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Ready, Shoot, Aim!!!!

We are unhappy with the effectiveness of the results of our ... - Mar 14, 2001 by davef  


Ready, Shoot, Aim!!!! | 14 March, 2001

We are unhappy with the effectiveness of the results of our problem trouble-shooting / corrective action process. It�s not as bad as the classic "Ready, Shoot, Aim!" ... but some things just never seem to get fixed. A partento of the causes of our problems is:

* Inadequate personnel performance

* Inadequate communications

* Noisy environment

* Machinery malfunction

* Rules known, but not used

* Poor judgment

* Inadequate training

Amazon shows the following "5 star" books written by consultants:

* "Root Cause Analysis - Improving Performance for Bottom Line Results" by Robert J. Latino & Kenneth C. Latino

* "What You Can Learn from Things that Go Wrong - a Guidebook to the Root Causes of Failure" by C. Robert Nelms

* "The Root Cause Analysis Handbook-A Simplified Approach to Identifying, Correcting, and Reporting Workplace Errors" by Max Ammerman

* "Root Cause Analysis : Simplified Tools and Techniques" by Bjorn Andersen

* "Apollo Root Cause Analysis - A New Way Of Thinking" by Dean L. Gano

Can anyone suggest a good, "hands on" root cause analysis methodology? Some of the crap written by consultants is so anal that the carbon units have a tough time working it out. Yano?

Oh, and we want to avoid is the "complex machine maintenance" approach. Some of these consultants make their dough helping trouble-shoot process plant problems. Some of these plants are really very complex and some times it can take several shifts to properly understand a problem, not to talk about the couple more shifts to fix the mutha bear. [I used to run a plant that cooked dirt 'til it glowed bright red in my younger days. So, I know of whence they speak.] So these cats [the consultants] specialize in developing a language and communication tools that help the maintenance techs on various shifts work as a team to figure-out why the bearings in the flammer valve keep seizing. [Bosses get brezerk when a process plant that makes a penny on a pound of material goes down for a week to fix a problem and then take another cuppla days of producing scrap before running good product.]

Our problem is more along the line of us not drilling-down through the causes of a problem to determine that shiny bright nugget that is the root cause. Yano, the ol' "ask 'Why?' three times" type stuff.

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Michael Parker


Ready, Shoot, Aim!!!! | 15 March, 2001

Whew, what set you off, amigo? You're absotively on target. Those book authors are writing to their own peer group audience, therefore all you get is techno geek jargon. It takes a seasoned (basted lightly)veteran to interpret. You know, the battle hardened sergeant, always in the trenches, who saves the butt of many a 90 day wonder 2nd Lieu-ey. I say, demand the publisher take the draft to the grass roots users for proofing and get something useful. That is my root cause analysis.

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Ready, Shoot, Aim!!!! | 15 March, 2001

Aw, the internal audit folks just busted us for recurring, potentially ineffective corrective actions on both the quality and safety sides.

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C. Robert Nelms


Ready, Shoot, Aim!!!! | 16 March, 2001

David Fish alerted me to this dialogue, after visiting my web site. I am one of the "anal" consultants that are trying to help people "learn from things that go wrong."

I don't know where to start. Perhaps by asking you not to lump all of us together. David suggested in his post that many approaches were developed for problems typical to heavy industry. Others were developed primarily for the nuclear industry. Others for healthcare.

You might not agree with me here, but it is valid to think that the way to address the PHYSICAL causes of our problems will be different depending on the industry. But the way to identify and deal with the REAL ROOT causes of a problem do NOT vary industry to industry, because they address HUMAN BEINGS.

The author of the post I am replying to could not have read the books suggested by David. My book, and Dean Gano's book are both written for EVERYONE. Yes, some of my examples are from the smokestack industry. But the bottom-line ROOTS are the same everywhere.

Give those of us who are trying to help a chance. Don't throw the baby out with the bath water.


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C. Robert Nelms


Ready, Shoot, Aim!!!! | 16 March, 2001


Thanks for telling me about this web-site! Great site!

I very much appreciated this message. To be honest, after reading some of the other messages here on this forum, I almost decided that this site was not for me. Seems like most / all of the talk is technical in nature. Technical is, of course, necessary. But it's not where the TRUE Root Cause Effort focuses.

In my "world," we make a distinction between PHYSICAL, HUMAN, and LATENT causes of "things that go wrong." The PHYSICAL causes are the technical causes. The HUMAN causes identify things people DO (or don't do) that lead to the PHYSICAL causes. LATENT causes address WHY PEOPLE DO WHAT THEY DO, and end-up talking about the things on your list.

I would very much like to participate in a dialogue here.

What can I do to assure this?

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Robert J. Latino


Ready, Shoot, Aim!!!! | 16 March, 2001

Dear David,

Like Mr. Robert Nelms, I must be included in the "anal" consultants category. While I understand your frustration and dissatisfaction with whatever approach you were using, there is progress being made out there.

The "right" consultants are oftentimes people that come from the industry they consult in. I suspect from the sounds of your extensive experience and expertise that you may one day take the early retirement package and come back to consult in your industry.

No matter what Root Cause Approaches are out on the market, all have to agree on the science behind the mechanics of failure: there are a series of cause and effect relationships that lead to any undesireable outcome. This is not opinion, this is fact.

The difference behind that various RCA approaches you mentioned is the manner in which they graphically derive and express these relationships. Some use 5-Whys, some use fishbones, some use fault trees; whatever the case, all of them express cause and effect relationships.

Your task is to find which one is the most valid for your circumstance. One of the main differences between these approaches are which ones require verification of their hypotheses. In many approaches, a team brainstorms and comes up with causes then moves right into solution. If the causes are not backed up with data, then it is basically hearsay. Does hearsay hold up in court?

It is unfortunate that you did not find value in whatever approach you used. I can assure you that many of consultants out there can provide you references to check with and sound case histories to demonstrate their success in the field.

However, many of these approaches do not fail because of a deficiency in the method, but because management does not support the effort. You can have the best analysts and method in the world, but if management does not support the task in the field, it is doomed. Just because a company has a fancy CMMS system, does that mean it will be useful and effective in the field. Not if the users do not know how to use it!!

I am one of those authors you listed and I invite you to read not only our approach, but the others. Then you decide which is the most practical for you.

Thanks for sparking the discussion and I hope you find the approach that will optimize your lengthy experience and expertise.

Best Regards,

Robert J. Latino Vice President Reliability Center, Inc.

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seeking better process | 16 March, 2001

C-Tech is the 8th fastest growing company in New Jersey, yet we are so small and can not afford to buy expensive assembly equipment. Currently in production, we have 8 different through-hole boards and 1 surface nount board. In the past we have had the smt boards asembled by a contract manufacturer which was ok but very expensive. We have since been assembling this board in-houseusing the simplest process known to man, but this still requires much time to complete even one panel (16 boards). This board consists of: 2 elec. caps, 4 ceramic chip caps, 8 chip resistors, 2 transistors, a diode and 1 IC. The package sizes include 0805, 1206, SOT-23, FM-1, and SOIC-14. I am currently screening the paste on by hand, then placing the parts on by hand and using a hot air iron to complete the process. This process does work for the quantities, but i am the only one here who can do this and i am up to my neck in protos. Would anyone be able to direct me towards a new method or maybe some cheap equipment? sorry for posting in this thread!

thanks, Ed Hart

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Ready, Shoot, Aim!!!! | 16 March, 2001

just gotta put in my two cents worth......

theories are great, and I do not disagreee that almost all root causes can be traced back to human error.

( just an aside, but it would be a little hard for me to get ahold of the production guy somewhere in Asia who went home early on a friday and rushed thru the last widgit he was building, that ultimatley ended up on my machine and failed just as I was in the middle of a million dollar order for the month, and now I need to wait a week to get the part ).

but in the real world ( my world anyway ), you are always behind the eightball with deadlines, and the boss wants as much product out of his expensive equipment as possible, first just to cover the cost of it, and secondly to make a little money if possible.

We all know how costly mistakes are and how easily they can add up to huge costs ( rework, scrap etc) and I'm sure I'm not alone in working 10-12 hours days busting my ass trying to get all the pieces to fit at the same time to keep the errors out and the product flowing.

I share the same frustrations as Dave in KNOWING what the problems are, but lacking the TIME and proper help ( tools, education etc )to resolve them.

Even worse, when you get busted by someone who really doesn't understand the day to day grind you are put thru

If you really want to help and improve us human beings, start at the top and get all the head honchos to buy into your theories. Then maybe I won't get crucified when my justification for missing the monthly target is that I took all my production staff off the floor for a week so we could all learn to work together better...........


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Michael Parker


Ready, Shoot, Aim!!!! | 16 March, 2001

To validate my previous response, I have many hours, both practical and class room, a burgeoning library of bokks, etc. No I have probably not read the specific books mentioned, that does not invalidate my point. To be more specific, I have to be the interpreter of the techno jargon to the masses. In Silicon Valley, we have every culture and education level imaginable. These are the ones that need to learn and implement the disciplines that keep the quality on track. Couple the culture, lack of education with a dynamic economy that goes up and down, lay-offs and new hires cycling. I am forever in a vicious loop of training and interpreting to achieve the end result. Give my elementary level books in Cantonese, Mandarin, Vietnamese, Tagalog, Sikh, Farsi, Spanish, etc. Make them available cheap. Minimize mean time to trained and effective. Unrealistic demand?

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Stefan Witte


Ready, Shoot, Aim!!!! | 16 March, 2001

Hi Dave, we were touching that topic already during our 6 sigma dialog. I strongly believe the root cause for most of the problems is lack of education. I also find that sometimes employees use the information deficit as a protective shield, like � I�m not trained to fix the problem, so I thought someone else will do.....�. Unfortunately, most of the time there is nobody else. Knowing how to fix the problem also means you are responsible for fixing it. What are the rewards if you do so? Do you get more pay?

If you are sufficiently trained for your job and you receive adequate payment, it will be difficult to explain to yourself and to your boss why you did not attack the problem.

Now, what is sufficient training? It used to take me a week to install a machine and train the customer. In fact, I could have easily spent four weeks and more. I assume the customers would not have bought the machine to begin with, knowing that there was 4 weeks of training involved to operate the machine. In a very competitive environment of electronic assembly, nobody seems to recognize the benefit of long time training. Manufactures seek for employees already trained. The kind of training these employees received were the one week instruction during installation some years ago, plus the experience that the machine always broke down and that the machine manufacturer has to take the blame for it.

The top level and their mislead managers may argue that employees training will result in higher cost of the end product. I can not proof that the increased quality and yield due to better skilled operators computes even with the cost of training, but I know for sure that the consumers are willing to spend more money for quality products. The employees pride for his/her contribution to the end product and the loyalty to the employer who covered the cost for the training can hardly be measured in $$$ figures.

Speaking about cost of training. How much does it cost in comparison to send a manager to a training class about leadership and problem solving and a machine operator for fixing machine problems? Why is it so much easier to spend that money and waste it, for yet another idea of leader ship and for the consultants who praise these ideas. I do admit that my employer wasted the money to send me to that manager training.

In the past ten years I have not seen much of a change the machines operate, or in the way the boards are manufactured, but I have seen a lot of different theses and book titles for problem solving managers.

As usual, Dave is right to attack the root cause of the problem instead of problem management. Spend the money for the grass roots manufacturing the products, instead of the managers who try to build the people!

On some other manufacturing sites I visited, unions did not permit the operators to fix the machine problems. But I guess this is another topic.


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Ready, Shoot, Aim!!!! | 17 March, 2001

Robert, this is an open forum. Everyone is welcome to post their experiences, opinions, and ideas.

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Ready, Shoot, Aim!!!! | 17 March, 2001

The Meeting is in 5 Minutes series "Root Cause Analysis" (initially published in Roundel Vol. 4 No. 2, September 1996) By Marek Wakulczyk

Panic time again ! The boss wants to talk about "root cause analysis" and somehow you get the feeling it has nothing to do with trees. Here is just enough information to let you fake it, this time. What is it ?

The goal of root cause analysis is finding the real problem and avoiding the old witch hunt approach. You want to discover the root of the problem, as opposed to simply treating symptoms. There are many tools and techniques that apply, and the issue can easily be made as complicated / painful as your heart desires.

How do you do it ?

The simplest , most basic way to find root cause is to ask "why ?" (at least) five times. (refer to example table below)

STEP 1: Define the starting point question.

STEP 2: Ask "why ?" to the previous answer

STEP 3: Repeat step 2 at least five times.

STEP 4: Voila, a root cause. Now you can do something about the problem.

Step Question Answer

1 Why was the meeting unproductive ? Not everyone was ready

2 Why ? It was a short notice meeting

3 Why ? Another office needed a quick answer

4 Why ? They had not been given all the information

5 Why ? The previous meeting's output was incomplete

6 Why ? Nobody was ready. It was a short notice meeting

Root cause: In this example, the likely root cause is that people are not given enough time/direction to prepare for the meetings.

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Ready, Shoot, Aim!!!! | 19 March, 2001

Hi Dave, I may read the �Root Cause Analysis� to get a better understanding what it is all about. My general impression is that the sessions are purposely held short and with a short prior notice. It is not supposed to give you too much time to question the entire system. Follow the instructions, but don�t implement your own thoughts. There is not enough time given to answer your questions. Just do it, you dick head, WE think for you! If you are raised and educated with critical thinking, you may apply that in a micro environment of your family and friends but at work it is not always desired. You belong to a minority. At work you have to balance your position between your boss and the people who work for you. Problem solving is one of the many tasks you have to educate your own employees. If you did educate them already your way, your team may get to the root cause already without instructions. You can not skip the meetings, only because it does not apply to you. You still have to please your boss. If you provided your team with enough instructions and all the tools they require to do their job (I know you do, as much as you share your knowledge here on this site), then your team may work more effectively then other teams in the plant. If this is not been recognized and rewarded, you may want to look into other options of you life.

Thousands of employees were laid of from Motorola, Compaq and others. Along with the employees, hundreds of placement machines and other assembly equipment becomes available on the used machine market. Rumors are that some of these plants will not continue manufacturing even when the economy picks up again. This will mean a boost in subcontracting manufacturing. Do you want to start your own business ? This is a good time. I guess quite a few readers of this site are looking for new opportunities. Wolfgang would even paddle over the ocean and join you ( or us ), if we settle somewhere at the south east coast. Stefan

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Ready, Shoot, Aim!!!! | 19 March, 2001

The technique you describe is contrary to the approach we've taken to educating our folk and helping all to understand what's going on and being involved. Not sure how well that would play in Peroria.

I'm looking for tools / techniques / what not that will help us be more organized / structured in our trouble-shooting. Without good corrective action, its like a quality system grand mal seizure. It's where all the screws end-up on the floor, not matter how well you do all the rest of the stuff.

Still looking for a good contractor down in 'Lanta, eh? Should we need to talk about moving south?

Yes, I miss Wolfgang too. He could always get past the dreck [if that isn't too much of it ... ], but I think he didn't like the new format of the Forum.

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CC to myself


Ready, Shoot, Aim!!!! | 20 March, 2001

I got into the electronic assembly business because I love fixing machines. It is very satisfying to see an assembly line working the way it should. Then comes the new operator, and the output graph goes down.

If most root causes are the human factor, then one solution is the training of the operator. Unfortunatly, operator are not machine and are prone to improvise, i.e.: not following procedures.

As for the problems that comes from the machines themselves, the only time I use any kind of root cause analysis was when I was faced with an unknown machine. Personal experience and total familiarity with the machines is best.

So, all employers want to have maximum output with minimum investment. That translate into dozens of button pushing operators and one overloaded, overstressed but knowledgable process engineer/maintenance tech.

I have tried many times to elevate the quality of the operators by sharing knowledge with them, but I found that in 90% of the cases, they could not even comprehend the importance of using the proper philips screwdriver size. Most did not even know there were different sizes!

This level of ignorance is hard to improve, because the reason they don't know is that they don't care. Why should they care if they can scrounge a living with what they do know?

Root cause analysis? I love my job, I love learning, the most efficient tool in troubleshooting is personal experience and familiarity with the machines. Root cause analysis is a good basic tool to organise knowledge in a logical manner. But what to do when you have to work with people who have as much interest working with machine than packing grocery bags?

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Ready, Shoot, Aim!!!! | 20 March, 2001

Dave, you may want to try an approach by categorizing upcoming issues by their priority. List the daily issues: machine down, operator sick, answer the phone... and give them a priority key (urgent, important, critical... ). Make a plan, on how to react to all these issues. If you find a root cause for some of these problems, this may be a good place to write them down. If the problems are unavoidable, you don�t want to sin over the root cause.

Do you really have a scenario of two or more problems to the same time? Or is it a chain reaction?

Do you have an escalation plan? What has do be done if the machine is not fixed within X hours? Can you run the job on another machine. How long does it take to shift the job to another machine? Do you have emergency resources ( help from other divisions )?

Think about a surgical operation, when the machine is down. Whoever operates has assistance with clear, shared responsibilities. This is a severe situation. Don�t joke around. You can relax when the crisis is over.

Play a false alert machine down scenario and see if your plan works (you may want to ask your boss for permission first)

Are the jobs scheduled correctly to begin with? Do you have room for errors? Are the jobs scheduled with priority, or do they all have priority one?

Do you have software tools scheduling and tracking the jobs?

Don�t look for a perfect plan on how to attack and solve problems. It seems to be more important to get a routine and be consistent in it. If you have a routine, you can measure time and efficiency. If you improve your plan, you can measure again, if your improvement was effective.

I kind of agree with Claude that it is difficult to find an incentive, why people should do more than they are already doing, if not for more money. However, in times like this, it could be a matter of keeping or loosing the job. How about this for an incentive?

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Bob Nelms


Ready, Shoot, Aim!!!! | 21 March, 2001


If I understand your note correctly, I certainly agree with some of it and disagree with some of it. Of course we all need to be able to communicate with whomever we have in front of us -- to speak and write at their level, etc.

But to help people LEARN, truly LEARN from things that go wrong requires an unusual effort -- because MOST human beings (actually all of us) do not really WANT to take the TIME to learn. Even your message suggests that you want something quick. See? Quick! Learning requires us to slow down. Fact of live. We can't get around that.

Let's keep talking

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Bob Nelms


Ready, Shoot, Aim!!!! | 21 March, 2001


The TIME predicament you talk about is something we "consultants" deal with every day. We certainly understand the issue. Interestingly, some of us think that TRUE root cause thinking WILL NOT OCCUR until or unless it is driven from the BOTTOM-UP. Think of it, the folks at the top, by job definition, are required to rivit their eyes on the bottom line. Don't fault them for this -- that's their job. They need to be convinved by YOU that its in their best interest to SLOW DOWN A BIT.

We have our case histories to show them, and we have our powerful sales pitches that wow them, but they're not stupid. Anyone can make the numbers look anyway they want them to. When it comes right down to it, and this is going to sound riduculous maybe, but it almost requires a REVOLUTION started by YOU.

From my perspecitve, I get frustrated when I hear ALL levels crying that "the other guy" needs to support this. YOU just do it! That's what I've done.

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Michael Parker


Ready, Shoot, Aim!!!! | 21 March, 2001

Having re-read my message I do not know where you deduced "quick", unless you are taking "minimize mean time to trained and effective" as being I want the fast food version.

What I mean is what you already agree with, make the information available in method and media that can be easily communicated to the masses, rather than put the trainer through hoops, just to get the intended message across. I find no lack of eagerness to learn from the people I am charged to educate, just a lack of resources that can be used to do the training effectively, crossing cultural, educational and language barriers.

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Ready, Shoot, Aim!!!! | 21 March, 2001

Thank you for the contributions you've made in this thread.

May be setting people free to be involved in other areas is the answer. Situations that have me grinding my teeth are:

* The head of Purchasing drop-ships a reel of resistors to a burn-in subcontactor, without first bringing the parts in-house for acceptance [which he knows he must do, since he wrote the procedure]. He doesn�t request a waiver [which he knows he must do, since he wrote the procedure] � awwwhhhh!!!

* Operators on a SMT process line shut the reflow oven down for 2 hours to remove a melted dry cleaner bag from the oven conveyor [they knew, but forgot, that "out-side materials" are prohibited form the line because they agreed they weren�t supposed to do that and signed their training class acknowledgment on "out side materials and tools" and ESD]. They don�t know the source of the bag [yeh, surh]. � awwwhhhhh!!!

* Supervisor uses unapproved solder on salable boards with no tracking, waiver request, or nuthin [which she knows she should do because she runs the protocols for critical materials evaluations to be used in her area]. � awwwhhhh!!!

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Michael Parker


Ready, Shoot, Aim!!!! | 21 March, 2001

Now that more of the root cause is evident, that which set your frustration in the first place, maybe the answer is READY, SHOOT, FLOG 'EM!!!

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Ready, Shoot, Aim!!!! | 26 March, 2001

Don�t panic and don�t hope to get past the dreck. I had a dream... but than I realized that it takes 1. hard work 2. perseverance 3. hard work (... because it takes twice as much hard work as it takes perseverance )

My personal experience (faults): - thinking that whatever I found out the others automatically know is wrong - thinking that telling others about my new "wisdom" would get them any further is wrong - thinking that defining clear processes and teaching them will solve all the problems is wrong - thinking that in the workplace only the work counts is wrong - thinking that just sufficient information for a certain task is sufficient is wrong - thinking that pressure improves something is wrong (I actually didn�t do that myself) - ...

Getting people to obtain a vision of what they do and how it adds to the success of the whole enterprise , and the other way round getting bosses to accept that Human beeings are no machines and do need a different kind of PM ( Personal maitenance ) than machines is the key to many problems in our industry. "We have to act as a team, that means you have to do what I tell you" just works if everything you say is so "omniright" and your team accepts you as the great guru they happily obey.

Getting people involved in the problems, asking their oppinions, explaining decisions, giving the opportunity to make own experiences showed to be the better way. At least it�s a more relaxed environment to work in and people develope a different attitude to work and they know of more problems than I could imagine. Taking them serious and offering a real service line instead of an answering machine is the real task for the teamleader, offering a way of problem management is the first step towards problem solving. The rest is done with whatever tool, intuition, decision, process improvement ....

I liked that word aptitude in one thread and would like to add attitude, if I get both together I have a real good base to start learning, teaching, developing, experiencing, applying, doing ....

Life is a process which needs constant improvement and adaption and everything is possible if you give it a chance ... and time ... and patience.

... and it�s not for the new forum that I wasn�t tuned, it�s more some other tasks that keep meself occupied at the moment like new challenges in climbing, preparing for the new paddling season and of course massive problems with my present occupation.... What�s that thing down there in the south ?

So just be you, that�s the best you have


PS: Just a short story from one "guru" Asked by somebody if he could be his student he said that if he would do everthing the guru asks him for for one week he would accept him as a student. The man accepted and was told to dig a hole at a certain spot for they needed a new well for their watersupply. Next day he was showed a new spot to dig ... and so on. After one week there were seven holes but no water and the student said angrily, if you have let me dig at one spot constantly we would have found water and the guru replied, so you already learnt your first lesson.

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Ready, Shoot, Aim!!!! | 29 March, 2001


It gladen's my heart to hear that I'm not the only person with problem's like this, and also that the forum is as good as ever.

So route causes and consultants or JAFO's as I call them...Just Another Friggin Obstruction!. I hate the way that many of them breeze in, talk to everyone, note your idea's then hold a conference with everyone including the bosses and repeat all that you've just told them, the bosses nod and cheer in admiration and we all go back to what we were doing in the 1st place....sorry ranting

So route cause...let me give you a recent example of a conversation I had with an Engineering manager who I'd just refuse to sign off a corrective action for. 1st teh background, our place do daily audit's on process conformance, we have paper work to say what your building, where your building it, on what machines your supposed to build it and with what tools. All of this is listed on 1 peice of paper that should follow the production batch, there is one for each production line that you want to run a product on so if you have 10 SMT lines and you decide you want to be able to run down any line...apparently because you want flexibility and not that you can't schedule work properly.... The Non Conformance is the bit of paper that say's you didn't follow what was documented as the process....turn's out that somebody had decided to build product on wave machine instead of another and not raised the paper work. part of the Non conformance close out is root cause and closure actions. the manager assessed this situation and decided that the route cause was that there was too much paper work in the factory so, because this product was now running on another line he wanted to revamp the entire control system's to create anew peice of paper that tell's you what's on a line, then cross reference this to the origonal bit of paper and now teh master stroke in all this is also to allow 1 profile to be generated for an oven and 1 for a wave solder machine that is then copied to all machines (note they are not thermally matched...) Our conversation was something like.... (Me) erm not that's not a corrective action and theer is no route cause (Him) route cause is too much paper work, the sysetm is also too labour intensive, slow and difficult to manage. the closure is to create these new bit's of paper (Me) so your going to solve this by adding more paper work then (Him) yes and restructure all the operating proceedures that don't work or ar too slow (ME) ok so WHY didn't somebody just raise an Engineering Change to say run on line A and not line B, that would have solved everything and triggered all the required new paperwork and profiles for the ovens etc (Him) that's not the issue (me) no the issue is that you guy's didn't follow the proceedure (Him) but it's too slow (Me) eh?..1 bit of paper that you'd write run product XXXX on lien A instead of Line B creating required profiles is difficult? (Him) your oversimplyfiying it (Me) that's the process....

teh upshot he never got his non conformance signed off , now he wasn't happy to accept that the route cause was that they didn't follow the process so he then raised this at a management meeting with the MD...the result...he was slapped down by the MD on the ground's that the route cause was they hadn't followed the proceedure and raised the change.

So the moral...Route cuase will only be found is you have someone at the top who at least understand's 1. what's going on 2. the basic's of what your dong 3. how to read proceedures 4. how to manage that's got be instilled down the way, not up as one of our consultant friend's suggested earlier. the other really useful tool for route cause, and my personal favorite is ask the person working there, and I don't mean the eng or the manager I mean the operator doing the job...I'll give you odd's of at least 95 going on 99% that they'll know WHY...


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