3-Legged 5 Why and 5 How Example - Quality-One
3-Legged 5 Why and 5 How Example
Event #:
1333
Event Date:
1/1/2017
Part #
N/A
Facility / Work Cell
B52
Shift:
3rd
Issue description (Clearly define the problem)
Machine operator fell and was injured during the first shift start
up.
Team
John Smith, Jane Doe, Paul Jones, Karen Klein, Bob Brewer
There was an oil spill next to machining center
Therefore
Process Specific
Machining center number 3 was leaking oil.
Therefore
Why
Seal deteriorated and began cracking.
The leak was not detected and cleaned up prior to the accident?
Therefore
Why
Detection / Control
Area is cluttered and floor dark and dirty so hard to spot any spills
Why
Therefore
Regular area cleaning not performed
The seal was not inspected and replaced prior to developing cracks?
Therefore
Why
Systemic
Regular Maintenance not performed on machine
Therefore
Therefore
The seal material was not robust to the application.
Why
Therefore
Therefore
Seals purchased through secondary supplier for lower
price. Why
Operators not trained in proper 5s procedures.
Therefore
Why
No 5s procedure in place in the machining department.
Therefore
Seal material not specified in service manuals Root Cause
Therefore
Why
Maintenance behind schedule on PM plans in department
Therefore
Why
There is no 5S program in place within the company.
Why
Demand on machines high and production running 24 / 7
Therefore
Root Cause
Why
Two older machining centers removed and not replaced
Therefore
Resolve the Problem 5 Hows (How to resolve problem and keep it from re-occurring) How Clean up machining area and add additional lighting and initiate 5S project in machining area including regular machine How Investigate better seal material to prolong life and prevent leaks How Outsource some of the workload on machining to other facilities until capacity issues can be resolved How Put together a plan to catch up all PM on machining centers and implement How Re-examine cost of new machining centers in c, etc. and present to management for approval.
Why
Management rejected capital expense as part of cost reductions
Root Cause
Who
Machining Manager
When / Timing
Clean up prior to next shift, 5S within 1 week
Purchasing and M. E.
Within 2 weeks
Engineering and SQA
30 days
M.E. Manager M.E. and Plant Managers
Within 2 weeks 60 days
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