If you have an intermittent or periodic problem, start counting frequency of occurrence, and then figure out what the order of magnitude is compared to your process.
To solve periodic or intermittent problems in our shops, the first step after identifying the problem is collecting data about “When” and “How often” it occurs. Then, comparing it to the orders of magnitude that occur naturally in your shop can help you narrow down the likely causes.
Relative frequency can be a big help, when you figure out that the frequency has some relationship or equivalence to some aspect of your process. For example, if the frequency is about equal to two occurrences per bar, than it becomes relevant to look at bar ends first, With two ends per bar, or the fact that you might get just two parts out of the first bar end, this tying of frequency to an order of magnitude denominator saves a lot of thrashing about to try to identify root cause.
What are some orders of magnitude that occur in your shop that you should consider for your problemsolving efforts on intermittent or periodic problems? Material Order of Magnitude
Your shop processes have orders of magnitude too. Per Machining Operation
Per Stock Up
Per Production Order
How does this work? In a prior life I had an intermittent customer complaint for a twisted square bar product. The customer was counting bad pieces cut from bars in bundles.The frequency was extremely low, it was not at one per bar or one per ten bars, nor one per twenty bars. It turned out to be approximately, slightly less than “one piece per bundle.” Knowing that the frequency was that low, we were able to eliminate most of our upstream of bundle process steps. They would have generated much higher frequencies – more on the order of multiple occurrences per bar.
Based on our frequency being an approximate order of magnitude of one per bundle, we focused our investigation on the product and process at and after the bundle stage. Which was where our problem occurred-when a single bar end was being twisted by the movement of the last strapping and clip installation as it was tightened for packaging. the balance of the bar was held securely by the prior installed starps, but the tensioning unit grabbed one corner of a bar as it secured the final band around the bars, creating a twist in the end of the bar held under the tension of the clip that locked in that last strap.
Without comparing frequency of occurrence to orders of magnitude in our process, we would probably still be trying to figure out where in our process we could twist just one 14″ segment out of 3,260 feet of bars. We’d be in denial, and eventually lose the customer. If you have an intermittent or periodic problem with your products, start counting frequency of occurrence, and then figure out what the order of magnitude is compared to your process.
It is critical that those of us who provide technical support, advice, or counsel communicate clearly and accurately. And make certain that our message is so received.
Six seismologists in Italy have been convicted on manslaughter charges because their advice was misunderstood and miscommunicated.
An Italian court yesterday sentenced the scientists to 6 year sentences for “giving false assurances” about the risk of an earthquake in 2009.
There is a difference between advising that there is no risk, and that there is no certainty of prediction.
Humans have a difficult time understanding, communicating and dealing with risk.
Background: In 2009 a series of small tremors were detected leading to predictions of a large earthquake to be forthcoming. While the probablility of a large earthquake increased on evidence of the swarms occurrence, it is impossible to “predict” an earthquake with any surety. Just as it is impossible to say that there is no risk of an earthquake. The Italian civil protection authorities were asked their opinion so that a panic could be avoided about the claims of a large earthquake being imminent.
The seismologists advised the Italian civil protection authorities that the series of small tremors were not a sure predictor of a larger one to follow. This was relayed to the press by the authorities that the seismologists had told them that there was no danger– an assurance that led many Italians to stay in their homes where they were killed or injured when the large quake struck L’Aquila the next day.
Causality: Humans also have difficulty in determining “true causes,” or as we say in critical thinking ‘causa sine qua non’– literally the ’cause without which nothing.‘
The cause of the deaths wasn’t bad advice- the root cause was buildings that collapsed because they were built to building codes which were not adequate to withstand the unstable geology of the region.
(Think back to the Challenger disaster- the root cause wasn’t ‘Groupthink’ at NASA or its contractors- it was a failure of an O-ring at temperatures at launch day.)
The advice given to the authorities was not that there was no risk, it was that there is no certainty of prediction. The civil authorities misconstrued that into “no risk” resulting in improper assurances to the general public, who became victims of the governments faulty building code and false assurances when the buildings were unable to withstand the larger tremor that came the next day.
Ask the right questions: There is a lesson here about asking the right questions. And this is is why I generally go back to first principles and assumptions when helping PMPA members solve a process problem.
The question should not have been “Will there be an earthquake tomorrow?”
The question should have been, “If there is an earthquake tomorrow, as engineers what do you think will be the consequences?”
When our client fails to ask us the proper questions, as technical professionals it is our duty to assure that the proper questions are brought up for consideration.
I am not surprised to find out that the Italian legal system managed to convict the scientists who gave advice which was not understood and miscommunicated.
Seldom are the courts courageous enough to recognize the fault of a government authority of which they are a part.
The lesson of the L’Aquila decsion for all of us in technical services is this:
It is no longer sufficient to answer the questions of our clients with factual renderings of our ‘science.’
As professionals we have an obligation to serve society by making clear that all relevant questions are asked and issues identified. And that our clients understand those issues, not just their question of the minute.
Protect the Customer: The first point of my moral compass is to “Protect the Customer.”
That definition is further amplified: Protect the customer from the organization and himself.
Failing to ‘protect the civil authorities and the L’Aquila citizenry from themselves’ is the real ‘offense’ of the six convicted seismologists.
Failing to clarify that “no danger” is not the same as “we can’t predict the moment of occurrence” allowed the authorities and citizens to take false comfort and remain vulnerable.
As professionals we must make sure that all relevant issues are identified. And that we communicate clearly and accurately, making certain that our message is so received.
Trying to solve a problem without baseline data is a fool’s errand. It is the contrast between the data of the process, and the baseline data, that makes it possible to identify that a problem exists and to analyze it for root cause.
Most problems are identified because the output departs from the expected.
Brainstorms do not solve problems, they usually just waste resources in a process of aggrandized groupthink.
I call this “the Diff” when I am working with continuous improvement teams. It is the difference between expected and actual.
You cannot have a difference without having an expected or baseline measure of the characteristic to be improved.
Four Measures that I have used in my continuous improvement work include
Frequency of Occurrence,
Location of Occurrence.
Frequency of Occurrence
The difference between expected (or under statistical control) frequency and the rate of occurrence in the current state gives insights into what may be occurring. If it is a small fraction of a percent- it is unlikely that a global change of process is needed. if the rate is in the double digit percentages, it is likely that there is a major change in the process (or needed!)
Simple ratios can also be powerful clues. Defects arriving in 20, 25 or 33 percent of the production point to areas within the greater process where there may be 5, 4, or 3 sub processes- like dies, cavities, or molds. Similarly, a rate of 12.5% on an 8 spindle screw machine tells me not to look at a single tool ( it hits all 8 spindles) but instead to look for one of the 8 spindles (12.5% of the machine’s total production) that might be out of line compared to the others. Costs
My cell phone costs spiked almost 100% in July of 2010. In August, I brought my Dad back home to a nearby assisted living facility. The cell phone cost data was a pretty clear ‘cost’ signal that something had changed compared to prior (baseline) bills- Dad need assistance. ( BTW- Dad’s doing fine!) Duration
Comparison of time to complete 100 ton orders on my mill grew by a significant figure, and follow up indicated a problem at an intermediate shear. Without baseline data, how would I have known that my production time had increased? Location of occurrence
This is another piece of data that when tallied against the baseline of “no occurrences” always leads your thinking. If it only occurs in the threaded area, but not on the original bar surface, what does that mean? Looking for deltas or “Diffs” between your baseline and current process data is a far better way to inform your Problemsolving than Brainstorming.
Interested? The Delta is the Difference
Here are a couple of tips to keep in mind when your company becomes involved in a crisis.
Communicate. At the very least, make a fact sheet of basic company information and your products. Answers to”Who, What, When, Where?” is a great template for a fact sheet.
Use your website to keep insiders and outsiders informed. Your website is on 24/7 worldwide. Why not use it to help you provide facts and minimize rumors.
Don’t oversell quality. Zero defects has an almost magical ring to it. But the fact is that in complex systems even redundant backups don’t always work. Statistically, outlying events can and will occur.
Do demonstrate your sincerity, and discuss the steps that your company is taking to identify the problem, get the problem contained, and the immediate and long term corrective actions that your team is working on.
Don’t speculate on “Cause” nor “Blame.”
As of noon May 3, 2010, Cameron International’s Website has nary a mention of the fact that their company’s Blow Out Preventers may be involved at the BP- Deepwater Horizon spill ongoing in the Gulf of Mexico.
The first quarter earnings release conference call seems to be the only “newsworthy” item on Cameron’s webpage.
No mention of any work or involvement by the Cameron Team to get the situation in the Gulf fixed.
No “Who, what, when, where?” information. No spokesperson.
The Washington Examiner meanwhile reports that Cameron has been named among other companies in “lawsuits seeking damages.”
The AP reports Cameron is the manufacturer of the “fail safe device on the well that is spewing crude into the Gulf” and that Cameron has “$500 million in liability insurance for legal claims.”
That would have probably been good info to have on their own site…
The website provides a company with a powerful means to get the facts out. To show their customers, their employees, other people who may be affected what efforts are being taken to get things under control and restore normalcy.
The best bargain in education is when you learn from other people’s mistakes. Watch how this one works out.
Meanwhile, how about sitting down with your team and asking “What if this happened to us?
As a steel company Metallurgist and Quality Director, I was the guy who got the call to visit a shop because the material we sent wasn’t machining right.
“This stuff won’t drill! Help!”
“This stuff is killing my OD form tool. Can you check the steel?”
“This steel you sent is acting crazy. It machines fine on one machine, but not on the other one.”
As the fellow responsible for the processes and quality system that produced the bars, and having visited my hot mill upstream suppliers, I was always confident that I had provided conforming product.
But how could I make sense of the problems reported? My solution was to always look at the wrong tool- first.
If they complained about the drill, I asked them to show me the cut off tool.
If they complained about the rough, finish form, or shave tool, I asked them to show me the cut off tool first.
They said “Hey Mr. Free you aren’t paying attention. I said the drill is giving me trouble, not the cut off tool.”
To which I cheerfully replied “Yes?”
After letting that sink in for a bit I would ask the following appreciative inquiry type of question to lead their thinking:
“If the cutoff tool sees every aspect of the steel provided- the very surface of the outside diameter (OD), the sub-surface, the mid-radius, the core, and it does not have any abnormal issues resulting from this material, what is there about this material that you think would allow it to affect this one tool, but not the cutoff?”
Then we focused on the aspects of the operation that inevitably were found to be the cause. How does the steel know to only interfere with the drill, lets say? Or the the finish form? While leaving the cut off tool unscathed?
While there can be material conditions that are specific to a certain zone in the steel and thus would manifest on a particular tool, that conditon would also have an impact on the cut off. If the cut off tool is A-OK, it’s probably not the steel.
It may not look like a canary, but a cutoff tool can sing a song about your process, if you can listen with your eyes. Canary. Cutoff.