Management Problem Solving

Techniques for Decision

Makers

ASA 2013 Annual Conference

GEORGE J. RINGGER, MAS, P.E.
FAA-DER FAA-DAR
Providing Engineering, Quality System, Training, and
Airworthiness services
to the aviation industry

office 954-655-6509
fax 954-680-5326
[email protected]
www.georgeringger.com
TRAINING PROVIDED TO THE
AVIATION COMMUNITY
 Overview
1; Introductions/Purpose
2: Approaches to solving problems
3: Where do problems come from? (CARs)
4: Defining some terms
5: Steps to an effective Problem Solving Strategy (RCA)
6: Management tools for problem-solving with examples
7: Summary
 Exercise
While pouring yourself a cup of coffee in the cafeteria, a
supervisor of Customer Service walks up to you for help:

Supervisor: “You know, ever since Sally was transferred to my

department, reported customer complaints have skyrocketed!
I had my best employee, Sam, train her. I really need some help
here. Any suggestions?”

1. What is your impression of the Supervisor?

2. What is your impression of Sally’s performance?
3. What do you recommend?
4. What information (data) have you collected and analyzed
to support your recommendations?
 4 Modes of Problem Solving
Predictive mode:
- Based on current performance what
is the likelihood of achieving
objectives?
Maturity

Proactive mode:
– Analyzing past failures and looking
for future improvements
Preventive mode:
– Putting in place solutions before
problems occur
Reactive mode:
– Solving the problem that has
occurred
 Maturity

Traditional Approach System Approach

• Fire Fighting • Many factors making up a complex

• Quick Fix situation
• Not taking enough time for analysis • Fully understanding the problem. Address
• Going from one crisis to another the systemic root cause(s)
• Look for the guilty party - ”Who did • Permanently fix and improve performance
that?” • Seek total understanding of the process:
• “How did that happen?”
• Generate laundry list of solutions to
firefight the symptoms • Take time to understand the big picture
• Narrow-focus results in sub- • Elicit dialogue, diverse perspectives, to
optimization of system apply the solution
• Focus on $ metrics alone and hope • Optimize the whole enterprise
processes improve • Focus on improving processes that
actually effect performance metrics
 The Scientific Process
Identify a Gather Formulate a
problem Information hypothesis

Record and Design and

Analyze Data
Organize Data Experiment

Draw Use conclusions to develop a new hypothesis
Conclusions
 The Management Process
Applies the Scientific Method (PDCA cycle)
to Management Systems . . .

Activities Activities Results

planned executed reported

Activities Problems
RCs & CFs
adjusted Identified Investigated
 The Audit Process
Applies the Scientific Method (PDCA cycle)
to Management Systems . . .

Audit Audit Results are

planned executed reported

Corrective Event
RCs & CFs
action Investigation
Identified
Steps of an Effective Problem
Solving Strategy (RCA)

Management
Problem
Solving

They are
one in the
same!!!
QMS Root
Cause
Analysis
 So, where do Management
Problems come from?

From unintended results!

 EXERCISE #1
In your own words…

1. What does “problem” mean?

2. What does “problem solving” mean?
3. What does “Root Cause Analysis” mean?
4. What does “Corrective Correction” mean?
5. What does “Corrective Action” mean?
 5 Steps to an Effective
Problem-Solving Strategy
1. Conduct Investigation (Data Collection)

2. Perform Root Cause Analysis

(using problem-solving management tools)

3. Implement Corrective Actions

4. Report your Results

5. Follow Up to Prevent Recurrence

Management Problem-Solving Tools
 Used by hundreds of major corporations including:
Boeing, Airbus, NASA, Lockheed, Apple, Microsoft,
GE, ASQ, major universities, FAA, DOD, ICAO etc.

 Six Sigma, Lean Manufacturing, Certified Quality

Managers.

 Taught at major universities in Quality Management,

Industrial engineering, Operations Management &
MBA programs.
Management Problem-Solving Tools
Check sheets Data Collection
Pareto Analysis
Flow Chart
Data Collection
Histogram
&
Scatter Diagram
Analysis
SPC Chart
Cause-and-Effect Diagram

The 5 Whys
Brainstorming
Barrier Analysis
Root Cause
Human Performance/ Human Factors
Analysis Techniques
Management Problem-Solving Tools
1. Check sheets Data Collection
2. Pareto Analysis
3. Flow Chart Data Collection
4. Histogram &
5. Scatter Diagram Analysis
6. SPC Chart
7. Cause-and-Effect Diagram
8. The 5 Whys
9. Brainstorming
10. Barrier Analysis
Root Cause
11. Management Oversight Analysis
Analysis Techniques
12. Human Performance/ Human
Factors
1. Check Sheet Example

EVENT: Pick Tickets w/ incorrect shipping instructions

TIME PERIOD: 01 Feb to 28 Feb 2013
OBSERVER: Bob Smith

Avionics ||||
Expendables |||| |||| |||| |||| |||| ||
Hydraulics ||
Pneumatics ||||
Structures |II
Other |
 2. Pareto Analysis
NUMBER OF
CAUSE DEFECTS PERCENTAGE

Poor design 80 64 %
Wrong part dimensions 16 13
Defective parts 12 10
Incorrect machine calibration 7 6
Operator errors 4 3
Defective material 3 2
Surface abrasions 3 2
125 100 %
2. Pareto Chart Example
70
(64)
60

50
Percent from each cause

40

30

20
(13)
(10)
10 (6)
(3) (2) (2)
0

Causes of poor quality

3. Flow Chart

Operation Operation

Start/
Decision Finish
3. Flow Chart Example
Documentation process
 4. Histogram

20

15

10

0
1 2 6 13 10 16 19 17 12 16 2017 13 5 6 2 1
 4. Histogram
• Bar-graph used to show the distribution of a set
of data
• Helps determine:
• If a process is in control (steady-state; bell-
shaped
• If outcomes of two processes are combined in
one set of data (Bi-modal; double-hump)
– e. g. day-shift & night-shift; airline customers
and distributor-customers
4. Histogram Bi-Modal Example

20

15

10

0
1 2 6 13 10 16 19 17 12 16 2017 13 5 6 2 1
 5. Scatter Diagram
Y

X
 5. Class Exercise
Your boss wants to improve efficiency in your inventory operations. The current process to receive and stock bulk
inventory takes 4 ¾ hours per crate. Your boss has proposed a new process. You conducted a test and gathered the
following data that describes the new proposed process. The data is shown below:

New Proposed Process Test Results

Trial 1 2 3 4 5 6 7 8
Time
7.5 6.4 5.8 5.4 5.1 4.9 4.8 4.6
(Hours)

Comparing Processes
Current process Average = 4.75 hours/process
Average = 5.6 hours/process
Proposed new process
Range = 4.6 to 7.5 hours/process

A rival department head doesn’t like your boss, doesn’t like change, and believes in sticking with the current “tried-and-
true” process. He wants to leave things “just the way they are”!

The rival has evaluated the above data (your data!) to support his position. Based on his review (of your data!) he claims
your boss’s new process will require 5 hours and sometimes up to 7 ½ hours per crate; a possible 68% increase in
workload above the way things are being done now!

He chants in the halls, “Don't fix what’s not broken!”

Your boss and the rival supervisor have been called into the President’s office to settle this matter and make an executive
decision to either:

(1) Roll out your boss’s new process, or

(2) Abandon the new idea and leave things the way they are.
So, what is the right decision?
(1) Roll out your boss’s new process?
or

(2) Abandon the new idea and leave things the

way they are?
 5. Comparing Processes
8.0
New Process
7.0

Current Process
6.0

5.0

4.0
Series1

3.0

2.0

1.0

0.0
0 5 10 15 20 25 30 35 40
 5. Comparing Processes
8.0

Current Process 1st 40 crates

7.0
Labor = (4.75)(40)=190 m-hrs

2nd 40 crates = 190 m-hrs

6.0

5.0

4.0
Series1

3.0

New Process 1st 40 crates

2.0
Labor = Σ 1thru 40 = 160 m-hrs
2nd 40 crates:
1.0
(3.2)(40) = 128 m-hrs (62 m-hrs savings)

0.0
0 5 10 15 20 25 30 35 40
 6. Control Chart
24
UCL = 23.35
21

c = 12.67
Number of defects

18

15

12

6
LCL = 1.99
3
2 4 6 8 10 12 14 16
Sample number
 Month QTY REJ %REJ %MR UCL LCL %REJ(ave)
2012 01 21 5 23.8% 59.01% 0.00% 20.33%
2012 02 16 4 25.0% 1.19% 59.01% 0.00% 20.33%
2012 03 24 3 12.5% 12.50% 59.01% 0.00% 20.33% Increasing
2012 04 13 3 23.1% 10.58% 59.01% 0.00% 20.33%
2012 05 22 4 18.2% 4.90% 59.01% 0.00% 20.33% variability.
2012 06 24 6 25.0% 6.82% 59.01% 0.00% 20.33%
2012 07 22 3 13.6% 11.36% 59.01% 0.00% 20.33%
2012 08 7 2 28.6% 14.94% 59.01% 0.00% 20.33% Losing control
2012 09 6 2 33.3% 4.76% 59.01% 0.00% 20.33%
2012 10 6 0 0.0% 33.33% 59.01% 0.00% 20.33% of the process.
2012 11 8 3 37.5% 37.50% 59.01% 0.00% 20.33%
2012 12 13 2 15.4% 22.12% 59.01% 0.00% 20.33%
Totals: 182 37 20.3% 159.99% 59.01%
MRave= 14.54%

COMPANY 339
Range chart w ith Shew hart Control Lim its

0.5

0.45

0.4
Series1
0.35
Center = 0.1454
0.3
UCL = 0.4756
0.25 LCL = 0
0.2 Zone A Above

0.15
Zone B Above
Zone A Below
0.1

0.05

0
1 2 3 4 5 6 7 8 9 10 11 12

Run
 7. Cause and Effect Diagram
Illustrates relationships between a given effect and its
possible causes. (same as Fishbone; Ishikawa; 5-Ms)

Approach:
- Identify problem
- Define major categories of possible causes
- Identify possible causes/root causes within each category

Machine Man

CAUSES Event

Material

Measurement Methods
 7. Cause-Effect Diagram
Measurement Human Machines
Faulty
testing equipment Poor supervision Out of adjustment

Incorrect specifications Lack of concentration Tooling problems

Improper methods Inadequate training Old / worn

Quality
Inaccurate Problem
temperature
control Defective from vendor Poor process design
Ineffective quality
Not to specifications management
Dust and Dirt Material- Deficiencies
handling problems in product design

Methods
Environment Materials ( )
(Process)
Management Problem-Solving Tools
1. Check sheets Data Collection
2. Pareto Analysis
3. Flow Chart Data Collection
4. Histogram &
5. Scatter Diagram Analysis
6. SPC Chart
7. Cause-and-Effect Diagram
8. The 5 Whys
9. Brainstorming
10. Barrier Analysis
Root Cause
11. Human Performance/ Human
Analysis Techniques
Factors
 8. The 5-Why Analysis
A technique where you start by re-stating
the identified problem, then continue to
ask more fundamental questions until you
arrive at the root cause of the problem.

Let’s look at 3 examples….

 8. 5-Why Problem Example
An elderly man picked up his medicine
prescription at a local Pharmacy. Upon
returning home his wife read the label on
the medicine bottle and discovered he
was prescribed the wrong medicine. She
called his doctor’s office on the phone and
complained about the mix-up.
 8. The 5 Whys – Example #1
Q 1: Why did the patient get the incorrect medicine?
A 1: Because the prescription was wrong.

Q 2: Why was the prescription wrong?

A 2: Because the doctor made an incorrect decision.

Q 3: Why did the doctor make an incorrect decision?

A 3: Because he did not have complete information in the patient’s chart. The chart
was missing the results of the patient’s latest laboratory report.

Q 4: Why wasn’t the patient’s medical chart updated ?

A 4: Because the doctor’s assistant had not entered the results of the latest
laboratory report.

Q 5: Why hadn’t the doctor’s assistant charted the latest laboratory report?
A 5: Because the lab technician telephoned the results to the receptionist, who forgot
to tell the assistant.
Solution: Develop a formal system for tracking lab reports.
Institute of Medicine July 20, 2006
Drug errors cause at least:
“At least 1.5  > 400,000 preventable
million Americans injuries and deaths in
are sickened, hospitals each year
injured or killed  > 800,000 in nursing
each year by homes and facilities for
errors in the elderly
prescribing,  530,000 among Medicare
dispensing and recipients treated in
taking outpatient clinics
medications.”
8. 5-Why Example #1
None of these are in the form of a question.

Who is the escalation process

left to the discretion of?
Is this allowed by your SOP?
But why was the
SOP not followed?
– Inadequate
procedure?
It either was or was
not escalated
– not both!
Why
not!?
This is just a restatement of the finding
and is not a root cause.
You need to address why CARs take a
backseat to vacations & Holiday
schedules. For instance, is this a symptom
of lack of Top Management commitment?
Some digging may be required here.
What are your plans to train
employees and top management
in the revised procedures?
 Who is the escalation process
left to the discretion of?
Is this allowed by your SOP?

But why wasn’t the SOP

followed? – Inadequate
procedure?

Why not!?

This is just a restatement of the finding and is not a root cause.

It either was or was not escalated
You need to address why CARs take a backseat to vacations &
– not both!
Holiday schedules. For instance, is this a symptom of lack of Top
Management commitment? Some digging may be required here.

What are your plans to train employees and top

management in the revised procedures?
 8. 5-Why Example #3

(Let’s revisit Sally!)

 Exercise # 3
While pouring yourself a cup of coffee in the cafeteria, a
supervisor of Customer Service walks up to you for help:

Supervisor: “You know, ever since Sally was transferred to my

department, reported customer complaints have skyrocketed!
I had my best employee, Sam, train her. I really need some help
here. Any suggestions?”

1. What is your impression of the Supervisor?

2. What is your impression of Sally’s performance?
3. What do you recommend?
4. What information (data) have you collected and analyzed to
support your recommendations?
Step #1 Perform Event Investigation:

Supervisor: “You know, ever since Sally was

transferred to my department, reported
customer complaints have skyrocketed! I
had my best employee, Sam, train her. I
really need some help here. Any
suggestions?”

So, what exactly is the problem?...

 5-Why Example #2

Problem Statement:
It was brought to the attention of Top
Management that there has been a recent
increase in customer complaint
submittals.
 Conduct Interviews
Supervisor: “You know, ever since Sally was transferred to my
department, reported customer complaints have skyrocketed! Sam
trained her. I really need some help here. Any suggestions?”

Sally: When Sam trained me before I took over full-time he told me I

didn’t need to complete the Customer Complaint form, even though it
is required by Procedure A02. The procedure isn’t very clearly written
but it requires the form to be completed and forwarded to the CS
Manager for every customer complaint received, so that’s what I do.

Sam: The Customer Complaint form? Sally shouldn’t be using it. It’s a
waste of time to fill them out! I’ve been here for over 10 years and
nobody ever reads those forms. We stopped using that ‘ole thing long
ago. Don’t worry, if there’s a real complaint we fix it right on the
spot! We don’t need a form to tell us what to do. We’ve always done
it this way!
 Review current CS Procedure A02

A review of the Customer Service Procedure was conducted

and Section 7 was found to be ambiguous with respect to
the use of the Customer Complaint form. See below
except from Procedure A02:

“Section 7:
Any customer complaints should be documented and
responded to by the CS Manager (ref: Form # 123).”
Review distribution history of Procedure A02
1) Not all CS staff were aware of or had access to the
procedure at point of use.

2) Not all CS staff had access to or were aware of the

intended use of the Customer Complaint form.

Step #4 Review training records.

Employee training records show no training had been

conducted in the requirements of Procedure A02.
 Step #2 Conduct RCA (5-WHY Analysis)
Q 1: Why is there an increase in customer complaints?
A 1: Because more Customer Complaint forms are being submitted than previously.

Q 2: Why are more Customer Complaint forms being submitted?

A 2: Because a new employee is submitting them.

Q 3: Why is a new employee submitting them?

A 3: Because Procedure A02, while not clearly written, requires all customer
complaints to be recorded and reported to the CS Manager using Customer
Complaint form.
Q 4: Why were they not reported by previous staff?
A 4: Employees lacked training resulting in a lack of awareness of company
requirements; company norms take priority over following company procedures.

Q 5: Why do company norms take priority over following company procedures?

A 5: Because a culture of complacency allows management to disregard company policy,
resulting in a corporate attitude that employee training and following company procedures are not
necessary.
#1 Event Investigation:
1) Interviewed CS Manager and Staff
2) Reviewed distribution history of Procedure A02
3) Reviewed current CS Procedure A02
4) Reviewed employee training records
5) Conducted a 5-Why Analysis

#2 Root Cause:
1) A culture of complacency allows management to disregard
company policy, resulting in a corporate attitude that employee
training and following company procedures are not necessary.

2) This caused employees to disregard company procedures

resulting in some of the staff not recognizing the importance in
forwarding the Customer Complaint form to the CS Manager.
#3 Correction:
1.Reviewed CS files to ensure all completed forms were
forwarded to the CS Manager.

2.Addressed all customer complaints that were previously

unknown to management.

#4 Corrective Action:
1. Top Management communicated throughout the organization the need
for compliance with company policy.
2. Conducted training with CS Management and staff regarding the
importance in following company procedures.
1. Revised Procedure A02 to Rev A to more clearly describe the use of
the Customer Complaint form.
2. CS Manager trained the staff on the use of the new Procedure A02 ,
Rev A and documented the training in their training files.
3. CS Manager scheduled follow-up meetings with staff in one month to
assess the effectiveness of CA.
Post-Script –
Is there more work to be done?

 Are there other departments experiencing

similar issues?

 How effective is the company’s training

program?

 What about other customers and all of those

complaints we weren’t aware of ?
 9. Brainstorming:
is a highly structured management
tool used to generate a large number
of ideas and manage them.
Procedure:
• Review problem to be discussed.
• Focus on why, how, and what questions.
• Invite team members to call out ideas.
• Write all ideas on post-its, index cards, or a flip chart.
• Arrange ideas by common categories or themes.
9. Brainstorming Rules
Brainstorming is a formal, recognized
management tool.

• Make sure entire team understands the

problem statement
• All ideas are to be recorded
• No discussion or evaluation is permitted!
• No criticism is allowed (e.g. laughter, groans,
sneers, or “That’s a great idea!”)
• All team members must participate
 10. Barrier Analysis
Identifies physical, administrative, and
procedural barriers or controls that
should (or could) have prevented the
problem, but did not.
 10. Barrier Analysis
Barriers in place No Barriers in place
 10. Barriers include…
• Inspections
• Approval sign-offs
• Authority rosters
• Double checks
• Required fields in completing on-line forms
 11. Human Factors – The Goal

“Maximize human performance

and
Minimize errors”
 Human Error Estimates
System % Due to Human Error

Airlines 70-80%

Air Traffic Control 90%

Ships 80%

Process Control 80%

Nuclear Power 70%

Road Transportation 85%

 Human Errors
 Human errors can be minimized,
not eliminated.

 Errors must be:

– detected and corrected, or
– at least managed.
 11. Human Factors Models
 Edward’s SHELL MODEL

• Heinrich’s Domino Theory

• Reason’s Swiss Cheese Model

• Boeing’s MEDA* Error Model

* Maintenance Error Decision Aid

 SHELL MODEL
Manuals,
procedures, WI’s, Tools,
computer equipment,
programs vehicles
H H: Hardware
S : Software
Health,
knowledge, Temp,
attitude, humidity,
stress, culture, S L E noise,
pressure, light,
complacency, rain,
norms, ice, etc.
awareness, E : Environment
teamwork, L: Liveware
leadership, L
communication

1972 Elwyn Edward; 1987 Hawkins (modified)

Human Error - Example
 SHELL - Forklift Example
Software
Hardware
Review Procedures
Check brakes, hydraulics
Training records
Warehouse door & ramp
Equip. maintenance records
Door barriers
Warehouse warning signs

L
Environment
Liveware
Slippery surfaces
Stress, norms,
Weather
pressure to get the job done,
Light
supervision?
Forklift/driver ergonomics
 7a. Cause and Effect Diagram Example
Software Hardware
Inadequate procedures New/unintentional brake action by operator
Inadequate training method Lack of experience/training
Imbalance in hydraulic pressure
Weight/ Imbalance in hydraulic pressure
balance Door & ramp operation?
Inadequate maintenance inspections Poor forklift ergonomics?
placards?
Forklift
Lack of supervision Accident
Pressure Skill level
Poor Supervision to get job Slippery surface?
Substance abuse
done
on-time Stress/fatigue
(duty-time)
Time of day– sun in eyes?
Liveware
Authority protocol not working
Liveware

Environment
 Summary
 Learned the 4 modes of problem-solving.

 The “Scientific Method” should be used for all

problem investigations.

 Management problems and QMS problems are one

and the same.

 Identified a 5-step structured approach to solving

company problems.

 Learned 12 management problem-solving techniques

and reviewed actual examples for making decisions.
 Thanks for attending!

and remember…

“To stop learning…. is to stop living.”

© 2007 George J. Ringger
Questions?
GEORGE J. RINGGER, MAS, P.E.
FAA-DER FAA-DAR
Providing Engineering, Quality System, Training, and
Airworthiness services
to the aviation industry

office 954-655-6509
fax 954-680-5326
[email protected]
www.georgeringger.com