Why-Why Analysis 2013 - PPM (CAP)

Why-Why Analysis
for SCG Chemicals
Phumpraj Manaspiti
QM Consultant
Internal Use Only – Do not distribute

Key to Effective Problem Analysis
Necessary Precautions:
1. Gather as much pertinent data (in line with the objective) as possible to
try to clearly understand the ‘symptoms’ before pursuing root cause
analysis
2. Stratify data into rationalized subgroups to reveal key characteristics /

patters of the symptoms
3. Visualize the data (use graphical tools)

4. Narrow down the investigation to specific phenomena (rather than
abstract or generic problem statement)
5. No jumping to conclusions. We start with ‘symptoms’ NOT

‘root cause’

Important Principle in Problem Analysis
5 GEN for thorough ‘Observation’

Genba : Actual Place
Genbutsu : Actual Parts
Genjitsu : Actual Circumstances
Genri : Theory/Principle
Gensoku : Governing Condition/
Constraints

Widely used Analytical Tools
• 7 QC Tools
• New 7 QC Tools
• Statistical Techniques (MVA, DOE, ...)
• Why-Why Analysis
• P-M Analysis
• Failure Mode and Effect Analysis
• Fault-Tree Analysis (FTA)
• Etc.

Step-by-Step
of
Why-Why Analysis

Why-Why Analysis Steps
1. Clearly define phenomena gap
2. Explore functions/components/mechanism
relevant to the targeted phenomena
3. Proceed from effects to factors and root cause


State the characteristic/occurrence that is the gap to analyze for root
cause in the leftmost box Narrow Down & Focus
Objectively state phenomena
Keep it ‘Concise & Precise’
Phenomena /
Characteristic/
Problem


เครืองจักร 1 เครืองจักร 2 เครืองจักร ….
Date ลั กษณะของเสี ย ลั กษณะของเสี ย ลั กษณะของเสี ย
A B C D A B C D A B C D
1
2
3
4 1 2 3 4 5
รวม เครืองจั
Which machine ิ ดของเสี
กรไหนเกhas most ยบ่breakdowns?
อย ๆ?
ใช้หDown
Narrow ลัก Narrow Down & Focus
& Focus
• เวลา
Time เครื
อ งจักร11
Machine
Place
• สถานที / กระบวนการ
/ Sub-process
Type ofิ Product
• ชนด/ประเภทของผลิตภัณฑ์
Physical Characteristics
Etc.• ลักษณะทางกายภาพ
• ฯลฯ A B C D
ลัWhat
กษณะของเสี
kind of defects ิ ด
ยแบบใดเก ขึน; มากที
occur the สmost?
ดุ ?


Breakdown
Breakdown Line
line 5 Jan-Jun
5 Jan-
Jan - Jun2006
2006(Hrs)
(Hr.)
Break down line5 Pallet Magazine Jan-Jun
Conveyor, ink jet, 34.7 Breakdown line 5 Pallet Magazine Jan-
Jan-Jun 2006 (Hrs)
38.4
2006
%
Weight Hr
99 100
Scale, 11
100
45 hour
85 Acc
90
40
80
Bagging 35 71
Machine, Palletizer, 70
53.1 66.7 30
60
25 33.0
50
20
40
Breakdown line 5 Palletizer Jan-

Jan-Jun 2006 (Hrs) 15 30
(Hr.)
Infeeder, Bag 10 20
Hoisting, 6.5 6.3
Layer plate, 23.0 18.0 turning,
5 10
28.3 10.5 0.5
0 0
Pusher, 2.7 ชุดงาเสี
งาเสียบยบPallet
Pallatไม่ ชุดกวาดพาเลตติดขัด ใบกวาดพาเลตฉีกขาด Sensor Pallet
ไม่เลือ" นเข ้า-ออก transfer ชํารุด
เลื4อนถอยกลับ
conv. belt, Pallet

32.5 Magazine,
46.3

Q: Why did plant shutdown?

A: Operation system have been cut off.
Q: Why has operation system been cut off?

A: High level sensor in F-800 silo is on.
Q: Why is high level sensor in f-800 silo on?

A: F-800 silo is completely filled up with powder.

Q: Why is F-800 silo filled up?

A: Powder can’t be transferred from F-800 silo
to extruder.
Q: Why can’t powder be transferred?

A: Gear motor of Q-810 auto feeder tripped.
Problem:
Problem: Gear motor of Q-
Q-810 auto feeder tripped!!


• From historical/observed data coupled with ‘5GEN’, narrow down the
investigation to find out: “What is the abnormal characteristic / phenomena ? ”
๏ Time that problem occurred / Sub-process

๏ Location / Machine / Part Specific symptom /
๏ Type / Group of product behavior/condition that
Summarize one could objectively
๏ Pattern of the symptom differentiate between
๏ Physical characteristics OK and NOT OK status.
๏ Any change in 4M’s
Observe to take notice of abnormal parameter(s), which we shall dig up root cause.


Example Key Issue
1. Late delivery of 1. There are probably dozens of items
Raw materials used as raw materials. One should
specifically name which item or which
supplier usually exhibits this symptom
2. What logo? Which product?

2. Mis-Printed logo What kind of package material?
on product package Which machine? … for example

Establish Known Parameters from available observation results

which will not be re-visited the scope of ‘Why-Why Analysis’.
Then list up Unknown Factors which we will check and verify later
on (Why#1, Why#2, Why#3)

• Develop a sketch of actual components in actual circumstance
• Study functions / components / mechanism
• Seek to understand relevant theories / constraints / standards

which can suggest additional factors and/or means to verifying
certain factors

Example Outline of equipment & process Diagram of P-0331
C-4100
M
WS
EY
WY
EW WA2 #15
D-4135 FV-4185
D-4125 P-0331
WA-1 #1
D-4225
P -4126A
RS1
RS-2
WW
MAAYS C-4200
SY
P-0331 เป็น centrifugal pump ใช ้ mechanical seal แบบ single
seal unbalance
FV-4189
P-0331 ทําหน้าที8 transfer liquid ผ่านเข้ามาทาง suction strainer

SL
D-4131
D-4101
จาก waste water tank T-0330 ซึง8 ประกอบด้วย นําJ เป็นส่วนใหญ่
FV -4130
TIC
และส่วนประกอบอืน 8 ๆ จะเป็น organic ซึง8 ได้แก่ MMA,MAA,MAL,

1.5S
TV-4144
WO
Toluene,acetic acid และ acrylic acid. ส่งไปย ัง waste liquid
E-4101
WA-3
treatment column C-6120 เพือ J อ

8 บําบ ัด ถ้า pump ต ัวนีต ้ ง stop
FT -4130
FV-4145
T-0300
เนือ
8 งด้วยสาเหตุใดๆก็ตาม จะต้อง ลดกําล ังการผลิต จนถึงขน ัJ shut
D-4101
SL
D-4517
E-3202
down โรงงาน

Example

Example

Example

Example

3. Proceed from effects to factors and root cause

2 Approaches for Why-Why Analysis
• Experience-Driven Approach
• Principle-Driven Approach
?
Characteristic/
Phenomena/ ?
Problem
?
Start with the origin of the problem or ‘processing point’

“Don’t lose your focus !!”

Experience-Driven Approach
• List possible contributing factors from in-depth knowledge or
available standards on the system / equipment in which the
problem lies
Comparison between the actual and the should-be

phenomena on the basis of past experience, knowledge,
or available standards

Example
Phenomena Factors to check Why (1) Why (2)

Bolt does Wrench is worn off OK
not turn !!
Bolt and plate Bolt & Plate Both are not
are rusted NG are rusted coated
Bolt and plate

are fused together OK Moisture / Water
is present
Wrong Wrench
Size is used OK
Inadequate force
exerted on wrench OK

Example
Under this circumstance, one might think. . .

The boy is crying because his beloved gold fish is dying
after the bucket toppled.
The boy tried to open the wooden crate with the wrench
and he accidentally hurt his hand from the attempt.
Principle-Driven Approach
๏ Focus on the mechanism, think about how factors / conditions
/ variables contribute to the observed phenomena
๏ You may not be highly experienced about the system,
but if you understand the relationship of factors, and know
the theories / principles behind it, you still have a chance !!

Example
Phenomena Why 1 Why 2 Why 3 Why 4
Wrench larger
Inadequate Force not exerted than Bolt
Bolt does Force exerted Transfer on contact point
Bolt worn out
not turn !! < of Torque
Resistance Inadequate Arm muscles
force on wrench are weak
Excess Presence of Covered
Resistance external resistance with Paint
Rust on contact
surface
Bolt threads Thread Damaged
jammed
Bolt Mis-aligned

Example
Why (1) Why (2)
Phenomena He is He fell down
hurting He ran into • Thinking about the theory /
the crate
He’s got principle behind a
water in his eyes phenomena helps us clear
biased opinions and mis-
The Boy He is sad
His gold fish
conception. It makes us
is Crying is going to die
stay focused on actual
He thinks
his father mechanism leading to
He is afraid is going to root cause(s).
punish him
He is A wrench
frightened fell from above.
Comparison:
Experience-Driven Approach Principle-Driven Approach
• Easy to initiate and proceed • Require theoretical knowledge
• Boundary of experience is the limit • Thorough consideration of all
• High risk of jumping to conclusion causal factors
(previous experience could cloud judgments) • Low risk of jumping to conclusion
Pick the one that suits the complexity of the problem

Conducting Why-Why Analysis
Try to get specialists/experts who are familiar with such phenomena to
participate in listing up the first level of factors (Why #1)
Begin the process either Put answers in the boxes
with Experience-Driven on the right
or Principle-Driven Approach
?
A ? Verify each
? factors using
objective
Characteristic/ ? evidence
Phenomena/ B ( OK / NG )
?
Problem
?
?
C
?
7 Points to keep in mind
for
Why-Why Analysis

Point #1 : Statement of “Phenomena” should be…
• Unsubjective
• Narrowed Down
• Like a single frame on a comic book page
Rely on fact & data (Genba, Genbutsu, Genjitsu)
to identify phenomena or problem

Example
Why?
Flashlight doesn’t
light up because Why?
of dead battery
Why?
Why?
Flashlight doesn’t
light up Battery is dead Why?
Why?
Bulb is damaged Why?
Why?
Circuit is open Why?
Why?
I have a stomach ache from eating too much
I ate too much I have a stomach ache
I have a stomach ache I ate too much
I got food poisoning
I caught a disease
การวิเคราะห์สาเหตุของป`ญหา AT-2051B อ่านค่า %O2 ผิดพลาด
การวิเคราะห์ สาเหตุของปั ญหา Analyzer B อ่านค่า %O2 ผิดพลาด
Problem Why 1 Result 1 Why 2 Result 2 Why 3 Why 4 Result 4 Why 5 Countermeasure
AT-2051B AT-2051B Check ด้วย standard gas

อ่านค่า %O2 เกิด error ค่า error สะสม
ผิดพลาด สะสม อยู่ในช่วงที"ยอมรับได้
Narrowed down analysis
Sensor เสีย
Check ค่า mA output

ค่า mA output ในช่วงนํา standard gas
error เข้า test พบว่าปกติ
Reference flow Check reference flow

swing พบว่า flow ปกติ
Boiler B เกิดจาก
ไม่มี filter ตัน มีเขม่าเกาะ มีเขม่า การเผาไหม้ Modify เพื"อ clean filter ได้ง่าย
sample gas ที" filter มาก เกิดขึ:นมาก ไม่สมบูรณ์
ไม่มีการ AT-2051B มีการ

clean filter clean filter บ่อยมาก
เมื"อเทียบกับ A และ C
filter สัมผัส
เพิ"มชุด protect guard ที" filter
Basic conditions should
process
โดยตรง
already be explored during Air asparrator

Flow ของ IA. ที"จ่ายให้กับ
air asparrator ปกติ
ตัน แสดงว่าปกติ
‘Observations’ step

Point #2 : Always ensure you have the complete
list of factors in each step
• Let’s say that none of the factors apply at all, would the phenomena
still occur?
If the answer is YES, then you’ve left out at least one more factor.
• Try to get a complete list of factors in the 1st level (Why #1) by…
- Focusing on ‘processing point’
- Study mechanism / condition / components related to it
- Apply ‘Genri’ and ‘Gensoku’ when formulating Why #1
This will help you ensure completeness of factors listing.

ตัวอย่ าง
Fishing line breaks when
fish took the bait Fish is very very big
Fishing line breaks when

fish took the bait Fish is very very big
Fishing line is
deteriorated over time
Fishing line is
damaged

If only we had shift the focus to ‘processing point’ . . .
Fishing line Fishing line is
breaks when subjected to
fish took the higher tension Fish is very very big
bait than its yield point
Fishing line is
deteriorated over time
Fishing line is
damaged

Phenomena Why (1) Why (2) Why (3)
Flange corroded
Contact
Gap between
Steam leak flange & gasket surfaces Gasket
deformed deteriorated
Foreign object
caught between
contact surfaces
Clamping force
Bolt loosened
on gasket reduced
Pipe
mis-aligned

Phenomena Why (1) Why (2)
No ink
Ball doesn’t Ball damaged
transferred
rotate
to paper
Foreign object
Focus on Think of basic obstructs ball
contact point principle /
mechanism Insufficient
force on paper
No ink on Pen is
top of ball out of ink
Ink is
You must first be dried out
aware of all
components Air bubble
and operating trapped inside
mechanism of a
ball point pen
Point #3 : Keep asking ‘Why’ until you reach the
factor on which there is an effective
countermeasure to prevent recurrence
DO NOT end root cause analysis too soon, e.g. ‘bearing damaged’,
‘end of equipment life’, ‘component deteriorated’ only to take simple
countermeasure like replacements.
Get to the bottom of the phenomena and fix that to ensure you have
prevented problem recurrence.

Phenomena Why Why Why Why Countermeasure
Bolt ขันโบลท์
~
Loosened ให้แน่ น
Bolt
Bolt Shaft
Find out why shaft
~
subjected to Shaft swings

Loosened Mis-Aligned
vibration initially got mis-
aligned and take
action to prevent it

Phenomena Why Countermeasure
Equipment Clean the
~ was not
cleaned equipment
Equipment Cleaning Develop

was not standard not
~
cleaned available cleaning standard
Cleaning Removing the Modify cover

is too cover takes
difficult a long time for quick removal

Why (1) Why (2) Why (3) --> Keep Asking !!
1.1 OK
STOP when . . .
1 1.2.1 OK 1. Factor is OK
NG
1.2 2. Reasonable measure
Phenomena NG 1.2.2 NG against recurrence of
that factor is available
2.1 OK 3. เน้ นการวิเคราะห์ ให้

ครบถ้ วนและลงลึก
2 2.2.1 NG ในสาเหตุทเี ป็ น (NG)
NG 2.2
NG
2.2.2 OK

OK or NG for each factor . . .
NG Use Why-Why to
identify root cause
and prevent recurrence
“What really happened” (Corrective Action)
VS
“What didn’t happen, but
might happen someday”
“Prevention by Prediction” OK
with FMEA
(Preventive Action)

Types of Actions (Countermeasures)
• Immediate Action (IA) : To stop or mitigate consequences
• Corrective Action (CA) : To prevent problem RECURRENCE
• Preventive Action (PA) : To prevent problem OCCURRENCE

Anticipate possible problems
and block out key factors
Replicate CA from one unit
to other similar units

Practice of Recurrence Prevention (Corrective Action)
• Eliminate Root Cause

• If root cause cannot be eliminated yet, take action to resolve
problem. After that, develop monitoring system to give
‘early warning’ so that you can respond quickly next time
before bad consequences arise.
• Countermeasure must be a practical standard (sustainable)

Point #4 : After finishing the entire why-why analysis
diagram, always verify your logic going
backward from the last ‘Why’ to ‘Phenomena’
If you jumped to conclusions or skipped certain causal

relationships along the way, you will likely notice
illogical representation.

Read backward from leading factors (root cause)
to the problem (phenomena)
Example
Staff misprinted
Part No.
Incorrect Part No. Staff is tired
on Order Slip
Staff received
incorrect Part No.
Staff misprinted Part No. SO Staff is tired SO Incorrect Part No. on Slip X
Staff is tired SO Staff misprinted Part No. SO Incorrect Part No. on Slip O
Chain guard is damaged !!

Are we jumping over some “Why” ?
Phenomena Why 1 Why 2 Why 3 Why 4 Why 5
Chain guard Bolt is Components Bearing Bearing

is damaged vibrate is worn out Foreign
loosened surface not objects
smooth
entered
bearing
No
tightening
after last Bearing
repair is not
greased
Forklift Unbalanced
Driver is force exerted
hit chain negligent on bearing
guard
Not enough
room to
manoeuver

1. Foreign objects entered bearing SO Bearing is worn out
2. Bearing is worn out SO Bearing surface not smooth
3. Bearing surface not smooth SO Components vibrate
4. Components vibrate SO Bolt is loosened
5. Bolt is loosened SO Chain guard is damaged
No. 5 is illogical . . .
Bolt being loosened alone does not damage the chain guard !!

Phenomena Why 1 Why 2 Why 3 Why 4 Why 5 Why 6 Why 7
Chain guard Guard Guard Bolt is Components Bearing Bearing Foreign

is damaged struck from impacted loosened vibrate surface not is worn out objects
underneath chain smooth entered
bearing
No
Digging up tightening
actual root cuase after last Bearing is
repair not greased
Chain Chain Sprockets

impacted swings distance Unbalanced
guard reduced force exerted
Sprocket on bearing
Guard Sprockets bearing
struck from รถยกชนถูก คนขับใจ swivel damaged
outside ฝาครอบ ลอย
รถยกหลบ Example of “logical” why-why

ฝาครอบไม่
พ้น formulation when checked backward

Which items are illogical or might have jumped steps?
1. Coffee is too strong Water/Coffee ratio to low
2. Pressure is reduced Air is cooled down
3. Windshield is fogged 6 people are in the car
4. TV does not turn on Power cord disconnected

Point #5 : Avoid putting in basic constraints that
you have no control/influence upon.
Don’t put in these factors Focus instead on . . .
• … is customer’s requirement • Factors under your control
• There is exceptionally large order within the context of those
• Machine is in operation 24/7 basic constraints
• Plant location is inappropriate
• It rained heavily
• Etc.

Can you actually control / change any of these factors ?
Work cannot It rained a lot
Construction is be done
delayed as scheduled
Strong wind &
turbulence
Material supplies Road
are delayed is too narrow
No alternate
route
Why-Why Analysis Diagram should not consist of such factors !

Phenomena Why (1) Why (2) Why (3) Why (4)
Dust particles in Machine is Planned

Machine Order
work area exceed always at volume
safe threshold gives out a doubled
full speed increased
lot of dust
?
Dust particles in Machine Dust escaped
work area exceed ?
safe threshold gives out a through xx slot
lot of dust ?

Point #6 : DO NOT blame it on psychological factors
or mere human errors.
To err is human . . .
Don’t put in these factors Focus instead on . . .
• Operator was absent-minded • How to accommodate for human
• Clerk was negligent factors while ensuring no faults /
• Worker was exhausted problem / hazard
• She forgot • Explore Pokayoke (Mistake
• Etc. (Human Errors) Proofing) solutions

Phenomena Why 1 Why 2 Why 3 Countermeasure
He was Tell him

Mr. A thinking to not
His head
He was not about think
sustains bumped into
fully aware of that fight about his
head sharp edge surrounding
of girder with his family
injury wife last while at
night work
Mr. A His head

Cover
bumped
sustains sharp
into sharp
head edge with
edge of soft pads
injury girder

Machine Final QC Check
Worker Worker
Worker removed
Product did not products from the line to Worker forgot to
Defective
pass final QC make corrections then put product
product sent
check sent directly to through QC
to customer
packaging Check
Worker removed
products from the line to Worker’s
Defective Product did not
make corrections then position is
product sent pass final QC
sent directly to behind final QC
to customer check
packaging Check
Countermeasure : Move workstation in front of final QC check

Pokayoke (Mistake-Proofing System)
1. Control system
Automated operation in critical processer / activities to eliminate human factor risks
Auto-stop intervention once abnormalities occur
Interlock work step when critical procedure is not yet correctly executed
Zero loss / defect / accident for any human
2. Warning / Alarm system

Instantly detect and alert for non-conformances
Visual / Audible warning
System to prompt operator for troubleshooting and provide instructions
Non-automated warning system: color coding

Point #7 : Be precise. Avoid ambiguous words
(e.g. Not enough, Improper, Bad).
Do not leave out the ‘subject’.
• Clearly describe quantitative / qualitative information

• Use sketches / pictures if necessary
• Do not leave out the ‘subject’ from factor statement

Phenomena Why
Coffee from vending machine

Too small
spilled out of paper cup
Coffee from vending machine Capacity of paper cup is less

spilled out of paper cup than volume of coffee poured in

• DO NOT say [ Poor Inspection ], but say
[ Inspection is not taken ]
[ Inspection is not possible ]
[ Inspection is difficult ]
• When referring to pressure / temperature / concentration / viscosity / etc.,
always be precise about it Std
[… Below standard] Std
[… Decreasing]
[… Occasionally fell below std] Std
• Avoid the words ‘Bad’ or ‘Improper’ (e.g. improper design, bad raw material)
7 Points to keep in mind for Why-Why Analysis
Point #1: Statement of ‘Phenomena’ Point #3: Keep asking ‘Why’ until you reach the factor on which
should be unsubjective , narrowed there is an effective countermeasure to prevent
down , and like 1 frame of comic recurrence
Phenomena
Rule of Thumb:
Early Why’s Actions on Hardware
Point #2: Always ensure
Deeper Why’s Actions on System
you have the complete
list of factors in each step
Point #5: Avoid putting in basic constraints

that you have no control/influence upon.
Point #6: DO NOT blame it on psychological Point #4: After finishing the entire why-why analysis
factors or mere human errors diagram, always verify your logic going
Point #7: Be precise. Avoid ambiguous backward from the last ‘Why’ to ‘Phenomena’
words. Don’t leave out the ‘subject’.

Points for consideration
The real culprit (criminal) in your workplace is not the
materials, the tools, nor the machines (Hardware).
It is the paradigm, the practice, the design, or the
management mechanism (System) that is ineffective.
Why-Why Analysis is meant to help identify that so you
can develop suitable and sustainable countermeasures.

Parallel to Why-Why Analysis . . .
Why-Why Diagram does not represent all the facts. It

simply covers relevant mechanism, which can then
become the starting point for us to plan for objective
evidences gathering and verify all factors.

General Structure of Why-Why Analysis Case
Improvement Theme: Team / Area 4. Why-Why Analysis
1. Theme Selection Components Process

/ Functions Parameters
2. Target & Plan
5. Actions 6. Confirmation
3. Observations
7. Standardization

Find the root cause of your problem !!
“ As the saying goes . . . ”
For want of a nail, the shoe was lost. Effect

For want of a shoe, the horse was lost.
For want of a horse, the rider was lost.
For want of a rider, the message was lost.
For want of a message, the battle was lost.
For want of a battle, the kingdom was lost. Cause
Hand all for the want of a horseshoe nail.
The saying refers to the death of Richard III of England at the Battle of Bosworth Field.
Source: http://en.wikipedia.org/wiki/For_Want_of_a_Nail

Why-Why Analysis
Presentation Techniques

Why-Why Analysis Presentation Techniques
“Use Photo / Real Sample”
Normal condition
Milky condition

“Use sketches
instead of written
statement to
make it easy to
understand”

“Sketches might be a
more effective way of
communication than
photograph as they
only highlight
relevant components”


“Model sets could

help clarify
complicated
mechanism”
Sometimes you
need to prepare an
actual sample or
model for
complicated cases



Workshop:
Review your case and
apply the concept
from today’s lesson

Steps for Workshop
Step 1 Review your Abnormality Treatment Case / Problem Solving

Case to identify improvement points according to the concept from
today’s lesson
Step 2 Draft improvements on those points
Step 3 Summarize improvement points and show examples of
‘Before’ VS ‘After’ in the form. (This could well be used to generate
OPL’s regarding root cause analysis for your own function.)

Form for Case Review Summary
Example
Step Improvement Point
Before After
1. Problem Selection
2. Observation
3. Conducting Why –
Why Analysis
4. Root cause / factor

verification (with
objective evidence)

Form for Case Review Summary
Example
Step Improvement Point
Before After
5. Confirming results
6. Standardization
7. Conclusion &
Future Plan

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Why-Why Analysis

for SCG Chemicals

Internal Use Only – Do not distribute

2. Stratify data into rationalized subgroups to reveal key characteristics /

3. Visualize the data (use graphical tools)

5. No jumping to conclusions. We start with ‘symptoms’ NOT

Internal Use Only – Do not distribute

5 GEN for thorough ‘Observation’

Internal Use Only – Do not distribute

Internal Use Only – Do not distribute

Internal Use Only – Do not distribute

3. Proceed from effects to factors and root cause

Internal Use Only – Do not distribute

1. Clearly define phenomena gap

Internal Use Only – Do not distribute

1. Clearly define phenomena gap

Internal Use Only – Do not distribute

1. Clearly define phenomena gap

Breakdown line 5 Palletizer Jan-

conv. belt, Pallet

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1. Clearly define phenomena gap

Q: Why did plant shutdown?

Q: Why has operation system been cut off?

Q: Why is high level sensor in f-800 silo on?

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1. Clearly define phenomena gap

Q: Why is F-800 silo filled up?

Q: Why can’t powder be transferred?

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1. Clearly define phenomena gap

๏ Time that problem occurred / Sub-process

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1. Clearly define phenomena gap

2. What logo? Which product?

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1. Clearly define phenomena gap

Establish Known Parameters from available observation results

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• Study functions / components / mechanism

• Seek to understand relevant theories / constraints / standards

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P-0331 ทําหน้าที8 transfer liquid ผ่านเข้ามาทาง suction strainer

และส่วนประกอบอืน 8 ๆ จะเป็น organic ซึง8 ได้แก่ MMA,MAA,MAL,

treatment column C-6120 เพือ J อ

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Internal Use Only – Do not distribute

Internal Use Only – Do not distribute

Internal Use Only – Do not distribute

Internal Use Only – Do not distribute

1. Clearly define phenomena gap

3. Proceed from effects to factors and root cause

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Start with the origin of the problem or ‘processing point’

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Comparison between the actual and the should-be

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Phenomena Factors to check Why (1) Why (2)

Bolt and plate

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Under this circumstance, one might think. . .

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