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Fundamental Questions to ask when an Issue arises...

Discussion in '5S, 5Why, 8D, TRIZ, SIPOC, RCA, Shainin Methods...' started by Tom Waite, Aug 3, 2015.

  1. Tom Waite

    Tom Waite Member

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    One of the first questions I ask when digging into an issue is:

    If we followed the system as written would we still have the issue?

    If yes, it is a systematic issue, if no, it's a human factor issue. Sometimes it's a little bit of both.

    What is one of the fundamental questions you ask when an issue arises?
     
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  2. Claes Gefvenberg

    Claes Gefvenberg Moderator Staff Member

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    Good question. I would say that the fundamental question is: What could we do better?
     
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  3. PaulJSmith

    PaulJSmith Well-Known Member

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    I think the two most important questions are;
    1) Where/why did the failure occur?
    2) What can we do to improve it?
     
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  4. Ganesh Sundaresan

    Ganesh Sundaresan Active Member

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    On a lighter side, Who can be given the ball. Jokes apart, my fundamental question, is there a standard or specification or rule or guidelines or a mechanism or a commonly agreed way of doing things?
     
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  5. Bev D

    Bev D Moderator Staff Member

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    Well since humans developed the system there is always some contribution of the human to the problem (or issue); that's not to say that they are to blame as it is about root cause not root blame.

    the first questions that I ask are about defining the Problem:
    "What is the Problem" in terms of object/event and defect/failure. This is terms of effect and not cause
    "What is the Y": This is the characteristic that can be measured or observed/assessed that results in the problem when in a 'bad' state.
    "How is measured or assessed": This is a first hint at the effectiveness of the measurement system
    "Why Does it matter". What is the negative effect to customer, delivery or cost of this Problem.
    "What is the occurrence rate and trend"
     
  6. RoxaneB

    RoxaneB Moderator Staff Member

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    This is, in my opinion, the most important question to ask and should be asked first. After all, if it does not matter, is it truly a problem? If it's not an issue, is it truly worth spending time, money, resources on...at least at this point in time?
     
  7. reynald

    reynald Member

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    I think somewhat similar to this, though the exact questions in my head are (1) is the issue real or just perceived, (2) to whom is it an issue, and (3) why is it an issue.
    The first question is to check alignment in operational definitions. Some people could be raising hell on what they thought they understood but when definitions are checked it turns out they just misunderstood something and thought there is an issue. The next is the stakeholder (and do they matter?). It is a reality that there will be some trade-offs in the business. If someone buys for instance two UPS (un-interruptible power supply) to reduce risk, a lean manager (the st*pid me, let's say) may say there is a waste. If I ask the IT manager, he/she would say it is not. This may not be a good example but the point is an issue may depend on a who is looking.
     
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  8. Pancho

    Pancho Active Member

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    I'm with Bev. "Digging into an issue" should mean gathering facts, so the first question we try to ask is "What happened?".

    Facts can be difficult to collect, but it's important to have them before starting to analyze.
     
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  9. Chris Glover

    Chris Glover Active Member

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    We put this together a few years back when we had several new QA associates who needed step-by-step guidance
     

    Attached File(s): 1. Scan for viruses before using. 2. Report any 'bad' files by reporting this post. 3. Use at your own Risk.:

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  10. David Bradley

    David Bradley Member

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    One of the first questions I ask is: "What changed?" If we were making good parts for months (or the process was working properly ), or years and suddenly we aren't. Something changed. Variation is always the cause of issues. Either we introduced a new source of variation, or increased the amount of existing variation.
     
  11. Bev D

    Bev D Moderator Staff Member

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    The New Science of Fixing Things (www.tnsft.com) has a paper entitled "3 good questions and 1 not so good question" that apply to questions regarding the diagnostic search for cause, particularly when approaching a new Problem that you know little about. (They also have a saying "equipment have Problems and People have issues" that alwasy make me laugh...we tend to use the term issue as a softer phrase than Problem) These are different questions than those used to describe the Problem which helps with prioritization and resourcing as well as providing a solid foundation to begin the diagnostic process. It's all a bit of an art and a bit of a discipline....

    you might find these useful:

    Question 1: What's wrong? this is the equivalent of "is it plugged in and turned on" type of question when you are looking for the obvious actionable immediate cause. "is it in specification" is another of these questions.
    Question 2: What Changed? fairly obvious what it's getting after but it's the weakest of the 4 questions from a diagnostic standpoint. It is very susceptable to 'post hoc ergo propter hoc' errors of coincidence. (the paper's John Allenalways answers this one with "everything" and of course he's right) Why is it so weak? because lots of things change continually so it's easy to see a surface change and think it caused the Problem. We can and should answer this question, but my expereince is that we only do this once we understand the causal mechanism through other means first. I will say that I do send my teams out to try to answer this question in the beginning anyway as due diligence demands we check the easy stuff first...
    Question 3: What's Different? This is a great question and gets us to the answer to "what changed" quicker. Whats different between the good parts or events or lots and the bad parts or events, or lots...
    Question 4: What's Happening? This may be more difficult or as easy as observing the actual failure happen.
     
  12. Tom Waite

    Tom Waite Member

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    Good feedback everyone. This is an example of the many ways we all look at things but ultimately getting to the same place with different paths. I think fundamentally we are all saying the same thing just with our own twists.

    Good stuff!
     
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  13. tony s

    tony s Well-Known Member

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    Since I always believe that a problem will only happen if an event, condition, situation, or outcome doesn't happen as expected or desired, I will usually start with this question: Why is it a problem?
     
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  14. ncwalker

    ncwalker Well-Known Member

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    Today I find my first question often is: Is this information real?

    Too many times I chase off after an issue only to find during investigation, it wasn't really an issue. Or the severity of it, at least, is apt to get quite overstated.
     
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  15. MarkMeer

    MarkMeer Well-Known Member

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    I'm a bit wary of the distinction between "systemic" and "human factor".

    How does this help? How does such a distinction affect the action(s) you take?

    To me, the better distinction is between:
    - "Systemic" - issues that have a reasonable probability of recurrence, or potential to impact other elements (product quality, customer satisfaction, record integrity, ...); versus
    - Issues that may be isolated incidents, with low probability of recurrence, and minimal potential impact.
     
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  16. Marc Smith

    Marc Smith Moderator

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    Reality: If we followed the system as written would we still have the issue?
    A) If not, Five Whys starting with why the person or persons didn't follow the protocol/procedure.
    B) If you did - Five Whys.

    * Five Whys = Ask relevant questions (see post 11).
     

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