, will
be the scarce resource in the future.
“A problem well put is half solved.”
― Esther Dyson
― John Dewey
“We fail more often because we solve the wrong problem than “It's so much easier to suggest solutions when you don't
because we get the wrong solution to the right problem.” know too much about the problem.”
– Russell L. Ackoff ― Malcolm Forbes
The problem definition step is the most critical of the whole problem solving process!
Define the Problem
Specific problem statements are required for the root cause process.
Problem descriptions should provide the answer to: What? Where? When? How Many?
What?
 What is the part/product with the problem?
 Typically the part number, but could be the output of any process (on-time delivery rating, part
cost, etc.)
 What is the specific problem?
 What is the requirement being violated? What is the actual value? What was the specific
performance or test failure?
Every problem statement should include both:

• “Should Be” – What is the requirement?
• “IS” – What is the actual condition?
Define the Problem
Where?
 Where was the problem detected and who detected it?
 At Oshkosh receiving inspection? At supplier final inspection? By the shift supervisor? At the quality
gate? Etc.
 Where was the problem not detected?
 The problem is only present after paint? Complaints are only received from customers in cold
climates? Etc.
When?
 When did the problem occur? What is the scope of the problem?
 Shipment dates, lot numbers, batch numbers, PO numbers, date ranges, Etc.
 When is the problem not present?
 Is the problem only identified during humid months? Does the problem impact all lots or only some?
Is the problem on-going or is it new? Etc.
How many?
 How many parts/products/etc. are affected?
 How many parts? What percentage of parts?
Class Discussion
Define the Problem
Example A: 42.75" +/- 0.10 dimension out of What? Where?

specification on 271828 (Weldment Brackets) for 3 271828 Weldment
repeated shipments (reject dates 5/12, 5/13, 5/27 Bracket
from supplier Quick Machine Co). Quantity of rejects: Harrison Street
27 out of 27 pieces. Should Be: 42.75" assembly line
Is: 43.10“-43.15”
(Sample)
Rejected at Harrison Street assembly line on 5/30
When? How many?
because they did not fit. Two shipments have been
3 repeated shipments
received since 5/27 and do not have problem.
from Quick Machine Co.
27 of 27
Sample of 10 parts measures at 43.10“ to 43.15”. 5/12, 5/13, 5/27
Define the Problem
Vague problem definitions make the root cause

process impossible!
• Part is bad
• Paint looks bad
• Part doesn’t fit

(Problem description submitted
by JLG Aftermarket customer)
• Missing weld
8D Rule 2: Incomplete problem
descriptions lead to bad solutions.
• Doesn’t work
Class Discussion
Webex - Chat
Define the Problem
What is missing from these problem descriptions?

– Supplier XYZ for Oshkosh Defense has an on-time delivery rating of 54.3% percent (multiple part numbers
supplied).
– From when to when? Is this a long term problem or only for the last month?
– 38 of 38 pins in stock at IMT (all of the pins that were received in May) are long by .03 to .08.
– What part number(s)?

– Paint is chipped and scuffed on 274A274 brackets from the first production lot, found in supplier’s warehouse.
– How many brackets are chipped and scuffed? Is this 2 parts or 1000 parts?
– All 37 of the 274A274 brackets built in July have oil/grease contamination on all surfaces.
– Where in the process are the parts? Are they in stock? Have they not been painted yet?
Define the Problem
Good problem descriptions require good data.
 Get hands on the parts or vehicles with the problems

 Take photos
 Collect any available data – numerical inspection results, test results, performance
(miles to failure or time to failure, etc.), historical results
 Document what you find
Don’t forget to make sure that the

Always update the problem description based on what is found during containment “problem” you are solving actually
activities, as well as later in the 8D effort! is a problem.
What the problem What else it might be but
Define the Problem Who reported the problem?
IS
Who did not report the problem?
IS NOT
Harrison Street assembly line Harrison Street receiving inspection
WHO
Who is affected by the problem? Who is not affected by the problem that could have been?
Harrison assembly line Other Oshkosh plants
What ID's or reference # are not affected that could have been? (similar
(IS / IS NOT example A) What is the product ID or reference number? parts or processes)
WHAT
P/N 271828 Weldment Brackets Other weldments from Quick Machine Co.
What is (describe) the defect? What is not the defect?
Instructions: Do not fit 42.75” dimension measures 43.10”-43.15” Parts do not appear to be damaged
Where does the problem occur? Where is it not occurring but could?
WHERE
Harrison Street assembly line N/A
– Do not make assumptions. Where was the problem first observed? Where else might it occur?
Harrison Street assembly line N/A
When was the problem first reported? When was the problem not reported?
– Define: First reported 5/30, shipment date 5/12 from supplier Shipments prior to 5/12 or since 5/27
WHEN
– What the problem IS When was the problem last reported? When might it reappear?
– What the problem could be but IS Shipment date 5/27 Any future shipments
Why is this a problem? Why is this not a problem?
NOT WHY
Causes line delays and part scrap Problem has not been reported on 2 shipments since 5/27
Why should this be fixed now? Why is the problem urgent?
– Investigate as needed to provide Continued line delays and part scrap Risk of line stoppage if problem occurs again
accurate/proven answers. How often is the problem observed? How often is it not observed?
27 out of 27 parts shipped between 5/12 and 5/27 Any parts shipped prior to 5/12 or since 5/27
HOW
How is the problem measured? How accurate is the measurement?
Dimensional inspection of 42.75” using FARO arm FARO arm accuracy is approximately +/- .003"
– Highlight potentially key items. Can the problem be isolated? Replicated? Is there a trend? Has the problem occurred previously?
OTHER
Problem can be isolated to shipments dated 5/12 to 5/27 but cannot yet be replicated. This problem has not occurred previously.
Define the Problem
IS / IS NOT Problem Descriptions focus on the

differences between what you would expect the
problem to be and what the problem actually is.
Benefits:
– Kick-starts the investigation.
– Provides direction for the investigation.
– Ensures the problem is fully described and

understood.
What I expect the What the problem
problem to be actually is
D2 – Summary
Key Questions – Problem Description:
What is the part number? What lot numbers/batch numbers/shipments are affected?
What is the requirement that was violated? Is the problem a single occurrence or intermittent?
What is the nonconformance? How many parts are suspect?
Is the nonconformance description specific enough? What percentage of the parts does that represent?
Where was the nonconformance detected? Based on the updated problem description, does the team
composition need to change?
Team Exercise
Class Exercise – Problem Description
Objective: Create a problem description for

an 8D
• Investigate and create a full problem

description
• Do not make anything up, limit the

problem description to what you can
prove
Customer Problem Description: “Defective Frog”
D3 – Containment and
Short Term Corrective
Actions
D3 - Containment and Short Term Corrective Actions 29
Contain the Problem
Oshkosh manufactures safety critical vehicles. Effective containment of problems

is critical to protective the customer.

Contain the Problem
Containment means identifying

suspect parts/materials and preventing
use until the nonconformance has
been resolved or a short term
corrective action has been put in place.
Containment needs to occur along the

whole pipeline of parts/materials/etc.
Containment is focused on Product.

Short Term Corrective Actions

We can’t always stop and wait for a full investigation, so we need a way to apply
a band-aid until the problem is solved.
• Short Term Corrective Actions are temporary band-aids that you use to give
you time to investigate properly
• Short Term Corrective Actions are focused on the Process.

Short term corrective actions are a quick and dirty Types of short term corrective actions:
fix (often actions that would not be acceptable as a • Correct the immediate cause if it is known
permanent corrective action)
• Replace a worn tool
• Re-train the operator
Effective short term corrective actions are: • Repair the fixture
1. Contained At The Source And At Points • Rework parts
Downstream In The Process
Add an inspection or double check:
2. Implemented Immediately After Containment Is
• 100% inspection after operation
Complete
• Review every PO before it is issued
3. Proven Effective By Evidence
• CL1 or CL2 to protect the customer

It is tempting to stop the 8D after implementing a

short term solution, because the symptoms are
gone
If you stop here, the problem will come back.

Short Term
Corrective Action
8D Rule 3: Never stop after the short

term fix, even if the symptoms go away.

D3 – Summary
Key Questions – Containment and Short Term Corrective Actions:

Containment Short Term Corrective Action(s)
 When did the containment activities occur?  Is the short term corrective action being
implemented immediately?
 Where were containment activities performed? Was any part of the

pipeline missed?  Is the short term corrective action formally
documented?
 How many suspect/nonconforming parts were found at each area?

 Is there objective evidence that the short term
corrective action effectively insulated the customer
 What containment activities were performed? from the nonconformance?
 Does the problem description need to be changed based on findings in

containment?

D4 – Root Cause
Analysis
D4 - Root Cause Analysis 36
Understand the Process
Before beginning the root cause analysis process, you need to

understand the current state of the process or processes where the
problem occurred is necessary:
Go see!
• Watch the processes in action. Ask questions. Review process set-up,
work instructions, documentation, tools, training requirements, etc.
Utilize process experts
• The people performing the processes (operators, etc.) are the experts,
so make sure to use them
Utilize process documents
Map the process (using a tool like a flowchart) Do not try to solve problems on a
process you don’t understand.
Flowcharts
Flowcharts help you understand the current state of the processes where the problem might have occurred.
Strict flow chart rules and conventions aren’t critical.
Use a whiteboard or post-it notes to quickly map the process to make sure that it’s understood:
 Make sure inputs and outputs are understood (suppliers and customers).
 Identify all activities.
 Note the controls for each activity (e.g., work instructions, tribal knowledge, etc.).
 Make any other notes that are helpful for understanding the process.
You are trying to understand the process, not determine a final

root cause. Note everything that could potentially be relevant.
Flowchart example A
A B C

Why do we struggle so much with change?
Identifying what we lose and in what category, and then replacing that loss with a gain, or a find, or something new that helps to fill the
void and move us closer to integration and resilience.
Comfort
Control
Because we
experience a
loss! Competence
Connection
D4 – Root Cause
Analysis (Definitions)
Definitions Detection
Failure Cause
Process/Design
Root Cause
Systemic Root
Cause
Problem
Description
(Like Parts, Similar Processes)

Preventative Actions

Definitions
Process/Design Root Cause(s) – the direct Systemic Root Cause(s) – the underlying systemic
process or design related cause(s) which led cause(s) which created or allowed the direct root
to the undesirable condition. Eliminating cause(s) to occur. Eliminating this cause(s) will
this cause(s) will prevent recurrences of the prevent related failures.
same failure.
Example: No defined process is in place to control the design of
Example: Weld fixture design allows multiple setups of weld fixtures.
components on weld fixture. Only one of the setups can
produce a conforming part.
Example: New product design process does not include a
review of historical DFMEAs for probable failure modes.
The Process/Design Root Cause is what is typically
meant by “root cause”. Addressing it is the
minimum requirement for an 8D.

Definitions
Detection Failure Cause(s) – The reason why the Contributing Cause –

earliest opportunity to catch the undesirable Generic term for important
condition did not prevent the defect from causes other than the root
progressing to the next step in the process. It causes. In other words,
should answer the question: “Why wasn’t it
caught?” watch for the phrase that:
“It didn’t help that…”
Example: Work instructions do not clearly identify the
requirement for 100% inspection of the first piece for each
production run. Example: Work instructions for
welding process do not clearly
define the required setup to
8D Rule 4: Inspection cannot be the root produce conforming parts.
cause. Inspection catches defects. It
doesn’t prevent them.

Analyze – Investigate (Root Cause)
The root cause investigation steps repeat The key is to use a method (5 Whys, etc.)
themselves. It usually takes several repetitions of and to write it down! If the analysis is not
investigating and analyzing to start identifying root documented, then it will be impossible to
causes. review.
Investigate:
Interview
8D Rule 5: Document your root
Gather data cause analysis, every time.
Test theories Don’t get frustrated. It
takes effort and time to
Analyze: find the root cause.
5 Whys
Fishbone Note: The Oshkosh supplier 8D procedure requires
documentation of the root cause analysis.

5 Whys
Human Error – Operator Error

Avoid the “Blame Game”. Blaming and training (or disciplining) people is quick and
easy, but it does not lead to long-term improvement.
Make sure to ask WHY they made the mistake. Not just if they made the mistake.
Keep digging! The goal is to find the process/design or systemic root cause that led to
the human error.
8D Rule 6: Human error is not an acceptable root cause.

Section 47
Human Error Root Cause Analysis (HERCA) Worksheet
D5 Problem Description
Human Error – Operator Error
Investigation Questions Next Steps
1 Is the process complex? Yes No
2 Is the process highly repetitive? Yes No

Investigate the process
The Corrective
•
3 Is the operator being rushed? Yes No further in order to
Three key steps for finding the root cause of human error:
Action(s) need to make
identify the
4 Are there any ergonomic difficulties? Yes No physical changes to the
Process/Design Root
process
5 Are there any visual obstructions that make parts of the job hard to see? Yes No Cause(s)
Does the operator need to do anything out of the ordinary to complete the
6 Yes No
process?
7 Are the tools adequate to complete the process sucessfully? Yes No
8 Does the operator have all the tools needed to complete the job? Yes No
Investigate the tools, The Corrective
9 Is the tooling error proofed? Yes No
tooling and/or Action(s) need to make
– Interview people in a non-confrontational way to find out why they

10 Is the tooling in good shape? Yes No equipment to identify permanent changes to
the Process/Design the tools, tooling, or
11 Is the equipment adequate to complete the process successfully? Yes No
Root Cause(s) equipment
12 Is the equipment in good shape? Yes No
13 Can the equipment settings be changed more than the process allows?
14 Are the process steps documented in a clear and easy to understand way?
Yes
Yes
No
No made the mistake. Make it clear that you want to help them
succeed, not punish them for failing.
Are the work instructions (or other process documentation) missing any
15 Yes No
steps/operations?
Investigate the process The Corrective
16 Are the work instructions (or other process documentation) up to date? Yes No documentation further Action(s) need to make
Do the work instructions (or other process documentation) indicate when to to identify the permanent changes to
17 Yes No
use each tool? Process/Design Root the process
Do the work instructions (or other process documentation) indicate when to Cause(s) documentation
18 Yes No
use each piece of tooling?
Do the work instructions (or other process documentation) indicate when to
19 Yes No
use each piece of equipment?
– Go see! Watch the process that failed as multiple people perform it

Is the workstation well laid out? (parts and tools easy to reach, adequate
20 Yes No
space to perform job, etc.)
Investigate the The Corrective
21 Is the workstation organized? (everything has a designated place) Yes No
workstation and/or Action(s) need to make
(person who made the mistake and personnel who didn’t).

22 Is lighting in the workstation adequate? Yes No work environment to permanent changes to
identify the the workstation or
23 Are there similar but different parts or tools in the workstation? Yes No
Process/Design Root work environment
24 Is it possible to tell the status of each part in the workstation? Yes No Cause(s) documentation
25 Are there any significant sources of distraction near the workstation? Yes No
26 Has the operator been trained on the job? Yes No

Has the operator been trained on the work instructions (or other process
27 Yes No
documentation) for the job?
– Ask a lot of questions! You can use the questions on the HERCA
28 Was the training adequate? Yes No Investigate the
The Corrective
competency and
Does the job require any special qualifications/training that the operator does Action(s) need to make
29 Yes No training system to
not have? permanent changes to
identify the
worksheet as a guide.
30 Is the operator qualified to perform the job? Yes No the competency and
Process/Design Root
training systems
Cause(s)
31 Does the operator know how to verify their work? Yes No
32 Does the operator know what to do if something is out of the ordinary? Yes No
33 Does the operator perform the job regularly? Yes No
Human Error Root Cause Analysis

(HERCA) Worksheet

D4 – Root Cause
Analysis (Fishbone)
Fishbone Diagrams
Fishbone Diagram Things to know:

1. Break the diagram into 6
-This is a form of structured
primary categories:
Measurement, Materials, brainstorming.
Environment, Manpower,
Method, and Machine - It should be paired with another
method to analyze possible causes
that have been identified.
2. For each category, brainstorm
possible/likely causes -Do not argue about which category
a specific cause belongs in.
3. Analyze the causes, discuss When to use:
Can be performed by drawing the
whether causes can or can not diagram on a whiteboard and writing - Problem where you don't know
be controlled
causes onto post-it notes. where to start).

Fishbone Diagrams
Untrained No visual
Part tagged Weld
inspector work
wrong performed
Gage out Moved instructions
out of
of cal. during weld sequence Wrong WPS
used
Measured at Wrong sub-
wrong component
location s used No Work
Instructions
Sub- Component
First piece component s assembled
made from Wrong weld wrong No WPS
not checked Different
wrong filler
inspection
method used material
Fishbone Diagram – Weld equip.

not
No fixture
control
42.75” +/- .10 Dim. Is
43.10”-43.15” (27 of
No control of calibrated
Example A Cluttered
which operator
does which job
Not
enough
Fixture
holds
27)
weld booth clamps

wrong
Operator dim.
No weld
not trained
table Fixture
to this weld Wrong
Welder not assembled
fixture
AWS wrong
used
certified
Operator
Damaged Too much new to this Fixture
area Fixture
on floor schedule Operator warped
warped
pressure not trained
to this
inspection

Fishbone Diagrams
Fishbone Diagram
Fishbone diagrams are only a brainstorming Each cause needs to be analyzed and investigated:
method!
• Identify the most likely causes and investigate/prove
Don’t stop once the fishbone diagram is
complete. • Cross off causes that have been eliminated from
consideration
You need to prove or disprove the • Add possible causes that may come up
possible causes that you identify.
Update the fishbone as you investigate

Team Exercise
Class Exercise – Fishbone Diagram
Objective: Each group should develop a fishbone

diagram of likely causes for the problem.
Write the possible causes on post-it notes and place on
the fishbone diagram
Categories:
Measurement Environment
Materials Manpower
Method Machine

D4 – Root Cause
Analysis (5 Whys)
5 Whys
5 Whys
5 Whys Things to know:
- Excellent "quick and dirty" method for problem
Start with the problem description and just solving.
keep asking “Why?” until you have reached
the root cause. - Focus is critical. The 5 Whys can be derailed easily
if questions are not answered carefully and logically.
- Be specific! For each “Why?”, try to provide the

It can take less than, or more than, 5 Whys to most basic answer instead of jumping right to the
reach the root cause root cause.
When to use:
- Problem that is likely to have few significant
contributing causes.
- Problem that is not highly complex or critical

(should be used with other tools for difficult
problems).

5 Why Example
56
5 Whys
5 Whys Example A
Problem: 42.75” dimension on bracket measures A B C A B C
43.10-43.15” on 27 of 27 for 3 repeated shipments.
Why does the bracket measure 43.15”? – Components ‘A’ and ‘C’ were welded to component ‘B’ 43.15” apart
from each other.
Why were components ‘A’ and ‘C’ welded to ‘B’ too far apart? – The components were held in the fixture too
far apart.
Why were the components held in the fixture too far apart? – The components were assembled and clamped
into the fixture too far apart.
Why were the components assembled in the fixture too far apart? – The components can be assembled into
the fixture in several different orientations.
Why can the components be assembled into the fixture in several different orientations? – The fixture design
allows several orientations instead of just one. Fixture Design Error (Process/Design Root Cause)
Why was the fixture designed incorrectly? – Further investigation needed to reach systemic root cause…
5 Whys
The “5 Whys Trap” Two things to prove:

One of the most common 1. The answer to “Why?” is true. For example:
mistakes that is made on
the 5 Whys is to answer a Question: Why didn’t the operator know which specific fixture to use?
“Why?” incorrectly. Answer: The work instructions do not specify the required fixture number.
Objective Evidence: The team examines the work instructions to prove that the
Each answer must be fixture number is not referenced.
backed up by logic and 2. The answer to “Why?” is the actual cause. For example:
evidence.
Question: Why wasn’t the hose assembled correctly?
If the answer to “Why?” is not Answer: The operator did not follow the work instructions.
apparent, keep investigating.
Do not make assumptions! Objective Evidence: The team shows that following the work instructions will
prevent the problem from occurring.

5 Whys
Expanded 5 Whys
Same process as the 5 Whys, except that Things to know:
more than one answer can be given for - Same basic process as the 5 Whys.
each “Why?”
- Careful reasoning is needed for
At each stage, determine which of the marking causes as critical or non-
answers provided are legitimate and critical.
which can be ignored. When to use:
- Problem that is not highly complex

Look for major contributing causes and or critical (should be used with other
detection failure causes as well as tools for difficult problems).
process/design and systemic root causes.

5 Whys
Expanded 5 Whys example A:
A B C

D4 – Root Cause
Analysis (Root Causes)
Root & Contributing Cause(s)
Five questions to ask, to determine if you have found the Process/Design Root Cause (“the Root Cause”):
1. If you fix it, will it prevent the problem from 3. Is it blaming a person or organization?
happening again? • If the root cause is blaming someone, that means you
need to keep digging. You need to ask WHY the
person or organization made that mistake.
2. Is it a process or design issue?
• Are you changing anything with the process or the
design to fix the root cause? If not, you need to 4. Can you fix it?
keep digging.
5. Do you want to fix it?

5 Whys
Contributing causes: Problem
Description
• Critical causes other than the root cause, which

made the undesirable condition more likely to
occur
Watch for phrases like: “It didn’t help that…”
Root Cause

Class Discussion
Examples of weak root causes:
• Operator error • Wrong material selected • No paperwork
• Inattention • Machining error • Process not followed
• Failure to follow procedures • Workmanship • Wrong part
• Operator wasn’t trained • Supplier error • Caused by supplier
• I was busy • Untrained operator • Second check not performed
• Machined wrong • Job set-up wrong • Management
• Inspection failure • Inspection didn’t catch it

D4 – Summary
Key Questions – Root Cause Analysis

Is the root cause that was identified a problem with the process Will eliminating the process/design root cause prevent
or design, not a symptom? recurrences of the problem?
Does the root cause blame someone or does it address the Is the root cause within the control of the team/organization?
process or design?
Are significant contributing causes and detection failure causes

What method (5 Whys, fishbone diagram, etc.) was used to identified for correction?
identify the root cause?
Do the process experts agree with the process/design root

Was the root cause proven by evidence/logic? cause?

D5 – Long Term
Corrective Actions
D5 - Long Term Corrective Actions 66
Class Discussion
Chat in Answers
Correct the Root & Contributing Cause(s)
Match the root cause to the corrective action:

A) Fire the operator
1) Fixture allows several alignments
B) Re-write the work instructions to
Corrective Actions:
include all requirements
Root Causes:
2) Work Instructions do not identify all

steps C) Error-proof the fixture
D) Update WI to require first piece

3) Planning process does not capture inspection for all setups
revision changes
E) Re-write planning procedures to cover
revision changes
4) Initial set-up of process not checked
out F) Re-train the operator
G) Fire the QA person

Long Term Corrective Action principles: There are always resource limitations:
For cost/weight/time reasons, sometimes the root cause
• Always address the root causes (mitigate or cannot be eliminated (e.g., adding inspection instead of
eliminate) changing the process)
• Be specific There are times when the corrective action can only
decrease the likelihood of recurrence (e.g., adding better
lighting and work instructions to a manual weld process,
• Be formally implemented (not a statement of intent rather than changing to a robotic weld process)
or tribal knowledge)
Always be honest on your 8Ds. If you cannot fix the
• Be verifiable (i.e., it is possible to audit the
root cause, be sure to record that fact. It will help if
corrective action to verify implementation) you deal with the problem if it happens again.

Long Term Corrective Action questions:
What are you going to change? Who is going to make the change?
Fixture
Machine When will the change be made?
Procedure
Work Instructions How will you make sure the change was made
Policies correctly?
Etc.
How will you make sure the change worked?
What change are you going to make?

Example A:
Corrective Action: Manufacturing Engineering will change the fixture to allow only one
setup of components in the fixture. Fixture drawing 777A111 will be updated and fixture
777A111-1 will be reworked to meet the new requirements.
Implementation Plan:
A B C
W. Smith – Update 777A111, attach updated drawing as evidence – Due July 15
K. Ishikawa – Rework fixture 777A111-1, attach photos of fixture as evidence – Due July 29
G. Taguchi – Update welding PFMEA and Control Plan – Due Aug. 8
Verification Plan: Five different operators will set-up and run a sample part. The sample
parts will be dimensionally inspected.
D5 – Summary
Key Questions – Long Term Corrective Actions

Do the long term corrective actions directly address the root causes?
Do the corrective actions eliminate the root causes (prevent defects from occurring) or mitigate the root causes (decrease
probability of occurrence or ensure detection)?
Will the corrective actions be formally implemented or are they tribal knowledge or training?
Are the corrective actions specific and auditable?
What is the plan to verify that the corrective actions are effective?

D6 – Implementation
and Verification of
Long Term Corrective
Actions
D6 - Implementation and Verification of Long Term Corrective Actions 72
Implementation
Implementing Corrective Actions
When you implement a Corrective Action, you must make it permanent!
Formally implement the Corrective Action

• Verbal instructions, tribal knowledge, and/or one time training are
not long-term fixes
Questions to ask:
• Will this corrective action still work if we hire someone or fire
someone?
• Will the corrective action still be in place in a month? In a year?
Implementation
Update core documents including:

• Work instructions – update with any changes to the
process
• Process Flow Diagram – update with any changes to the

process
• PFMEA – update with new/updated risks based on

everything learned during the 8D AND with any changes to
the process
• Control Plan – update with any changes to the process

Implementation
Getting buy in
Always get buy in with the process owners (whoever performs

the process day-to-day)! Many corrective actions fail because
the team never gets buy in.
Involve process experts.
Make sure the process owners know what the problem was
and how the corrective action will eliminate it. 8D Rule 7: Without buy in, even the best
corrective action in the world will fail.

Implementation
Effective methods for verifying implementation:
Go see! Go witness the updated process. Ask questions, make sure that the updated process is understood
by everyone using it.
Use the 8D as an audit guide. Can you find evidence that they completed every action that the 8D said they
would?
Photos or other objective evidence. Take pictures of changes to processes or fixtures or other relevant items.
Get copies of updated procedures, work instructions, and other documents.

Verify Effectiveness
Effectiveness Verification answers the The method and length of the verification should be based
question: Did you eliminate the problem? on:
 Problem description (When? How Many?)
The key requirement is objective evidence  Is it a rare problem (low percentage effected)?
that the corrective actions have prevented  Would it be present on every batch/lot/job or does it
recurrences of the problem. happen sporadically?
Another way to think of effectiveness  The strength of the correction action

verification is: “Can I remove my short  Is it physically changing the process or design (e.g., creation
term fix, without having the problem re- of a new fixture, error proofing, etc.)?
occur?”
 Does it prevent the problem or only make it less likely (e.g.,
installing lighting, adding a checklist, etc.)?

Fixed vs. Growth Mindset
Be aware of which
mindset you’re in and
the impact it has on
your wellness
Fixed Growth
Mindset Mindset
• I’m only good at certain things • I can be good at anything

• I give up when it gets too hard • I try until I get the results I want
• I hate challenges • I embrace challenges
• I take feedback/criticism personally • I welcome feedback/criticism
• I don’t like what I don’t know • I like learning about things I don’t
know
D6 – Summary
Key Questions – Implementation and Verification of Long Term Corrective Actions:
Were the corrective actions implemented as the team expected?
Is there objective evidence that the corrective actions were implemented correctly?
Has the short term corrective action been removed without causing problems?
What objective evidence is available to prove the corrective actions effectively eliminated the problem?

Team Exercise
Poll Everywhere
Class Exercise – Corrective Actions
Objective: Identify corrective action(s) for the process root cause(s) that was identified.
• Develop a specific corrective action plan.
• Identify the objective evidence needed to prove that the corrective action was implemented correctly.
• Develop the effectiveness verification plan.
Note: You would document this plan in D5 (Long Term Corrective Actions). In D6
you would provide evidence that you executed the plan and that it was effective.

D7 – Preventative
Actions
D7 - Preventative Actions 81
The Preventative Actions

step is where you have
biggest impact.
Preventative actions should

address:
• Systemic root causes
• Like parts and similar

processes
Prevent failures for similar parts and processes that could have the same, or similar, process/design
problems.
Example A: Identifying other fixtures that can allow multiple orientations of weldment components,
similar to the 271828 bracket. Error-proofing fixtures that are identified.
Addressing any like parts or similar processes is a necessary step in the 8D
process and should be completed every time.
Address systemic causes that were identified during the root cause investigation.
 Example A: Project developed to analyze and improve the current processes for the control of fixtures and the
design of new fixtures. Project charter developed and approved on 6/21.
(Note: Some projects may take a long time to address systemic or widespread issues. If a project charter or project plan is developed,
the 8D does not need to wait on its completion.)
8D Rule 8: If you want the 8D to have real impact,

focus on the systemic corrective actions.
Communication plays a key role
• Image courtesy of Efficient Thinking Solutions
Change Leadership Change Management
85
D7 – Summary
Key Questions – Preventative Actions:
Have like parts and similar processes with similar process problems been addressed?
Have any significant systemic root causes been identified?
Should any larger scale continuous improvement plans be initiated (based on the systemic root causes)?
D8 – Congratulate the
Team
D8 - Congratulate the Team 87
Congratulate the Team
Successfully completing an 8D is a big deal! The Team

Champion should recognize the accomplishments of the
team.
• Personal recognition (in-person or via note)
• Recognition during all-hands meetings
• Awards (key contributor, etc.)
You provide the 8D team with recognition so

that they will volunteer to be on the next one.

D8 – Summary
Key Questions – Congratulate the Team and Wrap-up:
Has the team received recognition for improvements made to the process and system?
Was the 8D process treated as a continuous improvement activity?
Has the 8D process been documented so that it can be used to help resolve future problems?

Conclusion
Conclusion 90
Conclusion
Discipline is key to problem solving
1. Follow the process step by step. Don’t skip steps!
2. Ensure that each step is completed correctly before

moving on.
3. Document your process.

 You will not be successful the on the first try with every 8D.
Documenting your work means that you will not have to start over at
Pencil whipping 8Ds leads to solutions
the beginning if a solution doesn’t work. that are ineffective, expensive, or both.
Conclusion 91
Conclusion
A few final notes:

• It takes practice to become a skilled problem solver.
• Make sure to get feedback from other skilled problem solvers.
• Don’t be discouraged if your 8D isn’t perfect. Ask yourself: “Did I make a permanent
improvement to the process or system?”
• Reach out if you need assistance, Oshkosh has people who can help.
Conclusion 92
Questions?
8D Rule 1: If there’s no team, it’s not an 8D. 8D Rule 5: Document your root cause
(D1) analysis, every time. (D4)
8D Rule 2: Incomplete problem 8D Rule 6: Human error is not an

descriptions lead to bad solutions. (D2) acceptable root cause. (D4)
8D Rule 3: Never stop after the short term 8D Rule 7: Without buy in, even the best
fix, even if the symptoms go away. (D3) corrective action in the world will fail. (D6)
8D Rule 4: Inspection cannot be the root 8D Rule 8: If you want the 8D to have real
cause. Inspection catches defects. It impact, focus on the systemic corrective
doesn’t prevent them. (D4) actions. (D7)
Conclusion 93

8D Problem Solving

Uploaded by

Copyright:

Available Formats

8D Problem Solving

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

8D Problem Solving

Uploaded by

Copyright:

Available Formats

8D

• D1 – Problem Solving Team

• D3 – Containment and Short-Term Corrective Actions

• D4 – Root Cause Analysis (Definitions, Fishbone, 5 Why, etc)

• D5 – Long Term Corrective Actions

• D6 – Implementation & Verification of Long-Term Corrective Actions

• D8 – Congratulate the Team & Conclusion

There is no method of improvement more effective than good problem solving

A problem is an opportunity for improvement that:

• You can quantify the benefit of addressing

• You can convince others is worth addressing

3. Prevention of similar problems

4. Overall improvement problem

Excel spreadsheet on the OSN Reliance SCAR

Before kicking off an 8D, you need to understand:

How significant is the impact? Is this an emergency? Does it need to be

What is the scope of the problem (best guess)?

Has this happened before?

Pareto analysis is one Pareto Chart

Develop long Implement

D4 Root Cause D5 Long Term D6 Implementation and Verification D7 Preventative D8 Congratulate

Teams are critical to problem solving!

• Overcoming initial biases is difficult and

• Getting buy-in is difficult as an individual

8D Rule 1: If there’s no team, it’s

D1 - Problem Solving Team 11

• Does not actively participate in team

• And many more reasons…

Key Questions – Problem Solving Team:

Is the team cross-functional?

D1 - Problem Solving Team 14

 Instructions are provided at origami.me/jumping-frog

 Materials are not provided. You’ll need to provide your own.

 The time limit for the build campaign is 10 minutes

 Frog must jump at least 12”

D1 - Problem Solving Team 15

Class Exercise – Identify the Team

Objective: Based on the initial problem statement

D1 - Problem Solving Team 16

Every problem statement should include both:

Define the Problem

Example A: 42.75" +/- 0.10 dimension out of What? Where?

Vague problem definitions make the root cause

• Paint looks bad

• Part doesn’t fit

What is missing from these problem descriptions?

– What part number(s)?

Good problem descriptions require good data.

 Get hands on the parts or vehicles with the problems

Don’t forget to make sure that the

Harrison Street assembly line Harrison Street receiving inspection

How is the problem measured? How accurate is the measurement?

IS / IS NOT Problem Descriptions focus on the

– Kick-starts the investigation.

– Provides direction for the investigation.

– Ensures the problem is fully described and

Key Questions – Problem Description:

What is the nonconformance? How many parts are suspect?

Class Exercise – Problem Description

Objective: Create a problem description for