Nestlé Continuous Excellence

Goal Alignment
Basic Problem Solving
(Go-See Think Do & Breakdown Analysis )

Michael Karpe 2016

 Agenda

Objectives

Introduction to Basic Problem Solving

(GSTD/BDA)

Basic Problem Solving Integrated Form

roadmap and tools

Basic Problem Solving Guidance Tools

Key messages

Go-See Think Do 2
 Objectives

At the end of this training session, participants will be able to:

 Understand the importance of Basic Problem

Solving tools with in NCE
 Identify when to apply a Basic Problem Solving tools

 Apply Basic Problem Solving tools within their reality

Go-See Think Do 3
 Agenda

Objectives

Introduction to Basic Problem Solving

(GSTD/BDA)

Basic Problem Solving Integrated Form

roadmap and tools

Basic Problem Solving Guidance Tools

Key messages

Go-See Think Do 4
 Basic Problem Solving will eliminate root causes
of problems, delivering consistent results
1. ALIGN AND
PRIORITIZE
Operational Master
Planning
3. DELIVER
CONSISTENT
RESULTS
Goal 2. REVIEW
Basic Problem Alignment PERFORMANCE
Solving
Performance
Standard Measures
Routines Operational
Reviews

Go-See Think Do 5
 Why do we need Basic Problem Solving in
Goal Alignment?
To develop people competency across all levels of the
organization to solve daily problems and learn from them
To support the achievement of business and functional
results
To release time for people to work on more value-added
activities

Go-See Think Do 6
 Mandatory Deliverables of GSTD/BDA

Results: • Was the target achieved (review of measure)?

• A standard was created/updated to achieve

Standardization:
sustainability and standardize the process

• Training was provided to all impacted employees

Training /
and knowledge was transferred to other
Reapplication:
areas/sites.

Capability • Team members gained knowledge and capability

Building: in problem solving activities and tools

Go-See Think Do 7
 Basic Problem Solving should be a team
activity

It is very hard to make an Good Continuous Improvement is

improvement individually achieved through teamwork

Go-See Think Do 8
 What is the Integrated Basic problem solving
form? (GSTD/BDA)
It is a combination of the “Go See Think Do” tool with
“Breakdown Analysis”, as well as SHE and Quality
reporting

The integrated Basic problem solving form is a step by

step methodology that can be applied when an issue is
identified or a sporadic problem appears

The process starts by understanding the problem, then

finding root causes, agreeing on solutions and finally
implementing and standardizing them

The integrated Basic problem solving form can be applied

by everyone in the organization
The Go-See or Intervention report engages people to go to where
the problem occurs (GEMBA)

Go-See Think Do 9
 Why an Integrated Form?

One problem solving tool for everyday problems

Guide teams to select the right tool for the loss

No confusion or delay when problem solving occurs

regarding what tool to use

Go-See, Incident &/or Intervention Report data is

obtained regardless of the root cause (i.e. breakdown
verses process failure)

Promotes collaboration between functions

One NCE, one basic problem solving tool

Go-See Think Do 10
 Most of the problems can be solved using Basic
Problem Solving Tools
Problems requiring high DMAIC Training
1%*

complexity problem
Problems requiring medium
solving tools Black Belt
complexity problem
solving tools
4%*

Green Belt
% Problems occurrence

Project leaders
solving tools
Yellow Belt
medium complexity problem
5%

Problems requiring simple to

tools
White Belt
10%*

Problem requiring simple problem solving

80%*

All employees
Basic Problem Solving
(all employees)
solving tools
Day-to-day problems involving requiring basic problem

rectional percentages. May vary from area to area

Go-See Think Do 11
 Comparison of the Basic Problem Solving Tool
and White Belt DMAIC Projects
Basic Problem Solving Tool White Belt
(Go See Think Do/Breakdown Analysis)
No charter, No formal Tollgates Charter, formal Tollgates
GSTD Guidance Tool

Triggered by issues with unknown root cause, like Triggered by recurring issues, trends, escalated
gaps from measures (e.g. performance gaps, problems or chronic losses identified through the
rework, lead time, consumer complaints, machine Business Priorities or a step change requirements
stoppages, non-conformity) in measures
Acts immediately Plans for data collection
Practiced by everyone, everyday Practiced by a trained WB / YB
Coached by a person who has basic problem solving Coached by at least a WB with competency level ≥
competency 4 (Level 4 - Can do alone)

Uses basic tools Uses basic tools

Short Duration (up to 2 weeks) Long Duration (no more than 2-3 months)
Can be a small group coming from the same team or Always a cross functional team
a cross functional team

Go-See Think Do 12
 The GSTD/BDA tool is triggered when…

…there is a gap against the …the measure shows a

target on a measure, or… negative trend, or…

…an sporadic problem happens…

…and the root cause is unknown.

Go-See Think Do 14
 GSTD/BDA Process
An
An issue
issue was
was identified
identified

Yes Continue
Continue monitoring
monitoring
Is
Is the
the root
root cause
cause Take
Take actions
actions the
the impacted
impacted
known?
known? measures
measures
No
Go-See/IR

Understand
Understand where,
where, how
how and
and who
who is
is
involved when the problem happens
involved when the problem happens
No* Create
Create
Is
Is there
there aa Standard
Standard
standard?
standard?
Yes
No Assure
Assure
Is
Is the
the standard
standard standard
standard is
is
being followed?
being followed? followed
followed
Yes
No
Is
Is BDA
BDA trigger
trigger Identify
Identify root
root causes
causes
Think

activated?
activated?

Validate/Eliminate
Validate/Eliminate
Yes Complete
Complete BDA
BDA Root
Root Causes
Causes
Section
Section of
of form
form

Yes
Yes Create/update/
Create/update/
Is
Is the
the All
All
Implement
Implement train/follow
train/follow the
the
Do

problem
problem deliverables
deliverables
sustainable
sustainable solutions
solutions standards/re-apply
standards/re-apply to to other
other
eliminated?
eliminated? met?
met?
areas
areas
No No

*If it is clear which standard is needed, create the Escalate

Escalate through
through
standard, continue monitoring the impacted measures. Operational
Operational Review
Review
or
or initiate
initiate DMAIC
DMAIC project
project
Go-See Think Do 15
 GSTD/BDA can be and input or an output of
Operation Reviews
Inputs Input for next
Actions
Measures Operational
Review
Issues to be

Increasingly difficult issues

escalated
Issues

Problem
Problem Solving Solving
activities activities

Escalated
issues Issue/Actio
Operational n
Review
Feedback from Feedback for
upper level lower level

Go-See Think Do 16
 Agenda

Objectives

Introduction to Basic Problem Solving

(GSTD/BDA)

Basic Problem Solving Integrated Form

roadmap and tools

Basic Problem Solving Guidance Tools

Key messages

Go-See Think Do 17
 Simulation Game – Puzzle exercise

ROUND 1:
• Conduct two rounds of puzzle assembly – see
instructions
• Background on the Puzzle exercise; what it is, how it
works
• My Requirements – see flip chart list

• Debrief Round 1
• How did you do?
• Do we have a problem Y/N?
• What is missing?

Go-See Think Do 18
 Go-See Think Do: Purpose and Output

33 11
Purpose: Purpose:
- Implement and standardise - Comprehensive and precise
solutions description of what
happened (crime scene)
Output: Do Go See/
- Solutions implemented (Action Interventio Output:
- Results achieved Planning) n Report - Understanding of how and
- Standard created / updated where problem happened
- Knowledge transferred - Impacted measures defined
- A focused problem statement
(training)
Think/
Equipment (Phenomenon Description )
Analysis

22
Purpose:
- Find root causes, then solutions

Output:
- Root causes identified and
verified
- Actionable solutions identified

Go-See Think Do 19
New Integrated PS Form

Facilitating and documenting recommended Integrated GSTD/BDA form

Go-See / IR FORM
Completed by BDA Team
CAUSE-EFFECT ANALYSIS ACTION to Eliminate Reoccurrence
!!! PLEASE FILL THIS FORM IN THE FIELD DURING OR JUST AFTER THE INCIDENT RESTORATION - IN THE SAME SHIFT !!!
Lead: Participant: Participant:
Leader Name: Name: ACTION PLAN - Implement preventive and sustainable solutions
Coach Name: Name: Participant: Participant: Participant: CAUSE-EFFECT ANALYSIS
Name: Name: Cause WHAT W HEN WHO Effort Impact
Problem Statement /
Name: Name: Est. Cost to Est. Potential
Defect Mode (WHAT WILL THE ACTION ELIMINATE, CONTROL, REDUCE OR
DRAW / SKETCH THE FAILED COMPONENT
(Sketch section or attach evidence: A picture of a good part & Failed part, cross section of the part, etc..)
Description N* SIM PLIFY?) Due date Responsible implement savings
Describe the problem (in case problem identified previously or during Operational Reviews,which measure is affected?)

Is there any interim correction that could be applied?

What was the interim correction? Who W hen Status

DRAW / SKETCH THE PROCESS OR FAILED COMPONENT

(Understand where and how the problem happens i.e. using process flow diagram, failed component diagram, information flow.)

Effect

es
Defect Mode

p
Potential Causes DEFECT CLASSIFICATION

t y 1. Focus on the problem(4W1H)

All
De fe ct Fam ily Generic Causes of Failure (based upon Root Cause Analysis). Check all applicable
1. What h ap p en ed b efo re or d urin g th e Issu e to o k place? What p rob lem was n oticed?
MUV (scrap) Quality Hold Safety (Accident, Near Miss, Risk)
(Cases/$) ( ) Physic al ( ) Sensorial ( ) Item not included in QMS plan ( ) Poor detection system
( ) Chemical ( ) Visual Aspect ( ) Inaccurate measurement system ( ) Poor Quality of raw material
( ) Microbiological ( ) Inadequate inspection frequency ( ) Poor operators' skills
2. Where exactly d id the Issue h ap pen ? (p hysically o n th e eq uipmen t/mach in e/lin e)
Other :___________________________________ ( ) Preventive intervention postponed / cancelled
( ) Operational mistake
Stoppage date: _____ / _____ /20_____ Quantify the impact of the Highest Loss :
3. When d id the Issu e h ap pen ? (wh at pro d u ctio n pro cess mom en t it was, pr od u ctio n /main ten ance etc. with d ate/time) (Estimate = MUV, Quality Hold Impact, Parts, Efficiency Point Loss, Downtime, = $$ Total Value of Loss) Cost of Parts Cost of DT Total Loss ($$) ( ) Pending corrective action ( ) SOP not detailed enough
Quality Team Responsible:_____________________
Issue start: _____H _____
4. Who was th e first to n otice the ab no rmality? min

5- How much / How man y? Issue finish: _____H _____

min

6 Pro blem Statemen t (Ph en omen on Descrip tio n)?

Equipment Gap Assessment Tool
ASSESS BASIC CONDITIONS AT THE LINE 5 WHYs ANALYSIS (Go deeper to find and verify the root cause)

es
GO - SEE

Break down M ode

Points to Check Define Ideal Condition Define Current Condition Gap
Move to Description:
2. STANDARDS INVESTIGAT ION (Numeric, Quantitative, (Numeric, Quantitative, (Refer to current vs. ideal to

p
(Basic Condition = Clean, Tight & Aligned, Lubed)

nly
Fishbone
Qualitative) Qualitative) quantify Gap)

THINK
What is the action? (Usage Conditions = Maint, Environment, Operating)

y
1. Start by identifying w hat direct cause s cause the Pr oblem or Break dow n M od e Des cription to occur

pes
If the answer is No and it

t
Check points
is applicable, write down Action Who When Status 2. Identify Pote ntial Indire ct Variable s "Contributors " that could have contributed to the Proble m or BD UNDER each Direct Variable
Write Y for Yes, N for No, N/A for Not Applicable on the tick box
Action, Who, When, Clean VERIFICATION OF EFFECTIVENESS

All
(Exam ple : Im proper Lube (Direct Variable - Indirect Variables are No Lube Standardized am ount id'd, no corre ct fre que ncy of Lube scheduled, no id of

DO
Status
All items need a physical prope r lube)
Is there a standard? (if Yes, move to next question, if No, m ove to Think Do phase)
check with the entire (Successful problem solving means that the problem does not recur during the next 3 or more opportunities (i.e. 3 days if the problem could happen on daily
team involved. If a > Is the Component free of contaminates (Dust, Glue, Oil, Grease, 1. basis). The number of verifications should be determined by the team.

A y
Is it being followed? (if Yes, m ove to Think Do phase, if No, m ove to the check points below) standard is not in place, Product buildup, Pkg Material Buildup, etc.?) 2. 1. Start by ask ing WHY, answ e r w ith BECAUSE 4. Re view list of Gaps from Asse ssing Basic Condition and Ens ure Incorporated into Why-Why

t
3.
complete the action and > Is there a Cleaning Schedule at the Component?
continue with the > If Clean Sched Exists, W as it completed? 2. Write YES if the caus e is confirm ed at gem ba No if the cause w as not confirm
5. Mark
ed each root cause w ith a 1,2... to link the actions afterw ar ds

BD All
Have people been trained on it?
Problem Solving
process. 3. Circle the ver ified root causes
Is the standard clear and available?
Tight and Aligned
Are materials and equipment parameters in specification ? (if applicable) P O S S IB LE D IR EC T
A/Q C A US E S
W HY? Y/N WHY? Y/N WHY? Y/N WHY? Y/N WHY? Y/N
1.
3. RESTORATION ACTIVITIES EXPLANATION > Are fasteners at appropriate tightness? 2.
3.
> Are Equip Settings Aligned Properly (Centerlined)? Question
!!! PLEASE TAKE ALL REPLACED COM PONENTS INT O DEDICATED PLACE FOR ANALYSIS - BDA CANNOT BE PERFORM ED WITHOUT PARTS !!!
*Write down the NUMBER corresponding to the root cause as identified in the 5-Why's (previous step)
Note: This area is to be used to define the content of the WO PM01

Answ er
Restoratio n particip ants:
Correction/Repair Start: __ ___H _____ min Lubricated
STANDARDIZE AND SHARE LEARNINGS
Name(s):
POINTS TO CHECK DOCUMENT WHO W HEN STATUS
Name(s):
Correction/Repair Finish _____H ___ _ min Question
> Are components lubricated with correct Lube Type?
1.
2.
Has a CIL and/or AMM standard been created and/or revised/updated?
Name(s): BDA # (WO#) _______ > Does Lubrication Standard exist (frequency, amount)? 3.
> Is Lubrication being executed correctly? Answ er
1.L o catio n wh ere failu re o ccu r ?
Were new OPL's created (One Point Lessons)?
L in e: Machine: FLOC (if Breakdown):

nly
Question
Was training delivered on the new and/or updated standards?
2. Please descr ib e all activities that was d o n e to resto re o p er atio n Maintenance Conditions
Is a MOC required (Management o change)?
1. 1. 1.
Answ er

o
> Are Defects/Abnormalities visible in Eq/Component?
2. 2. 2.
> Is there a PM for the failed component? Is there a follow up date to monitor the problem is resolved?
> Is the frequency right that matched Failure history? 3. 3. 3.
> If PM Exists, Are maint standards/procedures Correct?

A
4. 4. 4. Question Is the improvement documented on the improvement register? (described how this
improvement can / will be replicated to other machines / equipment?

BD
Answ er
Environmental Conditions

3. Was any m ech anical o r p ro cess ad ju stmen ts d o ne d u rin g resto ration activities? POTENTIAL FOR REPLICATION - SCOPE
1. 1. 1. Question
Yes No If yes, what was done? Please include details in the sketch, if needed 2. 2. 2.
>Is the equipment being used in an environment that’s acceptable (No 3. 3. 3. ACTION # (AMM or LC) DESCRIPTION OF THE ACTION IMPROVEMENT RECORD # Impact (potential savings)
buildup, Sources of Contamination, Extreme Temp, etc.)? 4. 4. 4.
Answ er

Operating Conditions Question

4. Was th ere com po nen ts th at failed or were replaced ?

>Does Equipment have Equipment Settings (Centerlines)? 1. 1. 1. Answ er
Equipment: Object Code: Damage Code: Cause Code: 2. 2. 2.
>Are Equipment Settings Correct?
3. 3. 3.
>Are Equipment settings used/adhered to?
4. 4. 4.
Equipment: Object Code: Damage Code: Cause Code: >Are SOP's for Changeover, Startup/Shutdown in place, Affective,
adhered to? Question
Equipment: Object Code: Damage Code: Cause Code:

Answ er

Page 1 Page 2 Page 3 Page 4

Go-See Think Do 20
 Different applications of the GSTD/BDA form

• Format can be tailored according to the needs

• Important to follow flow and content

Some examples of how the form is being used:

Go-See Think Do 21
 Different applications of GSTD form

Additional
examples

Go-See Think Do 22
 Step Go-See/Intervention Report:
Understanding the problem
1 2 3 4
Understand
Understand
Describe
Describe Focus
Focus on
on
how
how and
and where
where Check
Check
and
and contain
contain the
the
the problem
the problem standards
standards
the
the problem
problem happens problem
problem
happens

Objective
Go-See / IR FORM
Date ___________________ White area filled out by Operator/Technician Gray area filled out by Technician

!!! PLEASE FILL TH IS FOR M IN THE FIELD DURI NG OR JUST AFTER TH E INCIDENT R ESTORATION -IN THE SAME SHIFT !!!

Leader Name: Name:

Coach Name: Name:
Name: Name:
Name: Name:

Describe the problem (in case problem identified previously or during Ope rational Reviews ,which m easure is affected?)

Is there any interim cor rection that could be applied?

Describe the problem and identify measures that will be

What was the interim correction? Who When Status

DRAW / SKETCH THE PROCESS OR FAILED COMPONENT

(Understand where and how the problem happens i.e. using process flow diagram, failed com ponent diagram, information flow.)

positively impacted, if applicable 1. What was obser ved prior to and during the issue? What pr oblem was n oticed?
1. Focus on the problem (4W1H)

2. Where exactly did the Issue take place? (ph ysically on the equipment/m achin e/lin e)

Identify the people involved at time of issue

Stoppage date_ ___/______/
20____
3. When did th e Issue happen? (wh at production pr ocess m oment, production/m aintenance etc. with date/tim e)

Issue start _____H ____

4. Who was the fir st to notice the abnormality? Who was in volved in the issue? min

Issue finish _____H _____

5- How much / How many? How did the issue happen?
min

6 P roblem Stat emen t (Phenomenon Description)?

Implement interim corrections to reduce or contain the

G O - S EE
2. ST ANDARDS INVESTIGATION
Wha t is the action?
If the answer is No and it
Check po ints
is applicable, write d own Action Who When Status
Write Y fo r Ye s, N for No, N/A for No t Applicable on the tic k box
Action, Wh o, Wh en,

problem
Status
All items n ee d a p hysic al
Is there a standard? (if Yes , mov e to nex t question, if No, m ove to Think Do pha se ) c he ck with the entire
team involved. If a
Is it being followed ? (if Yes, move to Think Do pha se, if No, mo ve to the check poin ts be low) s tanda rd is not in place,
c omplete the action and
Ha ve people been trained on it? continue with the
Problem So lv ing
proc es s.
Is the standa rd cle ar and available?

Are ma ter ials a nd equipment para me ters in specification ? (if applicable)

3. RESTORATION ACT IVITIES EXPLANATION

!!! PLEASE TAKE ALL REPLACED COMPONENTS INTO DEDICATED PLACE FOR ANALYSIS - BDA CANNOT BE PERFORMED WITHOUT PARTS !!!
Note : This a rea is to be used to define the content of the WO PM01

Restor ation participants:

BDA # (WO#)
Name(s): __________________________

Name(s):

Tools
Name(s):

1.Location where failure occur ?

Line: Machine: FLOC (if Br eakd own):
2. Please describe all activities that were completed to r estore oper ation

Charts of measures
3. Was any mechan ical or process adjustments m ade d uring restorat ion activities?
Yes No If yes, what was done? Please include details in the sketch, if needed

4. Was component s r eplaced?

Equipment: Object Code: Dam age Code: Cause Code:

Action Board

Go-See Think Do 23
 Describe the problem and
identify impacted measures

Typical questions to help describe the problem:

- Which result has not been achieved?
- What is different from the expected?
- Which failure or defect was observed?
- …

Examples triggered by a measure:

Measures of travel expenses Travel expenses 15% above

 
did not meet the target the target in Aug/13

Go-See Think Do 24
 Implement interim corrections to reduce
or contain the problem

What is it? • Temporary solution to prevent reoccurrence

What it is • Fix or correction of what already happened e.g.

not? place product on hold

• Temporary solution to continue SAFE QUALITY

Objectives
production until completion of the GSTD/BDA

Go-See Think Do 25
 Milk Example

Describe the problem (problem identified previously or during an Operational

Review, which measure is affected?)
Milk spilled in the stove 3 times during heating, wasting the milk in
the kitchen
Is there any interim correction that could be applied?
What was the interim correction? Who When Status

One person to supervise the whole process

and remove the pot from the stove (turn off John 13.09.2017 Done
the stove) as soon as the milk starts to boil

Go-See Think Do 26
 Step Go-See/Intervention Report:
Understanding the problem
1 2 3 4
Understand
Understand
Describe
Describe Focus
Focus on
on
how
how and
and where
where Check
Check
and
and contain
contain the
the
the problem
the problem standards
standards
the
the problem
problem problem
problem
happens
happens

Objective
Record your observations from the GEMBA to understand how and where
the problem happens

Tool
Flow Chart

Go-See Think Do 27
 Flow Chart

• A map of all the steps in a process, and their real

sequence
What is it? • One way to illustrate how and where the problem
happens

• To get a shared understanding of how the process

works
• To understand where the issue happens so the
Objectives
problem can be narrowed down
• To identify steps that may be related to the problem
• To illustrate how and where problem happens

Go-See Think Do 28
 How to create a Flow Chart

Basic Flow Chart Symbols:

To create a Flow Chart This symbol… Represents…
Identify the main steps of the process
by following the sequence in which Start/stop
they are performed
Discuss and agree on the start and end Decision point
of the process
Create a simple sketch of the process
Activity

Highlight where the problem takes Connector (to

place in order to narrow down the another page or
part of the flow)
problem
Direction of flow

Go-See Think Do 29
 Other ways to illustrate how and where the
problem happens

Photos of the problems, drawings, observations from the Go-

See at the Gemba, can be used to illustrate how and where
the problem happens.

Go-See Think Do 30
 Milk Example: Flow Chart

DRAW / SKETCH THE PROCESS OR FAILED COMPONENT

(Understand where and how the problem happens i.e. using process flow diagram, failed
component diagram, information flow.)

Milk is placed in a Turn on the stove, set The milk no

pot to be boiled on Wait more time until it
the temperature #4 started
the stove (kitchen starts to boil
and wait 4 minutes to boiling
area). (monitoring it visually)
boil the milk. (visual)?

yes

Part of the Turn off the stove, Serve the hot milk
process where
take out the pot with for the family
the problem
"appears" hot milk. breakfast

"Visual support"
 

Go-See Think Do 31
 Step Go-See/Intervention Report:
Understanding the problem
1 2 3 4
Understand
Understand
Describe
Describe Focus
Focus on
on
how
how and
and where
where Check
Check
and
and contain
contain the
the
the problem
the problem standards
standards
the
the problem
problem problem
problem
happens
happens

Objective
Define the problem more precisely

Tool
4W1H

Go-See Think Do 32
 4W1H

• It is a structured technique which helps to focus the

problem by answering to what, where, when, who
What is it? and how much/ many questions
• It helps to describe the problem in a clear way

Objective: • To better understand the scope of the problem

Go-See Think Do 33
 How to describe the problem with 4W1H

• What is the problem observed? What is happening?

What • What specific product/service/machine/process is giving us a problem?

• Where did the problem occur?

Where • Geographic location?

• Dates and times of start and subsequent recurrences when the

When problem occurs?
• When in process cycle?

• Is this problem correlated to employee (e.g. operator) abilities?

Who • Who is affected by the problem?

• How much/how many of the specific product/service/machine/

How Much process was affected?
How Many
• How much/how many is there of the problem?

Go-See Think Do 34
 How to describe the problem statement
(phenomena statement)

Description of the Problem Statement:

What + Where + When + Who + How Much/How Many

Note:
The most important is to include all 4W1H elements in the problem
statement (it is ok if the order is not followed)

Go-See Think Do 35
 Milk Example: Describe the problem with
4W1H

1. Focus on the problem(4W1H)

1. What was observed prior to and during the issue? What problem was noticed?                                                           

   
 
Spillage of boiled milk on the stove
 
   
     
   

2. Where exactly did the Issue take place? (physically on the equipment/machine/line)                                    
         Stoppage
                   date
                 
  Kitchen                                 

3. When did the Issue happen? (what production process moment, production/maintenance etc. with date/time) 12th Jan
               ____/______/ 17
                         20____
              

                                 
 
Last 7 days during the preparation of breakfast  Issue start
                               
4. Who was the first to notice the abnormality? Who was involved in the issue?                                    
 
Milk spillage with different cooks (with all family members)  13 ____08 min
                               
_____H
                                 
Issue finish
5- How much / How many? How did the issue happen?                                    
                                 

  3 times out of 7, milk was spilled                                 

13 _____
_____H 47 min
6 Problem Statement (Phenomenon Description)?                                    
   

Last week during the daily preparation of family breakfast, the boiled milk spilled on the stove in
  kitchen area 3 times out of 7 the with different cooks (family members).  

 
                                                                                                                                                                                  

Go-See Think Do 36
 Step Go-See/Intervention Report:
Understanding the problem
1 2 3 4
Understand
Understand
Describe
Describe Focus
Focus on
on
how
how and
and where
where Check
Check
and
and contain
contain the
the
the problem
the problem standards
standards
the
the problem
problem problem
problem
happens
happens

Objective
Ensure standards relevant to the problem are in
place and being followed

Tool
Checklist

Go-See Think Do 37
 Check standards

After defining the problem (using 4W1H), check standards relevant to

this problem by asking the following questions:
Is there a standard? (if Yes: move to next question, if No: create standard and
monitor impacted measure)
Is it being followed? (if Yes: move to Think Do phase, if No: assure standard is
followed and monitor impacted measure)
Have people been trained on it?
Is the standard easy to understand?
Are materials and equipment parameters in specification ? (if applicable)

Go-See Think Do 38
 Milk Example: Check standards

2. STANDARDS INVESTIGATION
                                                                                                                                                                                   
What is the action?
If the answer is No and it
Check points
    is applicable, write down Action Who When Status
Write Y for Yes, N for No, N/A for Not Applicable on the tick box
Action, Who, When,
Status  
  Is there a standard? (if Yes, move to next question, if No, create standard and monitor measure)   All items need a physical Milk Boiling Standard 0001  Husband 09/30/16  Complete 
Y check with the entire  
team involved. If a Observed Cook Completing
  Is it being followed? (if Yes, move to Think Do phase, if No, move to the check points below)   Husband 09/30/16  Complete 
Y standard is not in place, Task   
complete the action and
  Have people been trained on it?   monitor the impacted Reviewed ILearn  Son  09/30/16   Complete 
Y measure.
 
  Is the standard clear and available?   Reviewed with GSTD Team   Husband 09/30/16   Complete 
Y  
Verified by Maintenance
  Are materials and equipment parameters in specification ? (if applicable)                         Son  09/30/16   Complete 
Y Operator  
                                                                                                                                                                                   
                                                                                                                                                                                   

Go-See Think Do 39
 Milk Example: Check standards

you have a N o
What if
2. STANDARDS INVESTIGATION
                                                                                                                                                                                   
What is the action?
If the answer is No and it
Check points
    is applicable, write down Action Who When Status
Write Y for Yes, N for No, N/A for Not Applicable on the tick box
Action, Who, When,
Status  
Review Current Training
  Y Is there a standard? (if Yes, move to next question, if No, create standard and monitor measure)  
All items need a physical material  
Husband   28/10/17  
 
check with the entire
 Develop and Train OPL to
  N Is it being followed? (if Yes, move to Think Do phase, if No, move to the check points below)   team involved. If a address immediate gaps
 Son  15/09/17 Complete 
 
standard is not in place,
  Have people been trained on it?   complete the action and        
monitor the impacted  
measure.
  Is the standard clear and available?          
 
  Are materials and equipment parameters in specification ? (if applicable)                                
 
                                                                                                                                                                                   
                                                                                                                                                                                   

Go-See Think Do 40
 Go See - Simulation Game – Puzzle exercise

ROUND 1: Part 2
• Complete the Go See step and record your work on the
GSTD form (25 minutes)
• After completing the form, conduct one more puzzle
assembly round
• Briefly discuss the outcome of the work done so far

Debriefing
What did you learn from the Go See step?
Did the standard help / not?

Go-See Think Do 41
 What if it’s a Breakdown?

Go-See Think Do 42
 Conditions and checkpoints

Go-See Think Do 43
 Conditions and checkpoints continued…

Go-See Think Do 44
 Step Think - Find root causes,
then solutions
1 2 3
Identify
Identify
Identify
Identify Detect
Detect and
and solutions
solutions
possible
possible verify root
verify root and
and build
build
causes
causes causes
causes action
action plan
plan

Objective
List and group similar possible causes in a clear and visual way

Tools
Brainstorming / Brainwriting
Cause and Effect diagram (Fishbone)
Go-See in GEMBA

Go-See Think Do 45
 Brainstorming / Brainwriting

• A dynamic group exercise in which participants

generate ideas and opinions on a given subject in
an organized way
What is
• During Brainstorming all participants speak out
it?
their ideas, while Brainwriting participants write
their ideas on a piece of paper

• To gather ideas on the subject that is discussed,

Objective:
e.g. to identify possible causes of the problem

Go-See Think Do 46
 How to run Brainstorming / Brainwriting to
find possible causes of the problem
1. Explain the problem

Coordinator explains the problem to the group

If possible, shares relevant historical data

2. Identify possible causes

Participants brainstorm / brainwrite the possible causes of the

problem

3. Team decides which causes should be further considered

4. Group similar causes together and organise them in the Cause and
Effect diagram (Fishbone)

5. All participants should have an opportunity to contribute

Go-See Think Do 47
 Cause and Effect Diagram

• A diagram to organize and categorize similar

possible causes in a clear and visual way
What is it?
• Known as a Fishbone. Also called Ishikawa
diagram or Cause and Effect diagram

Objective: • To group possible causes into similar categories

Go-See Think Do 48
 How to build a Cause and Effect diagram
(Fishbone)
CAUSE-EFFECT ANALYSIS
11
Possible Causes Effect

2 Write the problem statement

(from 4W1H) inside the rectangle
Think

on the right
3 1
Effect 22
2 Defect Mode

Define primary categories

(i.e. 6 M’s: Man, Method, Material, Machine,
33 Measure, Mother Nature (Environment).
Transfer brainstormed causes to the
Categorise possible causes
secondary bones (Place them under the
identified in the brainstorming
corresponding category)

44
Confirm cause based on observation in the GEMBA. Circle those confirmed to be cause.
Cross out those confirmed NOT to be the cause.

Go-See Think Do 49
 Description of the 6Ms

Man
Man Machine/Tools
Machine/Tools Material/
Material/ Inputs
Inputs
Skills
Skills and
and qualifications
qualifications Machine/tools
Machine/tools to
to perform
perform All
All variables
variables associated
associated
for
for the
the job
job operations
operations with
with required
required with
with inputs/materials
inputs/materials
(Training,
(Training, people
people motivation,
motivation, human
human quality
quality (Inputs
(Inputs from
from automation
automation system,
system,
relations, capabilities etc.)
relations, capabilities etc.) merchandising
(Automation
(Automation tools,
tools, supporting
supporting merchandising materials,
materials, condition
condition
materials, of
of material,
material, supplier
supplier performance,
performance,
materials, vehicles,
vehicles, features
features of
of
software, availability, process transportation,
transportation, etc.)
etc.)
software, availability, process
support,
support, machine
machine maintenance,
maintenance, etc.)
etc.)

Method
Method Measure
Measure Mother
Mother nature
nature
All
All methodologies
methodologies used
used in
in All
All measures
measures related
related to
to Variables
Variables associated
associated with
with
the
the process
process or
or procedure
procedure the
the process
process work
work environment
environment
(In
(In call
call execution,
execution, information
information on
on (Tolerance
(Tolerance of
of measures
measures necessary
necessary to
to
((Workplace
Workplace conditions:
conditions: cleanliness,
cleanliness,
tasks, procedures, standards,
tasks, procedures, standards, the process, calibration of
the process, calibration of humidity,
humidity, noise
noise levels,
levels, lighting,
lighting,
specifications,
specifications, activity
activity measuring
measuring instruments,
instruments, etc.)
etc.) temperature,
temperature, ergonomics; safety,
ergonomics; safety,
sequences,
sequences, etc.)
etc.) weather
weather conditions,
conditions, etc.)
etc.)

Go-See Think Do 50
 Milk Example: Cause and effect diagram

Analyse possible causes

(Check verified possible causes and cross the not verified possible causes)
CAUSE-EFFECT ANALYSIS
Effect
Cooks Others
TV in the kitchen
Quantity of milk Cooks do not know The milk bought
distracts the Cooks Problem statement
placed to be boiled is the visual aspect of is from another
different depending boiling milk to turn brand with
Last week during
on the Cook off the stove before different
characteristics
the daily
it spills
preparation of
THINK

family breakfast,
 
the boiled milk
Cooks are not The milk is boiling spilled on the stove
familiar with the before the expected 3 times out of 7
stove. time (4 min) with different cooks
(family members)
Temperature setting
used to heat the milk Time to reach
Stove temperature was not set as usual (#4) the boiled milk
setting is oscillating (4 minutes) is
not observed

Stove Boiling Process

Go-See Think Do 52
 Equipment and Defect Analysis for breakdown

Go-See Think Do 53
 Step Think - Find root causes,
then solutions
1 2 3
Identify
Identify
Identify
Identify Detect
Detect and
and solutions
solutions
possible
possible verify root
verify root and
and build
build
causes
causes causes
causes action
action plan
plan

Objective
Identify and confirm the root cause(s) of the problem

Tools
5 Whys analysis
Go-See in GEMBA

Go-See Think Do 54
 5 Whys analysis

• It is a question-asking technique used to explore

What is it? and deepen the analysis of the cause/effect
relationships underlying a particular problem

• Identify the root cause of a problem using a

Objective:
simple, structured approach

Go-See Think Do 55
 How to build the 5 Whys Analysis
11
Record verified possible causes identified in the fishbone in the column for the first
round of questioning, entering one cause per box
5 WHYs ANALYSIS (Go deeper to find and verify the root cause) 22
Breakdown Mode Description:   Write down the question
1. Start by identifying what direct causes cause the Problem or Breakdown Mode Description to occur
2. Identify Potential Indirect Variables "Contributors" that could have contributed to the Problem or BD UNDER each Direct Variable
(Example: Improper Lube (Direct Variable - Indirect Variables are No Lube Standardized amount id'd, no correct frequency of Lube scheduled, no id of proper lube)
“Why…<potential cause>
1. Start by asking WHY, answer with BECAUSE
2. Write if the cause is confirmed at Gemba if the cause was not confirmed
4. Review list of Gaps from Assessing Basic Condition and Ensure Incorporated into Why-Why
5. Mark each root cause with a 1,2... to link the actions afterwards ?” followed by the answer
to the question.
3. Circle the verified root causes  

A/Q POSSIBLE DIRECT CAUSES WHY? Y/N WHY? Y/N WHY? Y/N WHY? Y/N WHY? Y/N

Question          
         
Answer

Question
 

 
 

 
 

 
 

 
 

 
33
Answer
 
 
 
 
 
 
 
 
 
 
 
• Enter YES if the cause
is confirmed, then go to
Question          
           
Answer          

Question

1  
2
 

3 2
 
 
 
3 2
 
 
3 2
 

32 3
 
 
 
the next round
Answer          

Question

Answer
 

 
 
 

 
 
 

 
 
 

 
 
 

 
  • Enter NO if the cause is
Question
 
 
 
 
 
 
 
 
 
 
 
not confirmed, then stop
Answer

Question
 

 
 

 
4
 

 
 

 
 

 
the analysis for this
cause
           
Answer          

   
                                     

• Repeat the process

44
Always go back to check if the identified root cause is untill reach the root
linked with the possible cause identified at the beginning cause

Go-See Think Do 56
 Milk Example: 5 Whys Analysis
POSSIBLE Y/ Y/ Y/ Y/ Y/
Q/A Direct CAUSES
WHY? WHY? WHY? WHY? WHY?
N N N N N
Why is the stove
Why is the setting achieving a higher Why is the
Why is the milk number 4 Why is there a
temperature setting number 4
boiling before (specified) new stove with
Question faster than usual (specified) more
the expected heating the milk different
time (4 min)? faster than and the milk powerful than it settings?
starts to boil after used to be?
The milk is expected? only 2 minutes?
boiling before
the expected Y Because the stove Y Y Y Y
time (4 min) Because the is reaching a Because the Because the old
setting number 4 higher
(specified) is temperature setting number 4 Because there is stove was
Answer heating the milk faster than usual
(specified) is more a new stove with replaced by a
powerful than it different settings new one with
faster than and the milk
used to be different settings
expected starts to boil after
only 2 minutes

Go-See Think Do 57
 Milk Example: 5 Whys Analysis

POSSIBLE Y/ Y/ Y/ Y/
Q/A CAUSES
WHY? WHY? WHY? WHY?
N N N N
Why sometimes the
Why the quantity of Why they are using same holder used last Why they did not
milk placed to be see the necessity to
Question Quantity of milk different holders to day is not cleaned
boiled is different use the same holder
placed to be between the Cooks? boil the milk? and available to use everyday?
boiled is next day?
different Y Y Y Y
Because sometimes Because they did not Because they
between the Because they are using the same holder used thought the
Cooks see the necessity to
Answer different holders to boil last day is not
use the same holder
size/shape of the
the milk? cleaned and available everyday. holder does not
to use next day. make difference.

Go-See Think Do 58
 Milk Example: 5 Whys Analysis

POSSIBLE Y/ Y/ Y/
Q/A WHY? WHY? WHY?
Direct CAUSES N N N

Why the Cooks are not

Question familiar with the stove?
N
The Cooks are not used
Answer to boil the milk in
stoves.

Why is the equipment Why is it a quite new

different from the one equipment (stove)
Question they used to boil the different from
Cooks are not milk before? previous one?
familiar with the
stove Y Y Y
Because 7 days ago
Because the equipment Because it is a quite the family decided to
is different from the one new equipment
Answer buy a new stove, and
they used to boil the (stove) different from did not evaluate the
milk before previous one.
differences.

Question  

Because they used to N

Answer boil the milk in a
microwave

Go-See Think Do 59
 Step Think - Find root causes,
then solutions
1 2 3
Detect
Detect Identify
Identify
Identify
Identify and
and verify
verify solutions
solutions
possible
possible root
root and
and build
build
causes
causes causes
causes action
action plan
plan

Objective
Propose actions to eliminate each identified root cause
Define actions, person responsible and target date of completion
for the execution of the solutions

Tools
Brainstorming/brainwriting

Go-See Think Do 60
 Identifying solutions to root causes

Brainstorm on the solutions and record them on the

Go-See Think Do template

ACTION PLAN - Implement preventive and sustainable solutions

Cause WHAT WHEN WHO Effort Impact

N* (WHAT WILL THE ACTION ELIMINATE, CONTROL, Due date Responsible Est. Cost to Est. Potential savings
REDUCE OR SIMPLIFY?) implement
# corresponding to

Indicate Effort : Impact : Actual or

the root cause

Indicate
Write down actions that Due Actual or Est.Time resources
owner Est.Time needed,$ spent,
will be taken to address Date for
for each resources material lost, potential
the root cause each needed,$ Safety and Quality
action risks avoided
action spent

Go-See Think Do 61
 Milk Example: Action List

ACTION PLAN - Implement preventive and sustainable solutions

Cause WHAT WHEN WHO Effort Impact

N* (WHAT WILL THE ACTION ELIMINATE, CONTROL, REDUCE OR Due date Responsible Est. Cost to Est. Potential savings
SIMPLIFY?) implement

Elimination 3 of 7 days a week

1 person 15
 1 & 3 Understand the new stove settings and determine the new  14.09.17   Joseph Milk loss
Minutes when
setting and time needed to boil the milk.  Husband 3X500ml X52 weeks = 78Ltrs
needed
saved  

Reduction/elimination ,of potential

Before new acquisitions of electronics, understand the 1 person 20
 Joseph Safety risks and start up costs –
 1 & 3 differences from previous to learn how to properly operate it  14.09.17  Minutes when
Husband All in Labor and material loss from
and avoid new problems.  needed
milk incidents $120

Elimination 3 of 7 days a week,

Turn off the TV and radio during the milk boiling process to be  Entire family 10 Milk burn on to oven cleanup
 2  15.09.17  John Son 
able to listen to the stove alarm  minutes average 15minutes added ,
3X15min X52 =39 hrs. saved

*Write down the NUMBER corresponding to the root cause as identified in the 5
whys (previous step)

Go-See Think Do 62
 Think - Simulation Game – Puzzle exercise

ROUND 2:
Simulation of Think Step (45-60 minutes)
• Brainstorm and identify potential causes
• Complete the Fishbone diagram, confirm causes in the
GEMBA and identify the 2-3 most likely causes
• After the Fishbone – all teams to stop work for a
brief discussion
• Use 5 Why’s to identify root cause(s)
• Identify solutions and start building an action plant (3-4
solid actions)
• Conduct trials, if you wish
• Fill out the THINK part of the GSTD/BDA form

Go-See Think Do 63
 Step Do/Action Planning:
Implement and standardise solutions
1 2
Is
Is the
the Yes Standardize
Standardize and
and
Implement
Implement problem
problem share
share key
key
solutions
solutions eliminated?
eliminated? learning
learning

No

Objective
Implement the action list
Present GSTD/BDA during Operational Reviews for sharing,
learning and recognition
Follow up actions during Operational Reviews

Tool
Action Boards
GSTD Tracker
Go-See Think Do 64
 Update progress of GSTD/BDA during
Operational Reviews

If solutions need follow up, record it in

the Short Term/Long Term Action Board

ACTION to Eliminate Reoccurrence

ACTION PLAN - Implement preventive and sustainable solutions
Cause W HAT WHEN WHO Effort Impact

(WHAT WILL THE ACTION ELIMINATE, CONTROL, REDUCE OR Est. Cost to Est. Potential
N* SIMPLIFY?) Due date Responsible implement savings

1 Purchase 3 additional heat guns for carbon bushing replacement 30/06/2016 Dan S. $426 $13,500

Cost of affected
2 MOC to remove agitator rotation during sterilization 24/06/2016 Ryan L. $0 batches and
materials
Cost of affected
MOC to remove agitator rotation below a product level of 5k lbs. (above
2 24/06/2016 Ryan L. $0 batches and
agitator bushing assemblies)
materials
Mavag to investigate and implement corrective action in regards to Cap
screw design correction for previous O-ring Failures. Compare current O-
3 29/07/2016 Mavag/PTC
ring seat design (MDB 15000) to previous (MDB 13000). Currently Cap
screw Diameter is 39.9mm O-ring is 37.47mm. Cap Screw shoulder

2 Install agitator speed sensor to detect failure 24/06/2016 Ryan L.

Mavag to investigate O-ring bulging below Ceramic bushing due to design

N/a TBD Mavag/PTC
of o-ring seat.

Mavag to design agitator head lifting device for internal tank use. This will Undetermined
N/a reduce the chance of bushing damage due to tight tolerances during TBD Mavag/PTC (will come as an
installation additional Kit)
Develop and implement 90 day PM to inspect agitator components, this
Cost of affected
will augment the annual (365 day) bushing and O-ring replacement PM
3 24/06/2016 Dan S. $0 batches and
currently in place. This is a temporary measure until O-ring design
materials
corrections (to include the need for the additional shim) have been
Cost of affected
MOC to add Shim/Washer under Cap screw to allow complete cap screw
3 22/06/2016 Tom G. $1.15 batches and
engagement while O-ring is properly seated (without Bulging)
materials
Mavag to redesign drive magnet lowering device that allows the magnet to Undetermined
N/a lower out of the housing completely, reducing the magnetic pull that TBD Mavag/PTC (will come as an
affects installation of the agitator head additional Kit)

Cost of affected
2 Flattening agitator speed ramp-up during tank level changes 24/06/2016 Ryan L. $0 batches and
materials

VERIFICATION OF EFFECTIVENESS
DO

(Successful problem solving means that the problem does not recur during the next 3 or more opportunities (i.e. 3 days if the problem could happen on daily
basis). The number of verifications should be determined by the team.

*Write down the NUMBER corresponding to the root cause as identified in the 5-Why's (previous step)

STANDARDIZE AND SHARE LEARNINGS

POINTS TO CHECK DOCUMENT W HO WHEN STATUS

Has a CIL and/or AMM standard been created and/or revised/updated?

Were new OPL's created (One Point Lessons)?

Was training delivered on the new and/or updated standards?

Is a MOC required (Management o change)?

Is there a follow up date to monitor the problem is resolved?

Is the improvement documented on the improvement register? (described how this

improvement can / will be replicated to other machines / equipment?

POTENTIAL FOR REPLICATION - SCOPE

ACTION # (AMM or LC) DESCRIPTION OF THE ACTION IMPROVEMENT RECORD # Impact (potential savings)

Go-See Think Do 65
 Go-See Think Do/Breakdown Analysis
tracker
Illustrative example

Integrated Problem Solving Tracker

(GSTD, BDA, …….)
Status Indicators
Red: Delayed Green: On Time Please fill in green if Yes and in Red if No
Proces
Root Action
Problem Statement Leader Coach s
Owner
G0-See Think Do
Launched
REAL
Led by
Causes Effectivenes
Verified by s Verified by
GSTD/BDA
GSTD/BDA
Operator
TIME Process
Owner
Process
Owner
should
should be
be
tracked
tracked during
Date

during
Y Y Y Y
Status N N N N
Date Y Y Y Y
Status
Date
N
Y
N
Y
N
Y
N
Y
Operational
Operational
Reviews
Status N N N N

Reviews
1 2 3 4 5 6
Date Y Y Y Y
Status N N N N
Date Y Y Y Y
Status N N N N
Date Y Y Y Y
Status N N N N
Date Y Y Y Y
Status N N N N
Date Y Y Y Y
Status N N N N

11 Definition
Definition of
of the
the problem
problem based
based on
on 4W1H
4W1H 44 Person
Person responsible
responsible to
to sustain
sustain improvement
improvement

22 Person
Person responsible
responsible for
for GSTD
GSTD 55 Progress
Progress tracking
tracking of
of GSTD/BDA
GSTD/BDA

33 Person
Person responsible
responsible to
to coach
coach GSTD
GSTD 66 Measures
Measures and
and Verification
Verification

Go-See Think Do 66
 Step Do - Implement and standardise
solutions
1 2
Is
Is the
the Yes Standardize
Standardize
Implement
Implement problem
problem and
and share
share key
key
solutions
solutions eliminated?
eliminated? learning
learning
No

Objective
Verify effectiveness of solution
Review GSTD quality

Tool
Escalation Board (if expected result is not achieved)

Go-See Think Do 67
 Mandatory Deliverables of GSTD/BDA

Results: • Was the target achieved (review of measure)?

• A standard was created/updated to achieve

Standardization:
sustainability and standardize the process

• Training was provided to all impacted employees

Training /
and knowledge was transferred to other
Reapplication:
areas/sites.

Capability • Team members gained knowledge and capability

Building: in problem solving activities and tools

Go-See Think Do 68
 Verification of GSTD/BDA effectiveness

Compare measure results

before and after the actions
BEFORE AFTER
were implemented
Successful Problem Solving
means that the problem
does not reappear

If the expected result is not achieved:

Escalate through …or apply other problem solving
Operational Reviews… methodology (if available)

Go-See Think Do 69
 Examples: Verification of improvement

Milk Example:

VERIFICATION OF EFFECTIVENESS
(Successful problem solving means that the problem does not recur during the next 3 or
more opportunities (i.e. 3 days if the problem could happen on daily basis). The number of
verifications should be determined by the team.

After 8 consecutive days milk has not spilled again

   

Go-See Think Do 70
 Step Do - Implement and standardise
solutions
1 2
Is
Is the
the Yes Standardize
Standardize and
and
Implement
Implement problem
problem share
share key
key
solutions
solutions eliminated? learning
eliminated? learning

No

Objective
Create or update standards
Develop training required for all involved
Transfer knowledge through training
Share and replicate lessons learned (where applicable)

Tools
One Point Lesson (OPL) to communicate
Standards CIL(Clean Inspection Lubrication)
MOC (Management of Change)
Go-See Think Do 71
 Standardize and share key learning

The Standard Routines process supports the creation / update of

the standards as well as the knowledge transfer and trainings
STANDARDIZE AND SHARE LEARNINGS
POINTS TO CHECK DOCUMENT WHO WHEN STATUS
Has a standard been created and/or revised/updated, e.g CIL, WI, SOP,
       
NGMP, AMM standard?
Were new OPL's created (One Point Lessons)?        

Was training delivered on the new and/or updated standards?        

Is a MOC required (Management of change)?        

Is there a follow up date to monitor the problem is resolved?        

Is the improvement documented on the improvement register? (described

       
how this improvement can / will be replicated to other machines / equipment?

             

Standard Routines process

Go-See Think Do 72
 When is a Problem Solving Activity
completed?

We can consider a basic Problem Solving

activity to be completed when:
Actions to address root cause have been
implemented
The problem has not recurred in the next 3
opportunities
Mistake prevention methods has been
applied. (see next slide)
Standards have been created/updated
Knowledge regarding new/updated
standards has been transferred

Go-See Think Do 73
 Mistake Prevention Methods

Different prevention methods provide

Mechanical different level of barriers to mistakes
1 solutions to happen

Poka Yoke Prevent and/or Detect asap

Limit switches Error detection

2 Auto stopping 3 & alarm

4 Visual controls

5 Checklists

TPM
Go-See
- AM
Think
PillarDo Thursday, February 18, 2 74
 Mechanical
1 solutions

Before 之前 After 之后
Old profile New profile

Knife can be attached in 2 different ways,

leaving room for mistakes Knife can only be attached in 1 way,
physically impossible to make a mistake
there.
Go-See Think Do 75
 Mechanical
1 solutions

Even Little ceramic teapots have need of mistake-proofing.

The concern is that the lid will fall off while pouring and break.
To avoid this, The lid is designed with a lip that prevents it from toppling out. The
photo at right shows that the opening in the teapot is not circular, so that the lid can
only be put on the correct way.

Go-See Think Do 76
Poka yoke: where to use

1. Manual operations where technician vigilance is needed

2. Where mis-positioning can occur.
3. Where set-up/adjustment is required.
4. Where teams rotate the work positions.
5. Where attributes / not exact measurements are important.
6. Where training investment and employee turnover are high.
7. Where frequent changeovers take place.
8. Where special root causes can reoccur.

We will use poka yoke techniques in simplification strategies as well as in root

cause solutions for Breakdowns, Quality and Safety incidents but also for
repeating maintenance tasks.

TPM
Go-See
- AM
Think
PillarDo Thursday, February 18, 2 77
 Milk Example: Standardise and share key
learning

STANDARDIZE AND SHARE LEARNINGS

POINTS TO CHECK DOCUMENT WHO WHEN STATUS

Has a CIL and/or AMM standard been created and/or

     
revised/updated?

Were new OPL's created (One Point Lessons)?  OPL TV in Kitchen  John (Son)  15.09.17  

Was training delivered on the new and/or updated standards?        

Is a MOC required (Management o change)?        

Verify consistent
Is there a follow up date to monitor the problem is resolved? results for 1 month  Mary (Wife)  01.10.17  
period

Is the improvement documented on the improvement register?

(described how this improvement can / will be replicated to  SOP MB.01.01  Joseph (Husband)  15.09.17  
other machines / equipment?

             

Go-See Think Do 78
 Do - Simulation Game – Puzzle exercise

ROUND 3:
Simulation of Do Action Planning Step (20 minutes)
• Complete the Do section of the GSTD/BDA form
• Confirm the actions taken (do not need to list
everything you tried)
• Conduct one final round of the puzzle assembly to
confirm/validate sustainability of your improvement
results
• Complete the Verification and Standardization
sections

Go-See Think Do 79
 Agenda

Objectives

Introduction to Basic Problem Solving

(GSTD/BDA)

Basic Problem Solving Integrated Form

roadmap and tools

Basic Problem Solving Guidance Tools

Key messages

Go-See Think Do 80
 The Go-See Think Do Guidance Tool

The Guidance Tools:

Evaluates the quality of GSTD/BDA
Should be used for each GSTD/BDA
Evaluation done by the coach
Recommended to use it as guideline
during the execution

Coach:
Experience is needed to become a
GSTD/BDA coach
Ensure calibration of the Guidance Tool
prior to use

Go-See Think Do 81
 Agenda

Objectives

Introduction to Basic Problem Solving

(GSTD/BDA)

Basic Problem Solving Integrated Form

roadmap and tools

Basic Problem Solving Guidance Tools

Key messages

Go-See Think Do 82
 Basic Problem Solving implementation tips

Leverage current Focused Improvement competency in

the Market
Understand how to trigger and evolve the use of Problem
Solving in Operational Reviews
Integrate it into WOR/MOR (agenda, communication center)
Have a clear strategy
Include it into your training plan involving your Leadership Team
Appoint and develop initial problem solving leaders who will
evolve into problem solving coaches
Plan for a controlled implementation focusing on learning and
then expanding
Have a strategy for formal and informal recognition

Go-See Think Do 85
 Recognition Example: GSTD Contest

It is important to recognize Problem Solving results and

effort of problem solving teams

Yearly GSTD Contest in SAR for the best GSTD in Safety,

Productivity and Quality as one of the examples of problem
solving recognition

Go-See Think Do 87
 Recognition Example: GSTD of the Month

GSTD recognition posted in

plant for rolling year

Go-See Think Do 88
 Employee X
Has demonstrated skill and capability in using Go-See-Think-Do
to understand problems, determine root causes, drive actions that eliminate
root causes, and put processes in place to sustain the improvements.
Completed the DDth day of MMM, 20XX
Factory Location

Person Z Person Z
Factory Goal Alignment Leader Focused Improvement Pillar Leader
 Key Messages

The GSTD/BDA tools provide a simple stepped approach to

problem solving
Go-See: understand the problem
Think: find root causes, then solutions
Do: implement actions and standardizes solutions

Whenever there is an issue and the root cause is unknown, there is

an opportunity to do a GSTD

GSTD can be applied by everyone in the organization

Basic Problem Solving gives people the competency and method to

solve their own problems

Go-See Think Do 90
 QUESTIONS?

Go-See Think Do 91
Go-See Think Do 92