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Six Sigma Fun: For Want of an FMEA, the Empire Fell

by Matthew Barsalou, guest blogger

For want of a nail the shoe was lost,
For want of a shoe the horse was lost,
For want of a horse the rider was lost
For want of a rider the battle was lost
For want of a battle the kingdom was lost
And all for the want of a horseshoe nail. (Lowe, 1980, 50)

According to the old nursery rhyme, “For Want of a Nail,” an entire kingdom was lost because of the lack of one nail for a horseshoe. The same could be said for the Galactic Empire in Star Wars. The Empire would not have fallen if the technicians who created the first Death Star had done a proper Failure Mode and Effects Analysis (FMEA).

A group of rebels in Star Wars, Episode IV: A New Hope stole the plans to the Death Star and found a critical weakness that lead to the destruction of the entire station. A simple thermal exhaust port was connected to a reactor in a way which permitted an explosion in the exhaust port to start a chain reaction that blew up the entire station. This weakness was known, but considered insignificant because the weakness could only be exploited by small space fighters and the exhaust port was protected by turbolasers and TIE fighters. It was thought that nothing could penetrate the defenses; however, a group of Rebel X-Wing fighters proved that this weakness could be exploited. One proton torpedo fired into the thermal exhaust port started a chain reaction that led to the station reactors and destroyed the entire battle station (Lucas, 1976).

Why the Death Star Needed an FMEA

The Death Star was designed by the engineer Bevil Lemelisk under the command of Grand Moff Wilhuff Tarkin; whose doctrine called for a heavily armed mobile battle station carrying more than 1,000,000 imperial personnel as well as over 7,000 TIE fighters and 11,000 land vehicles (Smith, 1991). It was constructed in orbit around the penal planet Despayre in the Horuz system of the Outer Rim Territories and was intended to be a key element of the Tarkin Doctrine for controlling the Empire. The current estimate for the cost of building of a Death Star is $850,000,000,000,000,000 (Rayfield, 2013).

Such an expensive, resource-consuming project should never be attempted without a design FMEA. The loss of the Death Star could have been prevented with just one properly filled-out FMEA during the design phase:

FMEA Example

The Galactic Empire’s engineers frequently built redundancy into the systems on the Empire’s capital ships and space stations; unfortunately, the Death Star’s systems were all connected to the main reactor to ensure that power would always be available for each individual system. This interconnectedness resulted in thermal exhaust ports that were directly connected to the main reactor.

The designers knew that an explosion in a thermal exhaust port could reach the main reactor and destroy the entire station, but they were overconfident and believed that limited prevention measures–such as turbolaser towers, shielding that could not prevent the penetration of small space fighters, and wings of TIE fighters–could protect the thermal exhaust ports (Smith, 1991). Such thinking is little different than discovering a design flaw that could lead to injury or death, but deciding to depend upon inspection to prevent anything bad from happening. Bevil Lemelisk could not have ignored this design flaw if he had created an FMEA.

Assigning Risk Priority Numbers to an FMEA

An FMEA can be done with a pencil and paper, although Minitab’s Companion software for executing and reporting on process improvement has a built-in FMEA form that automates calculations, and shares data with process maps and other forms you’ll probably need for your project.

An FMEA uses a Risk Priority Number (RPN) to determine when corrective actions must be taken. RPN numbers range from 1 to 1,000 and lower numbers are better. The RPN is determined by multiplying severity (S) by occurrence (O) and detection D.

RPN = S x O x D

Severity, occurrence and detection are each evaluated and assigned a number between 1 and 10, with lower numbers being better.

Failure Mode and Effects Analysis Example: Death Star Thermal Exhaust Ports

In the case of the Death Star’s thermal exhaust ports, the failure mode would be an explosion in the exhaust port and the resulting effect would be a chain reaction that reaches the reactors. The severity would be rated as 10 because an explosion of the reactors would lead to the loss of the station as well as the loss of all the personnel on board. A 10 for severity is sufficient reason to look into a redesign so that a failure, no matter how improbable, does not result in injury or loss of life.

FMEA Failure Mode Severity Example

The potential cause of failure on the Death Star would be attack or sabotage; the designers did not consider this likely to happen, so occurrence is a 3. The main control measure was shielding that would only be effective against attack by large ships. This was rated as a 4 because the Empire believed these measures to be effective.

Potential Causes and Current Controls

The resulting RPN would be S x O x D =  10 x 3 x 4 = 120. An RPN of 120 should be sufficient reason to take actions, but even a lower RPN requires a corrective action due to the high rating for severity. The Death Star’s RPN may even be too low due to the Empire’s overconfidence in the current controls. Corrective actions are definitely needed.

FMEA Risk Priority Number

Corrective actions are easier and cheaper to implement early in the design phase; particularly if the problem is detected before assembly is started. The original Death Star plans could have been modified with little effort before construction started. The shielding could have been improved to prevent any penetration and more importantly, the interlinks between the systems could have been removed so that a failure of one system, such a an explosion in the thermal exhaust port, does not destroy the entire Death Star. The RPN needs to be reevaluated after corrective actions are implemented and verified; the new Death Star RPN would be 5 x 3 x 2 = 30.

FMEA Revised Metrics

Of course, doing the FMEA would have had more important impacts than just achieving a low number on a piece of paper. Had this step been taken, the Empire could have continued to implement the Tarkin Doctrine, and the Universe would be a much different place today.

Do You Need to Do an FMEA?

A simple truth is demonstrated by the missing nail and the kingdom, as well as the lack of an FMEA and the Death Star:  when designing a new product, whether it is an oil rig, a kitchen appliance, or a Death Star, you’ll avoid many future problems by performing an FMEA early in the design phase.

About the Guest Blogger: 
Matthew Barsalou is an engineering quality expert in BorgWarner Turbo Systems Engineering GmbH’s Global Engineering Excellence department. He has previously worked as a quality manager at an automotive component supplier and as a contract quality engineer at Ford in Germany and Belgium. He possesses a bachelor of science in industrial sciences, a master of liberal studies and a master of science in business administration and engineering from the Wilhelm Büchner Hochschule in Darmstadt, Germany..
  

Would you like to publish a guest post on the Minitab Blog? Contact publicrelations@minitab.com

 

References

Lucas, George. Star Wars, Episode IV: A New Hope. New York: Del Rey, 1976. http://www.amazon.com/Star-Wars-Episode-IV-Hope/dp/0345341465/ref=sr_1_2?ie=UTF8&qid=1358180992&sr=8-2&keywords=Star+Wars%2C+Episode+IV%3A+A+New+Hope

Opie, Iona and Opie, Peter. ed. Oxford Dictionary of Nursery Rhymes. Oxford, 1951, 324. Quoted in Lowe, E.J. “For Want of a Nail.” Analysis 40 (January 1980), 50-52. http://www.jstor.org/stable/3327327

Rayfield, Jillian. “White House Rejects ‘Death Star’ Petition.” Salon, January 13, 2013. Accessed 1anuary 14, 2013 from http://www.salon.com/2013/01/13/white_house_rejects_death_star_petition/

Smith, Bill. ed. Star Wars: Death Star Technical Companion. Honesdale, PA: West End Games, 1991. http://www.amazon.com/Star-Wars-Death-Technical-Companion/dp/0874311209/ref=sr_1_1?s=books&ie=UTF8&qid=1358181033&sr=1-1&keywords=Star+Wars%3A+Death+Star+Technical+Companion.

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3 Ways to Gain Buy-In for Continuous Improvement

Research out of the Juran Institute, which specializes in training, certification, and consulting on quality management globally, reveals that only 30 percent of improvement initiatives succeed

 

And why do these initiatives fail so frequently? This research concludes that a lack of management support is the No. 1 reason quality improvement initiatives fail. But this is certainly not a problem isolated to just continuous improvement, as other types of strategic initiatives across the organization face similar challenges. Surveys of C-level executives by the Economist Intelligence Unit concur—sharing that lack of leadership buy-in and support can stop the success of many strategic initiatives.

Why Else Do Quality Initiatives Fail? 

Evidence shows that company leaders just don’t have good access to the kind of information they need about their quality improvement initiatives. 

Even for organizations that are working hard to assess the impact of quality, communicating impacts effectively to C-level executives is a huge challenge. The 2013 ASQ Global State of Quality report revealed that the higher people rise in an organization’s leadership, the less often they receive reports about quality metrics. Only 2% of senior executives get daily quality reports, compared to 33% of front-line staff members.  

So why do so many leaders get so few reports about their quality programs? Scattered, and inaccessible project data makes it difficult to piece together the full picture of quality initiatives and their impact in a company. Because an array of applications are often used to create charts, process maps, value stream maps, and other documents, it can be very time consuming to keep track of multiple versions of a document and keep the official project records current and accessible to all key stakeholders.

On top of the difficulty of piecing together data from multiple applications, inconsistent metrics across projects can make it impossible to evaluate results in an equivalent manner. And even when organizations try quality tracking methods, such as homegrown project databases or even full-featured PPM systems, these systems become a burden to maintain or end up not effectively supporting the needs of continuous quality improvement methods like Lean and Six Sigma.

Overcoming Limited Visibility 

Are there ways to overcome the limited visibility stakeholders have into their company’s quality initiatives? For successful strategic initiatives, it has been identified that planning and good communication are drivers for success. These drivers also positively impact successful continuous improvement projects.

1. Ensure efficiencyUtilize a complete platform for managing your continuous improvement program to reduce inefficiencies. Using one platform to track milestones, KPIs, and documents addresses redundancies of gathering key metrics from various sources needed to report on projects, saving teams hours of valuable time. Looking past the current project at hand, one platform can also make it easy to quickly replicate processes such as roadmaps and templates that were useful in previous quality initiatives.

2. Aim for consistency. Centralize your storage by making all relevant documents accessible to all team members and stakeholders. As teams grow and projects become more complex, the benefit of having all team members aligned can prevent confusion and reduce the number of back and forth emails that tend to happen. 

3. Real-time visibility for all. Visibility into the progress of your quality project facilitates the daytoday management of tracking results and addressing any challenges. Utilize dashboards to provide a quick “snapshot” of your project’s progress. Cloud-based capabilities takes your dashboard to the next level—instantly communicating real-time results. 

Drive for Excellence 

For quality professionals and leaders, the challenge is to make sure that reporting on results becomes a critical step in each project and that all projects are using consistent metrics that are easily accessible. Teams that can do this will find reporting on their results a manageable taskfacilitating the needed visibility to all key stakeholders that’s necessary for leadership buy-in.  

 

5 Tips to Make Process Improvements Stick!

For a process improvement practitioner, finishing the Control Phase of the DMAIC process is your ticket to move on to your next project. You’ve done an excellent job leading the project team because they identified root causes, developed and implemented solutions to resolve those root causes, put a control plan in place and transitioned the process back to the Process Owner. Soon, however, you learn that the process has reverted to its original state.

I’ve often heard project leaders lament, “We worked so hard to identify and implement these solutions—why won’t they stick?”

So let’s talk about fishing for a moment, because it offers some great lessons for making process change. Remember the quote, “Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime?” Seems simple enough, right?  But what is involved and how long does it take to teach people to fish so they could eat for a lifetime?

The same is true for process improvements. Seems simple enough to make a change and expect it to stick. So why is it so hard?

catch a fish

The fishing analogy hits home with me. I love to go fishing and have been an avid angler since I was young. And though it’s been a while since I taught my kids how to fish, I do remember it was a complicated process. There is a lot to learn about fishing—such as what type of equipment to use, rigging the rod, baiting the hook, deciding where to fish, and learning how to cast the line.

One of the most important fishing tips I can offer a beginner is that it’s better to go fishing five times in a few weeks as opposed to five times in an entire year. Skills improve quickly with a focused effort and frequent feedback. People who spread those introductory fishing experiences out over a year wind up always starting over, and that can be frustrating. While there are people who are naturally good at fishing and catch on (pun intended) right away, they are rare. My kids needed repeated demonstrations and lots of practice, feedback and positive reinforcement before they were able to fish successfully. Once they started catching fish, their enthusiasm for fishing went through the roof!

Tips for Making Process Improvements Stick

Working with teams to implement process change is similar. Most workers require repeated demonstrations, lots of practice, written instructions, feedback and positive reinforcement before the new process changes take hold.

Here are several tips you can use to help team members be successful and implement process change more quickly. Take the time to design your solution implementation strategy and control plan with these tips in mind. Also, Companion by Minitab® contains several forms that can make implementing these tips easy.

Tip #1: Pilot the Solution in the Field

A pilot is a test of a proposed solution and is usually performed on a small scale. It’s like learning to fish from the shore before you go out on a boat in the ocean with a 4-foot swell. It is used to evaluate both the solution and the implementation of the solution to ensure the full-scale implementation is more effective. A pilot provides data about expected results and exposes issues with the implementation plan. The pilot should test both if the process meets your specifications and the customer expectations. First impressions can make or break your process improvement solution. Test the solution with a small group to work out any kinks. A smooth implementation will help the workers accept the solution at the formal rollout.   Use a form like the Pilot Scale-Up Form (Figure 1) to capture issues that need resolution prior to full implementation.

Pilot
Figure 1. Pilot Scale-Up Form

Tip #2: Implement Standard Work

Standard work is one of the most powerful but least used lean tools to maintain improved process performance. By documenting the current best practice, standardized work forms the baseline for further continuous improvement. As the standard is improved, the new standard becomes the baseline for further improvements, and so on.

Use a Standard Work Combination Chart (Figure 2) to show the manual, machine, and walking time associated with each work element. The output graphically displays the cumulative time as manual (operator controlled) time, machine time, and walk time. Looking at the combined data helps to identify the waste of excess motion and the waste of waiting.

Standard Work
Figure 2. Standard Work Combination Chart

Tip #3: Update the Procedures

A Standard Operation Procedure (SOP) is a set of instructions detailing the tasks or activities that need to take place each time the action is performed. Following the procedure ensures the task is done the same way each time. The SOP details activities so that a person new to the position will perform the task the same way as someone who has been on the job for a longer time.

When a process has changed, don’t just tell someone of the change: legitimize the change by updating the process documentation. Make sure to update any memory-jogger posters hanging on the walls, and the cheat sheets in people’s desk drawers, too. Including a document revision form such as Figure 3 in your control plan will ensure you capture a list of procedures that require updating.

Document Revision
Figure 3. Document Revision Form

Tip #4: Feedback on New Behaviors Ensures Adoption

New processes involve new behaviors on the part of the workers. Without regular feedback and positive reinforcement, new process behaviors will fade away or revert to the older, more familiar ways of doing the work. Providing periodic feedback and positive reinforcement to those using the new process is a sure-fire way to keep employees doing things right. Unfortunately, it’s easy for managers to forget to provide this feedback. Using a Process Behavior Feedback Schedule like Figure 4 below increases the chance of success for both providing the feedback and maintaining the gains.

Process BehaviorFigure 4. Process Behavior Feedback Schedule

Tip #5: Display Metrics to Reinforce the Process Improvements

Metrics play an integral and critical role in process improvement efforts by providing signs of the effectiveness and the efficiency of the process improvement itself. Posting “before and after” metrics in the work area to highlight improvements can be very motivating to the team.   Workers see their hard work paying off, as in Figure 5. It is important to keep the metric current because it will be one of the first indicators if your process starts reverting.

Before After ChartFigure 5. Before and After Analysis

When it comes to fishing and actually catching fish, practice, effective feedback, and positive reinforcement makes perfect.

The same goes for implementing process change. If you want to get past the learning curve quickly, use these tips and enjoy the benefits of an excellent process!

To access these and other continuous improvement forms, download the 30-day free trial of Companion from the Minitab website at http://www.minitab.com/products/companion/.

Improving Cash Flow and Cutting Costs at Bank Branch Offices

Every day, thousands of people withdraw extra cash for daily expenses. Each transaction may be small, but the total amount of cash dispersed over hundreds or thousands of daily transactions can be very high. But every bank branch has a fixed cash flow, which must be set without knowing what each customer will need on a given day. This creates a challenge for financial entities. Customers expect their local bank office to have adequate cash on hand, so how can a bank confidently ensure each branch has enough funds to handle transactions without keeping too much in reserve?

Grupo MutualA quality project team led by Jean Carlos Zamora and Francisco Aguilar tackled that problem at Grupo Mutual, a financial entity in Costa Rica.

When the project began, each of Grupo Mutual’s 55 branches kept additional cash in a vault to avoid having insufficient funds. But without a clear understanding of daily needs, some branches often ran out of cash anyway, while others had significant unused reserves.

When a branch ran short, it created high costs for the company and gave customers three undesirable options: receive the funds as an electronic transfer, wait 1–3 days for consignment, or travel to the main branch to withdraw their cash. Having the right amount of cash in each branch vault would reduce costs and maintain customer satisfaction.

Using Minitab Statistical Software and Lean Six Sigma methods, the team set out to determine the optimal amount of currency to store at each branch to avoid both a negative cash flow and idle funds. The team followed the five-phase DMAIC (Define, Measure, Analyze, Improve, and Control) method. In the Define phase, they set the goal: creating an efficient process that transferred cash from idle vaults to branches that needed it most.

In the Measure phase, the team analyzed two years’ worth of cash-flow data from the 55 branches. “Managing the databases and analyzing about 2,000 data points from each of the 55 branches was our biggest challenge,” says Jean-Carlos Zamora Mora, project leader and improvement specialist at Grupo Mutual. “Minitab played a very important part in addressing this issue. It reduced the analysis time by helping us identify where to focus our efforts to improve our process.”

The Analyze phase began with an analysis of variance (ANOVA) for to explore how the banks’ cash flow varied per month. They used Minitab to identify which months were different from one another, and grouped similar months together to streamline the analysis.

The team next used control charts to graph the data over time and assess whether or not the process was stable, in preparation for conducting capability analysis. To choose the right control chart and create comprehensive summaries of the results, the team used the Minitab Assistant.

grupo mutual i-mr chart

The team then performed a capability analysis of each group’s current cash flow to determine whether customer transactions matched the services provided, and establish the percentage of cash used at each branch.

grupo mutual capability analysis

The analysis revealed that, in total, the vaults contained more than the necessary funds each branch needed to operate effectively, but excessive circulation of the money caused some to overdraw their vaults while others stored cash that was not utilized.

“We found a positive cash balance at 95% of the branches,” says Zamora Mora. “The analysis showed the cash on hand to meet customer needs exceeded the requirements by over 200%, so we suddenly had lots of money to invest.”

The analysis gave the team the confidence to move forward with the Improve phase: implementing real-time control charts that enabled management to check each branch’s cash balance throughout the day. Managers could now quickly move cash from branches with excess cash to those needing additional funds, and make more strategic cash flow decisions.

The team found that being able to answer objections with data helped secure buy-in from skeptical stakeholders. “Throughout this project, we encountered questions and situations that could have jeopardized our team’s credibility and our likelihood of success,” recalls Zamora Mora. “But the accuracy and reliability of our data analysis with Minitab was overpowering.”

The changes made during the project increased cash usage by 40% and slashed remittance costs by 60%.The new process also cut insurance costs and shrank risks associated with storing and transporting cash. Overall, the project increased revenue by $1.1 million.

To read a more detailed account of this project, click here.

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Deming’s 14 Points to Improving Quality, Productivity and Economic Value

 

Deming’s 14 to Improving Processes and Profits!  Excerpts from the Deming Library with Dr. Deming, Robert Reich, Lloyd Dobbins and Clare Crawford Mason.

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